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Stovell MG, Ruetten PPR, Tozer DJ, Launey Y, Zimphango C, Thelin EP, Lupson VC, Giorgi-Coll S, Carpenter TA, Mada MO, Jalloh I, Helmy A, Wilson MH, Graves MJ, Menon DK, Carpenter KLH, Hutchinson PJ. Characterizing Diffusion from Microdialysis Catheters in the Human Brain: A Magnetic Resonance Imaging Study With Gadobutrol. J Neurotrauma 2024. [PMID: 38468502 DOI: 10.1089/neu.2023.0560] [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: 03/13/2024] Open
Abstract
Cerebral microdialysis (CMD) catheters allow continuous monitoring of patients' cerebral metabolism in severe traumatic brain injury (TBI). The catheters consist of a terminal semi-permeable membrane that is inserted into the brain's interstitium to allow perfusion fluid to equalize with the surrounding cerebral extracellular environment before being recovered through a central non-porous channel. However, it is unclear how far recovered fluid and suspended metabolites have diffused from within the brain, and therefore what volume or region of brain tissue the analyses of metabolism represent. We assessed diffusion of the small magnetic resonance (MR)-detectible molecule gadobutrol from microdialysis catheters in six subjects (complete data five subjects, incomplete data one subject) who had sustained a severe TBI. Diffusion pattern and distance in cerebral white matter were assessed using T1 (time for MR spin-lattice relaxation) maps at 1 mm isotropic resolution in a 3 Tesla MR scanner. Gadobutrol at 10 mmol/L diffused from cerebral microdialysis catheters in a uniform spheroidal (ellipsoid of revolution) pattern around the catheters' semipermeable membranes, and across gray matter-white matter boundaries. Evidence of gadobutrol diffusion was found up to a mean of 13.4 ± 0.5 mm (mean ± standard deviation [SD]) from catheters, but with a steep concentration drop off so that ≤50% of maximum concentration was achieved at ∼4 mm, and ≤10% of maximum was found beyond ∼7 mm from the catheters. There was little variation between subjects. The relaxivity of gadobutrol in human cerebral white matter was estimated to be 1.61 ± 0.38 L.mmol-1sec-1 (mean ± SD); assuming gadobutrol remained extracellular thereby occupying 20% of total tissue volume (interstitium), and concentration equilibrium with perfusion fluid was achieved immediately adjacent to catheters after 24 h of perfusion. No statistically significant change was found in the concentration of the extracellular metabolites glucose, lactate, pyruvate, nor the lactate/pyruvate ratio during gadobutrol perfusion when compared with period of baseline microdialysis perfusion. Cerebral microdialysis allows continuous monitoring of regional cerebral metabolism-the volume of which is now clearer from this study. It also has the potential to deliver small molecule therapies to focal pathologies of the human brain. This study provides a platform for future development of new catheters optimally designed to treat such conditions.
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Affiliation(s)
- Matthew G Stovell
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Department of Neurosurgery, The Walton Centre, Liverpool, United Kingdom
| | - Pascal P R Ruetten
- Department of Radiology, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Daniel J Tozer
- Stroke Research Group, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Yoann Launey
- Division of Anaesthesia, Department of Medicine, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Réanimation chirurgicale, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Chisomo Zimphango
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Eric P Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Victoria C Lupson
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Susan Giorgi-Coll
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - T Adrian Carpenter
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marius O Mada
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ibrahim Jalloh
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Mark H Wilson
- Imperial College London, St. Mary's Hospital, London, United Kingdom
| | - Martin J Graves
- Department of Radiology, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Keri L H Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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Pordel S, McCloskey AP, Almahmeed W, Sahebkar A. The protective effects of statins in traumatic brain injury. Pharmacol Rep 2024; 76:235-250. [PMID: 38448729 DOI: 10.1007/s43440-024-00582-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024]
Abstract
Traumatic brain injury (TBI), often referred to as the "silent epidemic", is the most common cause of mortality and morbidity worldwide among all trauma-related injuries. It is associated with considerable personal, medical, and economic consequences. Although remarkable advances in therapeutic approaches have been made, current treatments and clinical management for TBI recovery still remain to be improved. One of the factors that may contribute to this gap is that existing therapies target only a single event or pathology. However, brain injury after TBI involves various pathological mechanisms, including inflammation, oxidative stress, blood-brain barrier (BBB) disruption, ionic disturbance, excitotoxicity, mitochondrial dysfunction, neuronal necrosis, and apoptosis. Statins have several beneficial pleiotropic effects (anti-excitotoxicity, anti-inflammatory, anti-oxidant, anti-thrombotic, immunomodulatory activity, endothelial and vasoactive properties) in addition to promoting angiogenesis, neurogenesis, and synaptogenesis in TBI. Supposedly, using agents such as statins that target numerous and diverse pathological mechanisms, may be more effective than a single-target approach in TBI management. The current review was undertaken to investigate and summarize the protective mechanisms of statins against TBI. The limitations of conducted studies and directions for future research on this potential therapeutic application of statins are also discussed.
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Affiliation(s)
- Safoora Pordel
- Department of Immunology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alice P McCloskey
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Wael Almahmeed
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Naseri Alavi SA, Kobets AJ, Rezakhah A, Habibi MA, Rezvani K, Emami Sigaroudi F. Can Neutrophil to Lymphocyte Ratio Predict Early Outcome in Patients with Spinal Cord Injury? World Neurosurg 2023; 180:e243-e249. [PMID: 37741330 DOI: 10.1016/j.wneu.2023.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Spinal cord injury is a frequent debilitating neurologic condition with increasing prevalence and related morbidity over the last decades. The neutrophil-to-lymphocyte ratio is a promising biomarker for determining different medical conditions' disease course and outcome such as traumatic brain injury (TBI). This study aimed to investigate the predictive value of neutrophil to lymphocyte ratio (NLR) in the outcome of SCI. METHOD In a retrospective cross-sectional study from April 2019 to April 2022, all patients 18 to 65 years old, following spinal cord injury who were referred to Imam Khomeini Hospital and met inclusion and exclusion criteria enrolled in the study. A checklist including demographic data, lab, and clinical findings at admission, 24h, 48 h, and discharge were recorded. IBM SPSS Statistics software was used to analyze the data. A P-value of less than 0.05 was considered significant. RESULTS Six hundred patients met our inclusion criteria and enrolled in the study. The mean age of the patients was 40.93 ± 12.77, with 75% male and 25% female. There was a significant correlation between the N/L ratio at different time points (p.value=0.001), injury type, and ASIA score at admission and discharge (0.001). Furthermore, the NLR had approached significant value alone to predict outcomes in patients enrolled in the study (0.06). CONCLUSIONS A high NLR is unequivocally linked with poor outcomes in patients suffering from acute SCI and should be considered a negative prognostic factor; however, the NLR had approached significant predicting value in patients enrolled in the study.
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Affiliation(s)
| | - Andrew J Kobets
- Department of Neurological Surgery, Montefiore Medical, Bronx, New York, USA
| | - Amir Rezakhah
- Department of Neurosurgery, Urmia University of Medical Sciences, Urmia, Iran
| | - Mohammad Amin Habibi
- Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Clinical Research Development Center, Qom University of Medical Sciences, Qom, Iran
| | - Khashayar Rezvani
- Department of Neurosurgery, Urmia University of Medical Sciences, Urmia, Iran
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Lindblad C, Rostami E, Helmy A. Interleukin-1 Receptor Antagonist as Therapy for Traumatic Brain Injury. Neurotherapeutics 2023; 20:1508-1528. [PMID: 37610701 PMCID: PMC10684479 DOI: 10.1007/s13311-023-01421-0] [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] [Accepted: 08/02/2023] [Indexed: 08/24/2023] Open
Abstract
Traumatic brain injury is a common type of acquired brain injury of varying severity carrying potentially deleterious consequences for the afflicted individuals, families, and society. Following the initial, traumatically induced insult, cellular injury processes ensue. These are believed to be amenable to treatment. Among such injuries, neuroinflammation has gained interest and has become a specific focus for both experimental and clinical researchers. Neuroinflammation is elicited almost immediately following trauma, and extend for a long time, possibly for years, after the primary injury. In the acute phase, the inflammatory response is characterized by innate mechanisms such as the activation of microglia which among else mediates cytokine production. Among the earliest cytokines to emerge are the interleukin- (IL-) 1 family members, comprising, for example, the agonist IL-1β and its competitive antagonist, IL-1 receptor antagonist (IL-1ra). Because of its early emergence following trauma and its increased concentrations also after human TBI, IL-1 has been hypothesized to be a tractable treatment target following TBI. Ample experimental data supports this, and demonstrates restored neurological behavior, diminished lesion zones, and an attenuated inflammatory response following IL-1 modulation either through IL-1 knock-out experiments, IL-1β inhibition, or IL-1ra treatment. Of these, IL-1ra treatment is likely the most physiological. In addition, recombinant human IL-1ra (anakinra) is already approved for utilization across a few rheumatologic disorders. As of today, one randomized clinical controlled trial has utilized IL-1ra inhibition as an intervention and demonstrated its safety. Further clinical trials powered for patient outcome are needed in order to demonstrate efficacy. In this review, we summarize IL-1 biology in relation to acute neuroinflammatory processes following TBI with a particular focus on current evidence for IL-1ra treatment both in the experimental and clinical context.
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Affiliation(s)
- Caroline Lindblad
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
- Department of Neurosurgery, Uppsala University Hospital, entrance 85 floor 2, Akademiska Sjukhuset, 751 85, Uppsala, Sweden.
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Elham Rostami
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Department of Neurosurgery, Uppsala University Hospital, entrance 85 floor 2, Akademiska Sjukhuset, 751 85, Uppsala, Sweden
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Lindblad C, Neumann S, Kolbeinsdóttir S, Zachariadis V, Thelin EP, Enge M, Thams S, Brundin L, Svensson M. Stem cell-derived brainstem mouse astrocytes obtain a neurotoxic phenotype in vitro upon neuroinflammation. J Inflamm (Lond) 2023; 20:22. [PMID: 37370141 DOI: 10.1186/s12950-023-00349-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Astrocytes respond to injury and disease through a process known as reactive astrogliosis, of which inflammatory signaling is one subset. This inflammatory response is heterogeneous with respect to the inductive stimuli and the afflicted central nervous system region. This is of plausible importance in e.g. traumatic axonal injury (TAI), where lesions in the brainstem carries a particularly poor prognosis. In fact, astrogliotic forebrain astrocytes were recently suggested to cause neuronal death following axotomy. We therefore sought to assess if ventral brainstem- or rostroventral spinal astrocytes exert similar effects on motor neurons in vitro. METHODS We derived brainstem/rostroventral spinal astrocyte-like cells (ES-astrocytes) and motor neurons using directed differentiation of mouse embryonic stem cells (ES). We activated the ES-astrocytes using the neurotoxicity-eliciting cytokines interleukin- (IL-) 1α and tumor necrosis factor-(TNF-)α and clinically relevant inflammatory mediators. In co-cultures with reactive ES-astrocytes and motor neurons, we assessed neurotoxic ES-astrocyte activity, similarly to what has previously been shown for other central nervous system (CNS) regions. RESULTS We confirmed the brainstem/rostroventral ES-astrocyte identity using RNA-sequencing, immunocytochemistry, and by comparison with primary subventricular zone-astrocytes. Following cytokine stimulation, the c-Jun N-terminal kinase pathway down-stream product phosphorylated c-Jun was increased, thus demonstrating ES-astrocyte reactivity. These reactive ES-astrocytes conferred a contact-dependent neurotoxic effect upon co-culture with motor neurons. When exposed to IL-1β and IL-6, two neuroinflammatory cytokines found in the cerebrospinal fluid and serum proteome following human severe traumatic brain injury (TBI), ES-astrocytes exerted similar effects on motor neurons. Activation of ES-astrocytes by these cytokines was associated with pathways relating to endoplasmic reticulum stress and altered regulation of MYC. CONCLUSIONS Ventral brainstem and rostroventral spinal cord astrocytes differentiated from mouse ES can exert neurotoxic effects in vitro. This highlights how neuroinflammation following CNS lesions can exert region- and cell-specific effects. Our in vitro model system, which uniquely portrays astrocytes and neurons from one niche, allows for a detailed and translationally relevant model system for future studies on how to improve neuronal survival in particularly vulnerable CNS regions following e.g. TAI.
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Affiliation(s)
- Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden.
| | - Susanne Neumann
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden
| | | | | | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Enge
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Sebastian Thams
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Lou Brundin
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, J5:20 Svensson Group, Karolinska Universitetssjukhuset Solna, SE-171 77, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Jensen TSR, Binderup T, Olsen MH, Kjaer A, Fugleholm K. Subdural Levels of Interleukin 1-receptor Antagonist are Elevated in Patients with Recurrent Chronic Subdural Hematomas. Inflammation 2023:10.1007/s10753-023-01811-8. [PMID: 37039933 DOI: 10.1007/s10753-023-01811-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/20/2023] [Accepted: 03/27/2023] [Indexed: 04/12/2023]
Abstract
Anti-inflammatory treatment reduces the risk of recurrent chronic subdural hematoma (CSDH), but clinical implementation is improper due to side effects. Exact knowledge of subdural molecules involved in recurrent CSDH may lead to targeted medical treatment and possibly improve the prospect of a personalized approach by eliminating the broad use of anti-inflammatory drugs on the entire CSDH population. With this study, we aim to (1) describe the associations between cytokine levels at the primary surgery and the risk of subsequent recurrence and (2) describe the association between cytokines in patients with recurrent CSDH between the first and second operations. Systemic and subdural levels of pro- and anti-inflammatory cytokines were measured and compared between patients with the first-time CSDH and recurrent CSDH. Cytokine levels were analyzed using a multiplex antibody bead kit. In case of recurrent CSDH within 90 days of follow-up, the samples were re-collected and analyzed. We included 101 adult CSDH patients of which 20 had a recurrence. The levels of cytokines in the CSDH fluid from patients who were operated on for the first-time CSDH were not associated with the risk of later developing a recurrence. We found interleukin-1 receptor antagonist (IL-1ra) to be elevated in subdural fluid in patients with recurrent CSDH at the time of their second operation (p = 0.0005). This study provides knowledge on cytokine composition in the subdural fluid in patients with CSDH with and without recurrence. IL-1ra is elevated in subdural fluid in patients with recurrent CSDH at the time of the second operation, identifying a possible medical target.
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Affiliation(s)
- Thorbjørn Søren Rønn Jensen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Rigshospitalet, Copenhagen, Denmark.
| | - Tina Binderup
- Department of Clinical Physiology and Nuclear Medicine & Cluster for Molecular Imaging, Rigshospitalet & Department of Biomedical Sciences, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology and Nuclear Medicine & Cluster for Molecular Imaging, Rigshospitalet & Department of Biomedical Sciences, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kåre Fugleholm
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Rigshospitalet, Copenhagen, Denmark
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Dyhrfort P, Wettervik TS, Clausen F, Enblad P, Hillered L, Lewén A. A Dedicated 21-Plex Proximity Extension Assay Panel for High-Sensitivity Protein Biomarker Detection Using Microdialysis in Severe Traumatic Brain Injury: The Next Step in Precision Medicine? Neurotrauma Rep 2023; 4:25-40. [PMID: 36726870 PMCID: PMC9886191 DOI: 10.1089/neur.2022.0067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Cerebral protein profiling in traumatic brain injury (TBI) is needed to better comprehend secondary injury pathways. Cerebral microdialysis (CMD), in combination with the proximity extension assay (PEA) technique, has great potential in this field. By using PEA, we have previously screened >500 proteins from CMD samples collected from TBI patients. In this study, we customized a PEA panel prototype of 21 selected candidate protein biomarkers, involved in inflammation (13), neuroplasticity/-repair (six), and axonal injury (two). The aim was to study their temporal dynamics and relation to age, structural injury, and clinical outcome. Ten patients with severe TBI and CMD monitoring, who were treated in the Neurointensive Care Unit, Uppsala University Hospital, Sweden, were included. Hourly CMD samples were collected for up to 7 days after trauma and analyzed with the 21-plex PEA panel. Seventeen of the 21 proteins from the CMD sample analyses showed significantly different mean levels between days. Early peaks (within 48 h) were noted with interleukin (IL)-1β, IL-6, IL-8, granulocyte colony-stimulating factor, transforming growth factor alpha, brevican, junctional adhesion molecule B, and neurocan. C-X-C motif chemokine ligand 10 peaked after 3 days. Late peaks (>5 days) were noted with interleukin-1 receptor antagonist (IL-1ra), monocyte chemoattractant protein (MCP)-2, MCP-3, urokinase-type plasminogen activator, Dickkopf-related protein 1, and DRAXIN. IL-8, neurofilament heavy chain, and TAU were biphasic. Age (above/below 22 years) interacted with the temporal dynamics of IL-6, IL-1ra, vascular endothelial growth factor, MCP-3, and TAU. There was no association between radiological injury (Marshall grade) or clinical outcome (Extended Glasgow Outcome Scale) with the protein expression pattern. The PEA method is a highly sensitive molecular tool for protein profiling from cerebral tissue in TBI. The novel TBI dedicated 21-plex panel showed marked regulation of proteins belonging to the inflammation, plasticity/repair, and axonal injury families. The method may enable important insights into complex injury processes on a molecular level that may be of value in future efforts to tailor pharmacological TBI trials to better address specific disease processes and optimize timing of treatments.
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Affiliation(s)
- Philip Dyhrfort
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden.,Address correspondence to: Teodor Svedung Wettervik, MD, PhD, Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85 Uppsala, Sweden.
| | - Fredrik Clausen
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Lars Hillered
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Zhang L, Yang W, Li X, Dove A, Qi X, Pan KY, Xu W. Association of life-course traumatic brain injury with dementia risk: A nationwide twin study. Alzheimers Dement 2023; 19:217-225. [PMID: 35347847 PMCID: PMC10078668 DOI: 10.1002/alz.12671] [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: 11/18/2021] [Revised: 02/25/2022] [Accepted: 03/14/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The impact of life-course traumatic brain injury (TBI) on dementia is unclear. METHODS Within the Swedish Twin Registry (STR), 35,312 dementia-free twins were followed for up to 18 years. TBI history was identified via medical records. Data were analyzed using generalized estimating equation (GEE) and conditional logistic regression. RESULTS In multi-adjusted GEE models, the odds ratio (OR, 95% confidence interval [CI]) of dementia was 1.27 (1.03-1.57) for TBI at any age, 1.55 (1.04-2.31) for TBI at 50 to 59 years, and 1.67 (1.12-2.49) for TBI at 60 to 69 years. Cardiometabolic diseases (CMDs) increased dementia risk associated with TBI at age 50 to 69 years. The ORs in GEE and conditional logistic regression did not differ significantly (P = .37). DISCUSSION TBI, especially between ages 50 and 69 years, is associated with an increased risk of dementia, and this is exacerbated among people with CMDs. Genetic and early-life environmental factors may not account for the TBI-dementia association.
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Affiliation(s)
- Lulu Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Tianjin Medical University, Tianjin, China.,Tianjin Key Laboratory of Environment, Nutrition and Public Health, Tianjin, China.,Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, China
| | - Wenzhe Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Tianjin Medical University, Tianjin, China.,Tianjin Key Laboratory of Environment, Nutrition and Public Health, Tianjin, China.,Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, China
| | - Xuerui Li
- Department of Epidemiology and Biostatistics, School of Public Health, Tianjin Medical University, Tianjin, China.,Tianjin Key Laboratory of Environment, Nutrition and Public Health, Tianjin, China.,Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, China
| | - Abigail Dove
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Xiuying Qi
- Department of Epidemiology and Biostatistics, School of Public Health, Tianjin Medical University, Tianjin, China.,Tianjin Key Laboratory of Environment, Nutrition and Public Health, Tianjin, China.,Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, China
| | - Kuan-Yu Pan
- Department of Psychiatry, Amsterdam Public Health, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - Weili Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Tianjin Medical University, Tianjin, China.,Tianjin Key Laboratory of Environment, Nutrition and Public Health, Tianjin, China.,Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, China.,Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
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Fabisiak T, Patel M. Crosstalk between neuroinflammation and oxidative stress in epilepsy. Front Cell Dev Biol 2022; 10:976953. [PMID: 36035987 PMCID: PMC9399352 DOI: 10.3389/fcell.2022.976953] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022] Open
Abstract
The roles of both neuroinflammation and oxidative stress in the pathophysiology of epilepsy have begun to receive considerable attention in recent years. However, these concepts are predominantly studied as separate entities despite the evidence that neuroinflammatory and redox-based signaling cascades have significant crosstalk. Oxidative post-translational modifications have been demonstrated to directly influence the function of key neuroinflammatory mediators. Neuroinflammation can further be controlled on the transcriptional level as the transcriptional regulators NF-KB and nrf2 are activated by reactive oxygen species. Further, neuroinflammation can induce the increased expression and activity of NADPH oxidase, leading to a highly oxidative environment. These factors additionally influence mitochondria function and the metabolic status of neurons and glia, which are already metabolically stressed in epilepsy. Given the implication of this relationship to disease pathology, this review explores the numerous mechanisms by which neuroinflammation and oxidative stress influence one another in the context of epilepsy. We further examine the efficacy of treatments targeting oxidative stress and redox regulation in animal and human epilepsies in the literature that warrant further investigation. Treatment approaches aimed at rectifying oxidative stress and aberrant redox signaling may enable control of neuroinflammation and improve patient outcomes.
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Meilik R, Ben-Assayag H, Meilik A, Berliner S, Zeltser D, Shapira I, Rogowski O, Goldiner I, Shenhar-Tsarfaty S, Wasserman A. Sepsis Related Mortality Associated with an Inflammatory Burst in Patients Admitting to the Department of Internal Medicine with Apparently Normal C-Reactive Protein Concentration. J Clin Med 2022; 11:jcm11113151. [PMID: 35683538 PMCID: PMC9181046 DOI: 10.3390/jcm11113151] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Patients who are admitted to the Department of Internal Medicine with apparently normal C-reactive protein (CRP) concentration impose a special challenge due the assumption that they might not harbor a severe and potentially lethal medical condition. Methods: A retrospective cohort of all patients who were admitted to the Department of Internal Medicine with a CRP concentration of ≤31.9 mg/L and had a second CRP test obtained within the next 24 h. Seven day mortality data were analyzed. Results: Overall, 3504 patients were analyzed with a mean first and second CRP of 8.8 (8.5) and 14.6 (21.6) mg/L, respectively. The seven day mortality increased from 1.8% in the first quartile of the first CRP to 7.5% in the fourth quartile of the first CRP (p < 0.0001) and from 0.6% in the first quartile of the second CRP to 9.5% in the fourth quartile of the second CRP test (p < 0.0001), suggesting a clear relation between the admission CRP and in hospital seven day mortality. Conclusions: An association exists between the quartiles of CRP and 7-day mortality as well as sepsis related cause of death. Furthermore, the CRP values 24 h after hospital admission improved the discrimination.
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Affiliation(s)
- Ronnie Meilik
- Department of Internal Medicine “C”, “D”, & “E”, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel; (R.M.); (H.B.-A.); (S.B.); (D.Z.); (I.S.); (O.R.); (A.W.)
| | - Hadas Ben-Assayag
- Department of Internal Medicine “C”, “D”, & “E”, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel; (R.M.); (H.B.-A.); (S.B.); (D.Z.); (I.S.); (O.R.); (A.W.)
| | - Ahuva Meilik
- Clinical Performances Research and Operational Unit, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel;
| | - Shlomo Berliner
- Department of Internal Medicine “C”, “D”, & “E”, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel; (R.M.); (H.B.-A.); (S.B.); (D.Z.); (I.S.); (O.R.); (A.W.)
| | - David Zeltser
- Department of Internal Medicine “C”, “D”, & “E”, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel; (R.M.); (H.B.-A.); (S.B.); (D.Z.); (I.S.); (O.R.); (A.W.)
| | - Itzhak Shapira
- Department of Internal Medicine “C”, “D”, & “E”, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel; (R.M.); (H.B.-A.); (S.B.); (D.Z.); (I.S.); (O.R.); (A.W.)
| | - Ori Rogowski
- Department of Internal Medicine “C”, “D”, & “E”, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel; (R.M.); (H.B.-A.); (S.B.); (D.Z.); (I.S.); (O.R.); (A.W.)
| | - Ilana Goldiner
- Laboratory Medicine, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel;
| | - Shani Shenhar-Tsarfaty
- Department of Internal Medicine “C”, “D”, & “E”, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel; (R.M.); (H.B.-A.); (S.B.); (D.Z.); (I.S.); (O.R.); (A.W.)
- Correspondence:
| | - Asaf Wasserman
- Department of Internal Medicine “C”, “D”, & “E”, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel; (R.M.); (H.B.-A.); (S.B.); (D.Z.); (I.S.); (O.R.); (A.W.)
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11
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Axonal injury is detected by βAPP immunohistochemistry in rapid death from head injury following road traffic collision. Int J Legal Med 2022; 136:1321-1339. [PMID: 35488928 PMCID: PMC9375765 DOI: 10.1007/s00414-022-02807-z] [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: 11/03/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022]
Abstract
The accumulation of βAPP caused by axonal injury is an active energy-dependent process thought to require blood circulation; therefore, it is closely related to the post-injury survival time. Currently, the earliest reported time at which axonal injury can be detected in post-mortem traumatic brain injury (TBI) tissue by βAPP (Beta Amyloid Precursor Protein) immunohistochemistry is 35 min. The aim of this study is to investigate whether βAPP staining for axonal injury can be detected in patients who died rapidly after TBI in road traffic collision (RTC), in a period of less than 30 min. We retrospectively studied thirty-seven patients (group 1) died very rapidly at the scene; evidenced by forensic assessment of injuries short survival, four patients died after a survival period of between 31 min and 12 h (group 2) and eight patients between 2 and 31 days (group 3). The brains were comprehensively examined and sampled at the time of the autopsy, and βAPP immunohistochemistry carried out on sections from a number of brain areas. βAPP immunoreactivity was demonstrated in 35/37 brains in group 1, albeit with a low frequency and in a variable pattern, and with more intensity and frequency in all brains of group 2 and 7/8 brains from group 3, compared with no similar βAPP immunoreactivity in the control group. The results suggest axonal injury can be detected in those who died rapidly after RTC in a period of less than 30 min, which can help in the diagnosis of severe TBI with short survival time.
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12
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Zhao P, Zhu P, Zhang D, Yin B, Wang Y, Hussein NM, Yan Z, Liu X, Bai G. Sex Differences in Cerebral Blood Flow and Serum Inflammatory Cytokines and Their Relationships in Mild Traumatic Brain Injury. Front Neurol 2022; 12:755152. [PMID: 35153973 PMCID: PMC8825420 DOI: 10.3389/fneur.2021.755152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
This study aimed to investigate sex differences in cerebral blood flow (CBF) and serum inflammatory cytokines, as well as their correlations in patients with acute-stage mild traumatic brain injury (mTBI). Forty-one patients with mTBI and 23 matched healthy controls underwent 3D-pseudo-continuous arterial spin labeling imaging on 3T magnetic resonance imaging. The patients underwent cognitive evaluations and measurement of a panel of ten serum cytokines: interleukin (IL)-1I, IL-4, IL-6, IL-8, IL-10, IL-12, C–C motif chemokine ligand 2, interferon-gamma, nerve growth factor-beta (β-NGF), and tumor necrosis factor-alpha (TNF-α). Spearman rank correlation analysis was performed to evaluate the relationship between inflammation levels and CBF. We found that both male and female patients showed increased IL-1L and IL-6 levels. Female patients also demonstrated overexpression of IL-8 and low expression of IL-4. As for CBF levels, three brain regions [the right superior frontal gyrus (SFG_R), left putamen, and right precuneus] increased in male patients while three brain regions [the right superior temporal gyrus (STG_R), left middle occipital gyrus, and right postcentral (PoCG_R)] decreased in female patients. Furthermore, the STG_R in female controls was positively correlated with β-NGF while the right PoCG_R in female patients was negatively correlated with IL-8. In addition, compared with male patients, female patients showed decreased CBF in the right pallidum, which was negatively correlated with IL-8. These findings revealed abnormal expression of serum inflammatory cytokines and CBF levels post-mTBI. Females may be more sensitive to inflammatory and CBF changes and thus more likely to get cognitive impairment. This may suggest the need to pay closer attention to the female mTBI group.
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Affiliation(s)
- Pinghui Zhao
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Pingyi Zhu
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Danbin Zhang
- Department of Radiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bo Yin
- Department of Neurosurgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yu Wang
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Nimo Mohamed Hussein
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhihan Yan
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaozheng Liu
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
- China-USA Neuroimaging Research Institute, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
- Xiaozheng Liu
| | - Guanghui Bai
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
- Wenzhou Key Laboratory of Basic Science and Translational Research of Radiation Oncology, Wenzhou, China
- *Correspondence: Guanghui Bai
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13
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Wang G, Wu HL, Liu YP, Yan DQ, Yuan ZL, Chen L, Yang Q, Gao YS, Diao B. Pre-clinical study of human umbilical cord mesenchymal stem cell transplantation for the treatment of traumatic brain injury: safety evaluation from immunogenic and oncogenic perspectives. Neural Regen Res 2022; 17:354-361. [PMID: 34269210 PMCID: PMC8463980 DOI: 10.4103/1673-5374.317985] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Stem cell therapy is a promising strategy for the treatment of traumatic brain injury (TBI). However, animal experiments are needed to evaluate safety; in particular, to examine the immunogenicity and tumorigenicity of human umbilical cord mesenchymal stem cells (huMSCs) before clinical application. In this study, huMSCs were harvested from human amniotic membrane and umbilical cord vascular tissue. A rat model of TBI was established using the controlled cortical impact method. Starting from the third day after injury, the rats were injected with 10 μL of 5 × 106/mL huMSCs by cerebral stereotaxis or with 500 μL of 1 × 106/mL huMSCs via the tail vein for 3 successive days. huMSC transplantation decreased the serum levels of proinflammatory cytokines in rats with TBI and increased the serum levels of anti-inflammatory cytokines, thereby exhibiting good immunoregulatory function. The transplanted huMSCs were distributed in the liver, lung and brain injury sites. No abnormal proliferation or tumorigenesis was found in these organs up to 12 months after transplantation. The transplanted huMSCs negligibly proliferated in vivo, and apoptosis was gradually observed at later stages. These findings suggest that huMSC transplantation for the treatment of traumatic brain injury displays good safety. In addition, huMSCs exhibit good immunoregulatory function, which can help prevent and reduce secondary brain injury caused by the rapid release of inflammatory factors after TBI. This study was approved by the Ethics Committee of Wuhan General Hospital of PLA (approval No. 20160054) on November 1, 2016.
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Affiliation(s)
- Gang Wang
- Basic Medical Laboratory, General Hospital of the Central Theater Command; Hubei Key Laboratory of Central Nervous System Tumor and Intervention, Wuhan, Hubei Province, China
| | - Hua-Ling Wu
- Department of Clinical Laboratory, The Third People's Hospital of Yongzhou, Yongzhou, Hunan Province, China
| | - Yue-Ping Liu
- Basic Medical Laboratory, General Hospital of the Central Theater Command; Hubei Key Laboratory of Central Nervous System Tumor and Intervention, Wuhan, Hubei Province, China
| | - De-Qi Yan
- Department of Neurosurgery, 990th Hospital of Joint Logistic Support Troops of PLA, Zhumadian, Henan Province, China
| | - Zi-Lin Yuan
- Basic Medical Laboratory, General Hospital of the Central Theater Command; Hubei Key Laboratory of Central Nervous System Tumor and Intervention, Wuhan, Hubei Province, China
| | - Li Chen
- Basic Medical Laboratory, General Hospital of the Central Theater Command; Hubei Key Laboratory of Central Nervous System Tumor and Intervention, Wuhan, Hubei Province, China
| | - Qian Yang
- Basic Medical Laboratory, General Hospital of the Central Theater Command; Hubei Key Laboratory of Central Nervous System Tumor and Intervention, Wuhan, Hubei Province, China
| | - Yu-Song Gao
- Department of Neurosurgery, 990th Hospital of Joint Logistic Support Troops of PLA, Zhumadian, Henan Province, China
| | - Bo Diao
- Basic Medical Laboratory, General Hospital of the Central Theater Command; Hubei Key Laboratory of Central Nervous System Tumor and Intervention, Wuhan, Hubei Province, China
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14
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Chen Y, Tian J, Chi B, Zhang S, Wei L, Wang S. Factors Associated with the Development of Coagulopathy after Open Traumatic Brain Injury. J Clin Med 2021; 11:jcm11010185. [PMID: 35011926 PMCID: PMC8745860 DOI: 10.3390/jcm11010185] [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: 11/18/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 11/25/2022] Open
Abstract
Background: The incidence of coagulopathy after open traumatic brain injury (TBI) is high. Coagulopathy can aggravate intracranial hemorrhage and further increase morbidity and mortality. The purpose of this study was to determine the clinical characteristics of coagulopathy after open TBI and its relationship with the prognosis. Methods: This study retrospectively evaluated patients with isolated open TBI from December 2018 to December 2020. Coagulopathy was defined as international normalized ratio (INR) > 1.2, activated thromboplastin time (APTT) > 35 s, or platelet count <100,000/μL. We compared the relationship between the clinical, radiological, and laboratory parameters of patients with and without coagulopathy, and the outcome at discharge. Logistic regression analysis was used to evaluate the risk factors associated with coagulopathy. We then compared the effects of treatment with and without TXA in open TBI patients with coagulopathy. Results: A total of 132 patients were included in the study; 46 patients developed coagulopathy. Patients with coagulopathy had significantly lower platelet levels (170.5 × 109/L vs. 216.5 × 109/L, p < 0.001), and significantly higher INR (1.14 vs. 1.02, p < 0.001) and APTT (30.5 s vs. 24.5 s, p < 0.001) compared to those with no coagulopathy. A Low Glasgow Coma Scale (GCS) score, high neutrophil/lymphocyte ratio (NLR), low platelet/lymphocyte ratio (PLR), and hyperglycemia at admission were significantly associated with the occurrence of coagulopathy. Conclusions: Coagulopathy often occurs after open TBI. Patients with a low GCS score, high NLR, low PLR, and hyperglycemia at admission are at greater risk of coagulopathy, and therefore of poor prognosis. The efficacy of TXA in open TBI patients with coagulopathy is unclear. In addition, these findings demonstrate that PLR may be a novel indicator for predicting coagulopathy.
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15
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Siwicka-Gieroba D, Dabrowski W. Credibility of the Neutrophil-to-Lymphocyte Count Ratio in Severe Traumatic Brain Injury. Life (Basel) 2021; 11:life11121352. [PMID: 34947883 PMCID: PMC8706648 DOI: 10.3390/life11121352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 02/07/2023] Open
Abstract
Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality worldwide. The consequences of a TBI generate the activation and accumulation of inflammatory cells. The peak number of neutrophils entering into an injured brain is observed after 24 h; however, cells infiltrate within 5 min of closed brain injury. Neutrophils release toxic molecules including free radicals, proinflammatory cytokines, and proteases that advance secondary damage. Regulatory T cells impair T cell infiltration into the central nervous system and elevate reactive astrogliosis and interferon-γ gene expression, probably inducing the process of healing. Therefore, the neutrophil-to-lymphocyte ratio (NLR) may be a low-cost, objective, and available predictor of inflammation as well as a marker of secondary injury associated with neutrophil activation. Recent studies have documented that an NLR value on admission might be effective for predicting outcome and mortality in severe brain injury patients.
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16
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Chen C, Hu N, Wang J, Xu L, Jia XL, Fan X, Shi JX, Chen F, Tu Y, Wang YW, Li XH. Umbilical cord mesenchymal stem cells promote neurological repair after traumatic brain injury through regulating Treg/Th17 balance. Brain Res 2021; 1775:147711. [PMID: 34793756 DOI: 10.1016/j.brainres.2021.147711] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 10/18/2021] [Accepted: 11/03/2021] [Indexed: 12/11/2022]
Abstract
Traumatic brain injury (TBI) is a brain injury resulting from blunt mechanical external forces, which is a crucial public health and socioeconomic problem worldwide. TBI is one of the leading causes of death or disability. The primary injury of TBI is generally irreversible. Secondary injury caused by neuroinflammation could result in exacerbation of patients, which indicated that anti-inflammation and immunomodulatory were necessary for the treatment of TBI. Accumulated evidence reveals that the transplantation of umbilical cord mesenchymal stem cells (UCMSCs) could regulate the microenvironment in vivo and keep a balance of helper T 17(Th17)/ regulatory T cell (Treg). Therefore, it is reasonable to hypothesize that the UCMSCs could repair neurological impairment by maintaining the balance of Th17/Treg after TBI. In the study, we observed the phenomenon of trans-differentiation of T lymphocytes into Th17 cells after TBI. Rats were divided into Sham, TBI, and TBI + UCMSCs groups to explore the effects of the UCMSCs. The results manifested that trans-differentiation of Th17 into Treg was facilitated by UCMSCs, which was followed by promotion of neurological recovery and improvement of learning and memory in TBI rats. Furthermore, UCMSCs decreased the phosphorylation of nuclear factor-kappa B (NF-κB) and increased the expression of mothers against decapentaplegic homolog 3 (Smad3) in vivo and vitro experiments. In conclusion, UCMSCs maintained Th17/Treg balance via the transforming growth factor-β (TGF-β)/ Smad3/ NF-κB signaling pathway.
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Affiliation(s)
- Chong Chen
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China; Tianjin Key Laboratory of Brain Science and Neural Engineering, Tianjin University, Tianjin 300072, China; Tianjin Key Laboratory of Neurotrauma Repair, Pingjin Hospital Brain Center, Characteristic Medical Center of PAPF, Tianjin 300162, China
| | - Nan Hu
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China; Tianjin Key Laboratory of Brain Science and Neural Engineering, Tianjin University, Tianjin 300072, China
| | - Jing Wang
- Tianjin Key Laboratory of Neurotrauma Repair, Pingjin Hospital Brain Center, Characteristic Medical Center of PAPF, Tianjin 300162, China; Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan 030032, China
| | - Lin Xu
- Medical Psychology Section, Hubei General Hospital of Armed Police Force, Wuhan 430071, China
| | - Xiao-Li Jia
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China; Tianjin Key Laboratory of Brain Science and Neural Engineering, Tianjin University, Tianjin 300072, China
| | - Xiu Fan
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China; Tianjin Key Laboratory of Brain Science and Neural Engineering, Tianjin University, Tianjin 300072, China
| | - Jian-Xin Shi
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China; Tianjin Key Laboratory of Brain Science and Neural Engineering, Tianjin University, Tianjin 300072, China
| | - Feng Chen
- Tianjin Key Laboratory of Neurotrauma Repair, Pingjin Hospital Brain Center, Characteristic Medical Center of PAPF, Tianjin 300162, China
| | - Yue Tu
- Tianjin Key Laboratory of Neurotrauma Repair, Pingjin Hospital Brain Center, Characteristic Medical Center of PAPF, Tianjin 300162, China
| | - You-Wei Wang
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China; Tianjin Key Laboratory of Brain Science and Neural Engineering, Tianjin University, Tianjin 300072, China.
| | - Xiao-Hong Li
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin 300072, China; Tianjin Key Laboratory of Brain Science and Neural Engineering, Tianjin University, Tianjin 300072, China.
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17
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Zeiler FA, Iturria-Medina Y, Thelin EP, Gomez A, Shankar JJ, Ko JH, Figley CR, Wright GEB, Anderson CM. Integrative Neuroinformatics for Precision Prognostication and Personalized Therapeutics in Moderate and Severe Traumatic Brain Injury. Front Neurol 2021; 12:729184. [PMID: 34557154 PMCID: PMC8452858 DOI: 10.3389/fneur.2021.729184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/09/2021] [Indexed: 01/13/2023] Open
Abstract
Despite changes in guideline-based management of moderate/severe traumatic brain injury (TBI) over the preceding decades, little impact on mortality and morbidity have been seen. This argues against the “one-treatment fits all” approach to such management strategies. With this, some preliminary advances in the area of personalized medicine in TBI care have displayed promising results. However, to continue transitioning toward individually-tailored care, we require integration of complex “-omics” data sets. The past few decades have seen dramatic increases in the volume of complex multi-modal data in moderate and severe TBI care. Such data includes serial high-fidelity multi-modal characterization of the cerebral physiome, serum/cerebrospinal fluid proteomics, admission genetic profiles, and serial advanced neuroimaging modalities. Integrating these complex and serially obtained data sets, with patient baseline demographics, treatment information and clinical outcomes over time, can be a daunting task for the treating clinician. Within this review, we highlight the current status of such multi-modal omics data sets in moderate/severe TBI, current limitations to the utilization of such data, and a potential path forward through employing integrative neuroinformatic approaches, which are applied in other neuropathologies. Such advances are positioned to facilitate the transition to precision prognostication and inform a top-down approach to the development of personalized therapeutics in moderate/severe TBI.
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Affiliation(s)
- Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.,Centre on Aging, University of Manitoba, Winnipeg, MB, Canada.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Yasser Iturria-Medina
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada.,McConnell Brain Imaging Centre, Montreal Neurological Institute, Montreal, QC, Canada.,Ludmer Centre for Neuroinformatics and Mental Health, Montreal, QC, Canada
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Jai J Shankar
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ji Hyun Ko
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada
| | - Chase R Figley
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada
| | - Galen E B Wright
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada.,Department of Pharmacology and Therapeutics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Chris M Anderson
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada.,Department of Pharmacology and Therapeutics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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19
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Zou J, Sun H, Xiang Y. Correlation of serum cystatin C with inflammatory cytokines in patients with traumatic brain injury. Synapse 2021; 75:e22201. [PMID: 33797795 DOI: 10.1002/syn.22201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/19/2021] [Indexed: 11/09/2022]
Abstract
Traumatic brain injury (TBI) is a world-wide leading health problem with high morbidity and mortality rates. Emerging studies have demonstrated that TBI is the consequence of a series of inflammatory responses in the body. The alteration of Cystatin C (Cys C) was reported in a variety of chronic inflammatory diseases and was also recommended as a biomarker for predicting renal diseases. In this study, we aimed to investigate the relationship between serum Cys C and TBI, and to evaluate the prognostic role of Cys C in TBI prediction. One hundred and seventy-six patients with TBI were recruited and 102 patients were finally analyzed, with 30 healthy control subjects. The concentrations of Cys C were significantly reduced in the healthy control group compared to the TBI group, and correlated with high GCS scores. The levels of hsCRP, counts of white blood cells, and levels of IL-6 and TNF-α were remarkably elevated in the TBI patients compared with the control group in a severity-dependent manner. Moreover, the concentration of Cys C was negatively correlated with TBI severity and positively correlated with inflammatory factors. In conclusion, serum Cys is an inflammatory cytokine-related factor and might indicate the severity of TBI thus serving as a prognostic biomarker.
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Affiliation(s)
- Jingrong Zou
- Department of Emergency, Wuxi Huishan District People's Hospital, Wuxi, China
| | - Haitao Sun
- Department of Emergency, Wuxi Huishan District People's Hospital, Wuxi, China
| | - Yang Xiang
- Department of Emergency, Wuxi Huishan District People's Hospital, Wuxi, China
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20
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Loxton NW, Rohlwink UK, Tshavhungwe M, Dlamini L, Shey M, Enslin N, Figaji A. A pilot study of inflammatory mediators in brain extracellular fluid in paediatric TBM. PLoS One 2021; 16:e0246997. [PMID: 33711020 PMCID: PMC7954352 DOI: 10.1371/journal.pone.0246997] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/30/2021] [Indexed: 12/15/2022] Open
Abstract
Tuberculous meningitis (TBM) is the most fatal form of tuberculosis and frequently occurs in children. The inflammatory process initiates secondary brain injury processes that lead to death and disability. Much remains unknown about this cerebral inflammatory process, largely because of the difficulty in studying the brain. To date, studies have typically examined samples from sites distal to the site of disease, such as spinal cerebrospinal fluid (CSF) and blood. In this pilot study, we examined the feasibility of using direct brain microdialysis (MD) to detect inflammatory mediators in brain extracellular fluid (ECF) in TBM. MD was used to help guide neurocritical care in 7 comatose children with TBM by monitoring brain chemistry for up to 4 days. Remnant ECF fluid was stored for offline analysis. Samples of ventricular CSF, lumbar CSF and blood were collected at clinically indicated procedures for comparison. Inflammatory mediators were quantified using multiplex technology. All inflammatory markers, with the exception of interleukin (IL)-10 and IL-12p40, were detected in the ECF. Cytokine concentrations were generally lower in ECF than ventricular CSF in time-linked specimens. Individual cases showed ECF cytokine increases coinciding with marked increases in ECF glycerol or decreases in ECF glucose. Cytokine levels and glycerol were generally higher in patients with more severe disease. This is the first report of inflammatory marker analysis from samples derived directly from the brain and in high temporal resolution, demonstrating feasibility of cerebral MD to explore disease progression and possibly therapy response in TBM.
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Affiliation(s)
- Nicholas W. Loxton
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Ursula K. Rohlwink
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
| | - Mvuwo Tshavhungwe
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Lindizwe Dlamini
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Muki Shey
- Wellcome Centre for Infectious Disease Research in Africa, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nico Enslin
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Anthony Figaji
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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21
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Hou Q, Chen H, Liu Q, Yan X. FGF10 Attenuates Experimental Traumatic Brain Injury through TLR4/MyD88/NF-κB Pathway. Cells Tissues Organs 2021; 209:248-256. [PMID: 33440393 DOI: 10.1159/000511381] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/27/2020] [Indexed: 11/19/2022] Open
Abstract
Traumatic brain injury (TBI) can induce neuronal apoptosis and neuroinflammation, resulting in substantial neuronal damage and behavioral disorders. Fibroblast growth factors (FGFs) have been shown to be critical mediators in tissue repair. However, the role of FGF10 in experimental TBI remains unknown. In this study, mice with TBI were established via weight-loss model and validated by increase of modified neurological severity scores (mNSS) and brain water content. Secondly, FGF10 levels were elevated in mice after TBI, whereas intraventricular injection of Ad-FGF10 decreased mNSS score and brain water content, indicating the remittance of neurological deficit and cerebral edema in TBI mice. In addition, neuronal damage could also be ameliorated by stereotactic injection of Ad-FGF10. Overexpression of FGF10 increased protein expression of Bcl-2, while it decreased Bax and cleaved caspase-3/PARP, and improved neuronal apoptosis in TBI mice. In addition, Ad-FGF10 relieved neuroinflammation induced by TBI and significantly reduced the level of interleukin 1β/6, tumor necrosis factor α, and monocyte chemoattractant protein-1. Moreover, Ad-FGF10 injection decreased the protein expression level of Toll-like receptor 4 (TLR4), MyD88, and phosphorylation of NF-κB (p-NF-κB), suggesting the inactivation of the TLR4/MyD88/NF-κB pathway. In conclusion, overexpression of FGF10 could ameliorate neurological deficit, neuronal apoptosis, and neuroinflammation through inhibition of the TLR4/MyD88/NF-κB pathway, providing a potential therapeutic strategy for brain injury in the future.
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Affiliation(s)
- Qinhan Hou
- Department of Neurosurgery, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou City, China
| | - Hongmou Chen
- Department of Neurosurgery, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou City, China,
| | - Quan Liu
- Department of Neurosurgery, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou City, China
| | - Xianlei Yan
- Department of Neurosurgery, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou City, China
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22
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Abstract
Traumatic brain injury leads to cellular damage which in turn results in the rapid release of damage-associated molecular patterns (DAMPs) that prompt resident cells to release cytokines and chemokines. These in turn rapidly recruit neutrophils, which assist in limiting the spread of injury and removing cellular debris. Microglia continuously survey the CNS (central nervous system) compartment and identify structural abnormalities in neurons contributing to the response. After some days, when neutrophil numbers start to decline, activated microglia and astrocytes assemble at the injury site—segregating injured tissue from healthy tissue and facilitating restorative processes. Monocytes infiltrate the injury site to produce chemokines that recruit astrocytes which successively extend their processes towards monocytes during the recovery phase. In this fashion, monocytes infiltration serves to help repair the injured brain. Neurons and astrocytes also moderate brain inflammation via downregulation of cytotoxic inflammation. Depending on the severity of the brain injury, T and B cells can also be recruited to the brain pathology sites at later time points.
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23
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Verapamil Inhibits Mitochondria-Induced Reactive Oxygen Species and Dependent Apoptosis Pathways in Cerebral Transient Global Ischemia/Reperfusion. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:5872645. [PMID: 33133347 PMCID: PMC7591985 DOI: 10.1155/2020/5872645] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022]
Abstract
The prefrontal cortex is the largest lobe of the brain and is consequently involved in stroke. There is no comprehensive practical pharmacological strategy for ameliorating prefrontal cortex injury induced by cerebral ischemia. Therefore, we studied the neuroprotective properties of verapamil (Ver) on mitochondrial dysfunction and morphological features of apoptosis in transient global ischemia/reperfusion (I/R). Ninety-six Wistar rats were allocated into four groups: control, I/R, I/R+Ver (10 mg/kg twice 1 hour prior to ischemia and 1 hour after reperfusion phase), and I/R+NaCl (vehicle). Animals were sacrificed, and mitochondrial dysfunction parameters (i.e., mitochondrial swelling, mitochondrial membrane potential, ATP concentration, ROS production, and cytochrome c release), antioxidant defense (i.e., superoxide dismutase, malondialdehyde, glutathione peroxidase, catalase, and caspase-3 activation), and morphological features of apoptosis were determined. The results showed that mitochondrial damage, impairment of antioxidant defense system, and apoptosis were significantly more prevalent in the I/R group in comparison with the other groups. Ver decreased mitochondrial damage by reducing oxidative stress, augmented the activity of antioxidant enzymes in the brain, and decreased apoptosis in the I/R neurons. The current study confirmed the role of oxidative stress and mitochondrial dysfunction in I/R progression and indicated the possible antioxidative mechanism of the neuroprotective activities of Ver.
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24
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Sun GU, Park E, Kim DW, Kang SD. Dual antiplatelet treatment associated with reduced risk of symptomatic vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. J Cerebrovasc Endovasc Neurosurg 2020; 22:134-140. [PMID: 32971572 PMCID: PMC7522390 DOI: 10.7461/jcen.2020.22.3.134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/08/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Cerebral vasospasm and delayed cerebral ischemia (DCI) are considered complications after aneurysmal subarachnoid hemorrhage (aSAH). Several hypotheses involving platelet activation have been asserted in the pathophysiology of cerebral vasospasm and DCI. This study aimed to investigate the effect of dual antiplatelet treatment (DAPT) on symptomatic vasospasm and DCI in patients with aSAH. METHODS A retrospective study was conducted on patients with aSAH from 2009 to 2018. The patients are divided into 2 groups according to the treatment method such as simple or balloon-assisted coil embolization group (SB coiling), and stent-assisted coil embolization group. Patients treated by SB coiling without DAPT were classified as the control group. Patients who required dual antiplatelet treatment due to stent-assisted coil embolization were classified as DAPT group. The incidence of symptomatic vasospasm and DCI was compared between the two groups. RESULTS Of 743 patients with aSAH, 563 patients were treated with clipping, 115 patients treated with SB coiling, and 65 patients receive stent-assisted coiling. Among 115 patients underwent SB coiling, 14 patients were excluded by the exclusion criteria. Total number of control group (SB coiling) was 101, DAPT group (stent-assisted coiling) was 65. Depending on whether or not taking DAPT, the incidence of symptomatic vasospasm was lower in the DAPT group (p=0.010). DCI incidence was also lower in the DAPT group, which was statistically significant (p=0.029). CONCLUSIONS DAPT reduces the frequency of symptomatic vasospasm and DCI in patients with aSAH in our single-center study. To warranting this topic, further, larger prospective and randomized studies should be needed.
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Affiliation(s)
- Gyeong-Ung Sun
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
| | - Eunsung Park
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
| | - Sung-Don Kang
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
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25
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Cantu D, Croker D, Shacham S, Tamir S, Dulla C. In vivo KPT-350 treatment decreases cortical hyperexcitability following traumatic brain injury. Brain Inj 2020; 34:1489-1496. [PMID: 32853051 DOI: 10.1080/02699052.2020.1807056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PRIMARY OBJECTIVE We tested whether KPT-350, a novel selective inhibitor of nuclear export, could attenuate cortical network hyperexcitability, a major risk factor for developing post-traumatic epilepsy (PTE) following traumatic brain injury (TBI). RESEARCH DESIGN All mice in this study underwent TBI and were subsequently treated with either KPT-350 or vehicle during the post-injury latent period. Half of the animal cohort was used for electrophysiology while the other half was used for immunohistochemical analysis. METHODS AND PROCEDURES TBI was induced using the controlled cortical impact (CCI) model. Cortical network activity was recorded by evoking field potentials from deep layers of the cortex and analyzed using Matlab software. Immunohistochemistry coupled with fluorescence microscopy and Image J analysis detected changes in neuronal and glial markers. MAIN OUTCOMES AND RESULTS KPT-350 attenuated TBI-associated epileptiform activity and restored disrupted input-output responses in cortical brain slices. In vivo KPT-350 treatment reduced the loss of parvalbumin-(+) GABAergic interneurons after CCI but did not significantly change CCI-induced loss of somatostatin-(+) GABAergic interneurons, nor did it reduce reactivity of GFAP and Iba1 glial markers. CONCLUSION KPT-350 can prevent cortical hyperexcitability and reduce the loss of parvalbumin-(+) GABAergic inhibitory neurons, making it a potential therapeutic option for preventing PTE.
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Affiliation(s)
- David Cantu
- Department of Neuroscience, Tufts University School of Medicine , Boston, MA, USA
| | - Danielle Croker
- Department of Neuroscience, Tufts University School of Medicine , Boston, MA, USA
| | | | | | - Chris Dulla
- Department of Neuroscience, Tufts University School of Medicine , Boston, MA, USA
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26
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Validation of reference genes for expression analysis in a murine trauma model combining traumatic brain injury and femoral fracture. Sci Rep 2020; 10:15057. [PMID: 32929099 PMCID: PMC7490670 DOI: 10.1038/s41598-020-71895-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023] Open
Abstract
Systemic and local posttraumatic responses are often monitored on mRNA expression level using quantitative real-time PCR (qRT-PCR), which requires normalisation to adjust for confounding sources of variability. Normalisation requests reference (housekeeping) genes stable throughout time and divergent experimental conditions in the tissue of interest, which are crucial for a reliable and reproducible gene expression analysis. Although previous animal studies analysed reference genes following isolated trauma, this multiple-trauma gene expression analysis provides a notable study analysing reference genes in primarily affected (i.e. bone/fracture callus and hypothalamus) and secondarily affected organs (i.e. white adipose tissue, liver, muscle and spleen), following experimental long bone fracture and traumatic brain injury. We considered tissue-specific and commonly used top-ranked reference candidates from different functional groups that were evaluated applying the established expression stability analysis tools NormFinder, GeNorm, BestKeeper and RefFinder. In conclusion, reference gene expression in primary organs is highly time point as well as tissue-specific, and therefore requires careful evaluation for qRT-PCR analysis. Furthermore, the general application of Ppia, particularly in combination with a second reference gene, is strongly recommended for the analysis of systemic effects in the case of indirect trauma affecting secondary organs through local and systemic pathophysiological responses.
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27
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Zhao JL, Lai ST, Du ZY, Xu J, Sun YR, Yuan Q, Wu X, Li ZQ, Hu J, Xie R. Circulating neutrophil-to-lymphocyte ratio at admission predicts the long-term outcome in acute traumatic cervical spinal cord injury patients. BMC Musculoskelet Disord 2020; 21:548. [PMID: 32799840 PMCID: PMC7429795 DOI: 10.1186/s12891-020-03556-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 08/03/2020] [Indexed: 01/11/2023] Open
Abstract
Background The prognostic value of Neutrophil-to-Lymphocyte Ratio (NLR) for the outcome of acute cervical traumatic spinal cord injury (tSCI) patients has rarely been studied by now throughout the world. Methods We performed a single-center retrospective cohort study to evaluate the prognostic value of NLR from peripheral whole blood count in patients with acute cervical tSCI. Patients within 6 h of acute cervical tSCI treated between Dec 2008 and May 2018 in Huashan Hospital of Fudan University were enrolled. Outcomes of patients with tSCI were assessed using American spinal injury association Impairment Scale (AIS). 6-month outcomes were dichotomized into poor outcome group (AIS A to C) and good outcome group (AIS D and E). Uni- and multivariate analyses were performed to assess the independent predictors of 6-month outcome. Two prediction models based on admission characteristics were built to evaluate the prognostic value of NLR. The discriminative ability of predictive models was evaluated using the area under the curve (AUC). Results A total of 377 patients were identified from our single center in China PR. Multivariate analysis showed that age, AIS grade at admission, NLR (p < 0.001) and coagulopathy (p = 0.003) were independent predictors of the 6-months outcome for acute cervical tSCI patients. The model combing NLR and standard variables (AUC = 0.944; 95% CI, 0.923–0.964) showed a more favorable prognostic value than that without NLR (AUC = 0.841; 95% CI, 0.798–0.885) in terms of 6-month outcome. Conclusions NLR is firstly identified as an independent predictor of the 6-month outcome in acute cervical tSCI patients worldwide. The prognostic value of NLR is favorable, and a high NLR is associated with poor outcome in patients with acute cervical tSCI.
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Affiliation(s)
- Jian-Lan Zhao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Song-Tao Lai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Zhuo-Ying Du
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Jian Xu
- Department of General Surgery, the Seventh Affiliated Hospital, SUN Yat-sen University, Shenzhen, 518000, China
| | - Yi-Rui Sun
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Zhi-Qi Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.
| | - Rong Xie
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Neurosurgical Institute of Fudan University, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Shanghai Clinical Medical Center of Neurosurgery, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China. .,Shanghai Key laboratory of Brain Function and Restoration and Neural Regeneration, 12 Wulumuqi Road (M), Shanghai, 200040, P.R. China.
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28
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Eastman CL, D'Ambrosio R, Ganesh T. Modulating neuroinflammation and oxidative stress to prevent epilepsy and improve outcomes after traumatic brain injury. Neuropharmacology 2020; 172:107907. [PMID: 31837825 PMCID: PMC7274911 DOI: 10.1016/j.neuropharm.2019.107907] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/26/2019] [Accepted: 12/05/2019] [Indexed: 12/14/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability in young adults worldwide. TBI survival is associated with persistent neuropsychiatric and neurological impairments, including posttraumatic epilepsy (PTE). To date, no pharmaceutical treatment has been found to prevent PTE or ameliorate neurological/neuropsychiatric deficits after TBI. Brain trauma results in immediate mechanical damage to brain cells and blood vessels that may never be fully restored given the limited regenerative capacity of brain tissue. This primary insult unleashes cascades of events, prominently including neuroinflammation and massive oxidative stress that evolve over time, expanding the brain injury, but also clearing cellular debris and establishing homeostasis in the region of damage. Accumulating evidence suggests that oxidative stress and neuroinflammatory sequelae of TBI contribute to posttraumatic epileptogenesis. This review will focus on possible roles of reactive oxygen species (ROS), their interactions with neuroinflammation in posttraumatic epileptogenesis, and emerging therapeutic strategies after TBI. We propose that inhibitors of the professional ROS-generating enzymes, the NADPH oxygenases and myeloperoxidase alone, or combined with selective inhibition of cyclooxygenase mediated signaling may have promise for the treatment or prevention of PTE and other sequelae of TBI. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.
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Affiliation(s)
- Clifford L Eastman
- Department of Neurological Surgery, 325 Ninth Ave., Seattle, WA, 98104, USA.
| | - Raimondo D'Ambrosio
- Department of Neurological Surgery, 325 Ninth Ave., Seattle, WA, 98104, USA; Regional Epilepsy Center, University of Washington, 325 Ninth Ave., Seattle, WA, 98104, USA
| | - Thota Ganesh
- Department of Pharmacology and Chemical Biology, Emory University School of Medicine, 1510 Clifton Rd, Atlanta, GA, 30322, Georgia.
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29
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Diaz MF, Horton PD, Kumar A, Livingston M, Mohammadalipour A, Xue H, Skibber MA, Ewere A, Toledano Furman NE, Aroom KR, Zhang S, Gill BS, Cox CS, Wenzel PL. Injury intensifies T cell mediated graft-versus-host disease in a humanized model of traumatic brain injury. Sci Rep 2020; 10:10729. [PMID: 32612177 PMCID: PMC7330041 DOI: 10.1038/s41598-020-67723-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 06/10/2020] [Indexed: 12/29/2022] Open
Abstract
The immune system plays critical roles in promoting tissue repair during recovery from neurotrauma but is also responsible for unchecked inflammation that causes neuronal cell death, systemic stress, and lethal immunodepression. Understanding the immune response to neurotrauma is an urgent priority, yet current models of traumatic brain injury (TBI) inadequately recapitulate the human immune response. Here, we report the first description of a humanized model of TBI and show that TBI places significant stress on the bone marrow. Hematopoietic cells of the marrow are regionally decimated, with evidence pointing to exacerbation of underlying graft-versus-host disease (GVHD) linked to presence of human T cells in the marrow. Despite complexities of the humanized mouse, marrow aplasia caused by TBI could be alleviated by cell therapy with human bone marrow mesenchymal stromal cells (MSCs). We conclude that MSCs could be used to ameliorate syndromes triggered by hypercytokinemia in settings of secondary inflammatory stimulus that upset marrow homeostasis such as TBI. More broadly, this study highlights the importance of understanding how underlying immune disorders including immunodepression, autoimmunity, and GVHD might be intensified by injury.
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Affiliation(s)
- Miguel F Diaz
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.,Center for Stem Cell and Regenerative Medicine, The Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.,Department of Integrative Biology and Pharmacology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Paulina D Horton
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.,Center for Stem Cell and Regenerative Medicine, The Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.,Department of Integrative Biology and Pharmacology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Akshita Kumar
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Megan Livingston
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.,Center for Stem Cell and Regenerative Medicine, The Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.,Department of Integrative Biology and Pharmacology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Amina Mohammadalipour
- Department of Integrative Biology and Pharmacology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Hasen Xue
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Max A Skibber
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.,Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Adesuwa Ewere
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.,Center for Stem Cell and Regenerative Medicine, The Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.,School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Naama E Toledano Furman
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Kevin R Aroom
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Songlin Zhang
- Department of Pathology and Laboratory Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Brijesh S Gill
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Charles S Cox
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.,Center for Stem Cell and Regenerative Medicine, The Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Pamela L Wenzel
- Children's Regenerative Medicine Program, Department of Pediatric Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA. .,Center for Stem Cell and Regenerative Medicine, The Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA. .,Department of Integrative Biology and Pharmacology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.
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30
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Edwards KA, Pattinson CL, Guedes VA, Peyer J, Moore C, Davis T, Devoto C, Turtzo LC, Latour L, Gill JM. Inflammatory Cytokines Associate With Neuroimaging After Acute Mild Traumatic Brain Injury. Front Neurol 2020; 11:348. [PMID: 32508732 PMCID: PMC7248260 DOI: 10.3389/fneur.2020.00348] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/08/2020] [Indexed: 01/03/2023] Open
Abstract
Introduction: Elevated levels of blood-based proinflammatory cytokines are linked to acute moderate to severe traumatic brain injuries (TBIs), yet less is known in acute mild (m)TBI cohorts. The current study examined whether blood-based cytokines can differentiate patients with mTBI, with and without neuroimaging findings (CT and MRI). Material and Methods: Within 24 h of a mTBI, determined by a Glasgow Coma Scale (GCS) between 13 and 15, participants (n = 250) underwent a computed tomography (CT) and magnetic resonance imaging (MRI) scan and provided a blood sample. Participants were classified into three groups according to imaging findings; (1) CT+, (2) MRI+ (CT–), (3) Controls (CT– MRI–). Plasma levels of circulating cytokines (IL-6, IL-10, TNFα), and vascular endothelial growth factor (VEGF) were measured using an ultra-sensitive immunoassay. Results: Concentrations of inflammatory cytokines (IL-6, TNFα) and VEGF were elevated in CT+, as well as MRI+ groups (p < 0.001), compared to controls, even after controlling for age, sex and cardiovascular disease (CVD)-related risk factors; hypertension, and hyperlipidemia. Post-concussive symptoms were associated with imaging groupings, but not inflammatory cytokines in this cohort. Levels of VEGF, IL-6, and TNFα differentiated patients with CT+ findings from controls, with the combined biomarker model (VEGF, IL-6, TNFα, and IL-10) showing good discriminatory power (AUC 0.92, 95% CI 0.87–0.97). IL-6 was a fair predictor of MRI+ findings compared to controls (AUC 0.70, 95% CI 0.60–0.78). Finally, the combined biomarker model discriminated patients with MRI+ from CT+ with an AUC of 0.71 (95% CI 0.62–0.80). Conclusions: When combined, IL-6, TNFα, and VEGF may provide a promising biomarker cytokine panel to differentiate mTBI patients with CT+ imaging vs. controls. Singularly, IL-6 was a fair discriminator between each of the imaging groups. Future research directions may help elucidate mechanisms related to injury severity and potentially, recovery following an mTBI.
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Affiliation(s)
- Katie A Edwards
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Cassandra L Pattinson
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States
| | - Vivian A Guedes
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States
| | - Jordan Peyer
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States
| | - Candace Moore
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States
| | - Tara Davis
- Center for Neuroscience and Regenerative Medicine, Bethesda, MD, United States.,Johns Hopkins Suburban Hospital, Bethesda, MD, United States
| | - Christina Devoto
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - L Christine Turtzo
- National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Lawrence Latour
- National Institutes of Health, National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Jessica M Gill
- National Institutes of Health, National Institute of Nursing Research, Bethesda, MD, United States.,Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Biomarker Core, Bethesda, MD, United States
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31
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Zeiler FA, Ercole A, Czosnyka M, Smielewski P, Hawryluk G, Hutchinson PJA, Menon DK, Aries M. Continuous cerebrovascular reactivity monitoring in moderate/severe traumatic brain injury: a narrative review of advances in neurocritical care. Br J Anaesth 2020; 124:440-453. [PMID: 31983411 DOI: 10.1016/j.bja.2019.11.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 12/18/2022] Open
Abstract
Impaired cerebrovascular reactivity in adult moderate and severe traumatic brain injury (TBI) is known to be associated with worse global outcome at 6-12 months. As technology has improved over the past decades, monitoring of cerebrovascular reactivity has shifted from intermittent measures, to experimentally validated continuously updating indices at the bedside. Such advances have led to the exploration of individualised physiologic targets in adult TBI management, such as optimal cerebral perfusion pressure (CPP) values, or CPP limits in which vascular reactivity is relatively intact. These targets have been shown to have a stronger association with outcome compared with existing consensus-based guideline thresholds in severe TBI care. This has sparked ongoing prospective trials of such personalised medicine approaches in adult TBI. In this narrative review paper, we focus on the concept of cerebral autoregulation, proposed mechanisms of control and methods of continuous monitoring used in TBI. We highlight multimodal cranial monitoring approaches for continuous cerebrovascular reactivity assessment, physiologic and neuroimaging correlates, and associations with outcome. Finally, we explore the recent 'state-of-the-art' advances in personalised physiologic targets based on continuous cerebrovascular reactivity monitoring, their benefits, and implications for future avenues of research in TBI.
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Affiliation(s)
- Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, Winnipeg, Canada; Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK; Biomedical Engineering, Faculty of Engineering, Winnipeg, Canada; Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Section of Brain Physics, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Section of Brain Physics, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Gregory Hawryluk
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, Winnipeg, Canada
| | - Peter J A Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, the Netherlands
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32
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Kuter KZ, Cenci MA, Carta AR. The role of glia in Parkinson's disease: Emerging concepts and therapeutic applications. PROGRESS IN BRAIN RESEARCH 2020; 252:131-168. [PMID: 32247363 DOI: 10.1016/bs.pbr.2020.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Originally believed to primarily affect neurons, Parkinson's disease (PD) has recently been recognized to also affect the functions and integrity of microglia and astroglia, two cell categories of fundamental importance to brain tissue homeostasis, defense, and repair. Both a loss of glial supportive-defensive functions and a toxic gain of glial functions are implicated in the neurodegenerative process. Moreover, the chronic treatment with L-DOPA may cause maladaptive glial plasticity favoring a development of therapy complications. This chapter focuses on the pathophysiology of PD from a glial point of view, presenting this rapidly growing field from the first discoveries made to the most recent developments. We report and compare histopathological and molecular findings from experimental models of PD and human studies. We moreover discuss the important role played by astrocytes in compensatory adaptations taking place during presymptomatic disease stages. We finally describe examples of potential therapeutic applications stemming from an increased understanding of the important roles of glia in PD.
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Affiliation(s)
- Katarzyna Z Kuter
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, Krakow, Poland.
| | - M Angela Cenci
- Basal Ganglia Pathophysiology Unit, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Anna R Carta
- Department of Biomedical Sciences, University of Cagliari, Cittadella Universitaria di Monserrato, Cagliari, Italy.
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33
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Lu M, Yan XF, Si Y, Chen XZ. CTGF Triggers Rat Astrocyte Activation and Astrocyte-Mediated Inflammatory Response in Culture Conditions. Inflammation 2020; 42:1693-1704. [PMID: 31183597 PMCID: PMC6717176 DOI: 10.1007/s10753-019-01029-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
To improve clinical outcomes for patients with traumatic brain injury (TBI), it is necessary to explore the mechanism of traumatic brain injury (TBI)-induced neuroinflammation. Connective tissue growth factors (CTGF) have been reported to be involved in the process of inflammatory response or tissue repair, whereas whether and how CTGF participates in the astrocyte-mediated inflammation after TBI remains unclear. In the present study, the TBI-induced activation of astrocytes and augmentation of inflammatory response were simulated by stimulating rat astrocytes with TGF-β1 or CTGF in cultured conditions. TGF-β1 and CTGF both upregulated the expression of GFAP in astrocytes and facilitated the production of inflammatory cytokines and chemokines. Activation of astrocytes by CTGF is in an autocrine manner. According to the results of Boyden chamber assay, CTGF enhanced the recruitment of peripheral blood mononuclear cells (PBMCs) by reactive astrocytes. Besides, CTGF-mediated activation of astrocytes and augmentation of inflammatory response can be terminated by the inhibitor of ASK1 or p38 and JNK. Thus, our data suggested that CTGF could activate astrocytes in an autocrine manner and promote astrocyte-mediated inflammatory response by triggering the ASK1-p38/JNK-NF-κB/AP-1 pathways in astrocytes. Collectively, our study provided evidence that astrocyte-secreted CTGF serves as an amplifier of neuroinflammatory and could be a potential target for alleviating TBI-induced inflammation.
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Affiliation(s)
- Ming Lu
- Department of Neurosurgery, The First People's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou, 311200, China
| | - Xiao-Feng Yan
- Department of Neurosurgery, The First People's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou, 311200, China.
| | - Yun Si
- Department of Neurosurgery, The First People's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou, 311200, China
| | - Xin-Zhi Chen
- Department of Neurosurgery, The First People's Hospital of Xiaoshan District of Hangzhou City, 199 Shixin South Road, Xiaoshan District, Hangzhou, 311200, China
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34
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Letter to the Editor: Reduced intraepidermal nerve fiber density after a sustained increase in insular glutamate: a proof-of-concept study examining the pathogenesis of small fiber pathology in fibromyalgia. Pain Rep 2019; 4:e733. [PMID: 31583349 PMCID: PMC6749923 DOI: 10.1097/pr9.0000000000000733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 11/16/2022] Open
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35
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Thelin EP, Hall CE, Tyzack GE, Frostell A, Giorgi-Coll S, Alam A, Carpenter KL, Mitchell J, Tajsic T, Hutchinson PJ, Patani R, Helmy A. Delineating Astrocytic Cytokine Responses in a Human Stem Cell Model of Neural Trauma. J Neurotrauma 2019; 37:93-105. [PMID: 31452443 PMCID: PMC6921298 DOI: 10.1089/neu.2019.6480] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Neuroinflammation has been shown to mediate the pathophysiological response following traumatic brain injury (TBI). Accumulating evidence implicates astrocytes as key immune cells within the central nervous system (CNS), displaying both pro- and anti-inflammatory properties. The aim of this study was to investigate how in vitro human astrocyte cultures respond to cytokines across a concentration range that approximates the aftermath of human TBI. To this end, enriched cultures of human induced pluripotent stem cell (iPSC)-derived astrocytes were exposed to interleukin-1β (IL-1β) (1–10,000 pg/mL), IL-4 (1–10,000 pg/mL), IL-6 (100–1,000,000 pg/mL), IL-10 (1–10,000 pg/mL) and tumor necrosis factor (TNF)-α (1–10,000 pg/mL). After 1, 24, 48 and 72 h, cultures were fixed and immunolabeled, and the secretome/supernatant was analyzed at 24, 48, and 72 h using a human cytokine/chemokine 39-plex Luminex assay. Data were compared to previous in vitro studies of neuronal cultures and clinical TBI studies. The secretome revealed concentration-, time- and/or both concentration- and time-dependent production of downstream cytokines (29, 21, and 17 cytokines, respectively, p<0.05). IL-1β exposure generated the most profound downstream response (27 cytokines), IL-6 and TNF had intermediate responses (13 and 11 cytokines, respectively), whereas IL-4 and IL-10 only led to weak responses over time or in escalating concentration (8 and 8 cytokines, respectively). Notably, expression of IL-1β, IL-6, and TNF cytokine receptor mRNA was higher in astrocyte cultures than in neuronal cultures. Several secreted cytokines had temporal trajectories, which corresponded to those seen in the aftermath of human TBI. In summary, iPSC-derived astrocyte cultures exposed to cytokine concentrations reflecting those in TBI generated an increased downstream cytokine production, particularly IL-1β. Although more work is needed to better understand how different cells in the CNS respond to the neuroinflammatory milieu after TBI, our data shows that iPSC-derived astrocytes represent a tractable model to study cytokine stimulation in a cell type-specific manner.
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Affiliation(s)
- Eric Peter Thelin
- Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Claire E. Hall
- Department of Molecular Neuroscience, Institute of Neurology, University College London, London, United Kingdom
| | - Giulia E. Tyzack
- Department of Molecular Neuroscience, Institute of Neurology, University College London, London, United Kingdom
| | - Arvid Frostell
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Susan Giorgi-Coll
- Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Aftab Alam
- Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Keri L.H. Carpenter
- Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jamie Mitchell
- Department of Molecular Neuroscience, Institute of Neurology, University College London, London, United Kingdom
| | - Tamara Tajsic
- Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Peter J. Hutchinson
- Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Rickie Patani
- Department of Molecular Neuroscience, Institute of Neurology, University College London, London, United Kingdom
- The Francis Crick Institute, London, United Kingdom
- Address correspondence to: Rickie Patani, MD, PhD, Department of Neuromuscular Diseases, UCL Institute of Neurology, Queen Square, London WC1N 3BG, United Kingdom
| | - Adel Helmy
- Division of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
- Adel Helmy, FRCS (SN), PhD, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom
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36
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Trautz F, Franke H, Bohnert S, Hammer N, Müller W, Stassart R, Tse R, Zwirner J, Dreßler J, Ondruschka B. Survival-time dependent increase in neuronal IL-6 and astroglial GFAP expression in fatally injured human brain tissue. Sci Rep 2019; 9:11771. [PMID: 31417126 PMCID: PMC6695416 DOI: 10.1038/s41598-019-48145-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 07/30/2019] [Indexed: 01/31/2023] Open
Abstract
Knowledge on trauma survival time prior to death following a lethal traumatic brain injury (TBI) may be essential for legal purposes. Immunohistochemistry studies might allow to narrow down this survival interval. The biomarkers interleukin-6 (IL-6) and glial fibrillary acidic protein (GFAP) are well known in the clinical setting for their usability in TBI prediction. Here, both proteins were chosen in forensics to determine whether neuronal or glial expression in various brain regions may be associated with the cause of death and the survival time prior to death following TBI. IL-6 positive neurons, glial cells and GFAP positive astrocytes all concordantly increase with longer trauma survival time, with statistically significant changes being evident from three days post-TBI (p < 0.05) in the pericontusional zone, irrespective of its definite cortical localization. IL-6 staining in neurons increases significantly in the cerebellum after trauma, whereas increasing GFAP positivity is also detected in the cortex contralateral to the focal lesion. These systematic chronological changes in biomarkers of pericontusional neurons and glial cells allow for an estimation of trauma survival time. Higher numbers of IL-6 and GFAP-stained cells above threshold values in the pericontusional zone substantiate the existence of fatal traumatic changes in the brain with reasonable certainty.
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Affiliation(s)
- Florian Trautz
- Institute of Legal Medicine, Medical Faculty University of Leipzig, Leipzig, Germany
| | - Heike Franke
- Rudolf Boehm Institute of Pharmacology and Toxicology, Medical Faculty University of Leipzig, Leipzig, Germany
| | - Simone Bohnert
- Institute of Forensic Medicine, University of Würzburg, Würzburg, Germany
| | - Niels Hammer
- Department of Anatomy, University of Otago, Dunedin, New Zealand.,Department of Orthopedic and Trauma Surgery, University Hospital of Leipzig, Leipzig, Germany.,Fraunhofer IWU, Dresden, Germany
| | - Wolf Müller
- Department of Neuropathology, University Hospital of Leipzig, Leipzig, Germany
| | - Ruth Stassart
- Department of Neuropathology, University Hospital of Leipzig, Leipzig, Germany
| | - Rexson Tse
- Department of Forensic Pathology, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | - Johann Zwirner
- Department of Anatomy, University of Otago, Dunedin, New Zealand
| | - Jan Dreßler
- Institute of Legal Medicine, Medical Faculty University of Leipzig, Leipzig, Germany
| | - Benjamin Ondruschka
- Institute of Legal Medicine, Medical Faculty University of Leipzig, Leipzig, Germany.
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37
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Giorgi-Coll S, Thelin EP, Lindblad C, Tajsic T, Carpenter KLH, Hutchinson PJA, Helmy A. Dextran 500 Improves Recovery of Inflammatory Markers: An In Vitro Microdialysis Study. J Neurotrauma 2019; 37:106-114. [PMID: 31298609 PMCID: PMC6921287 DOI: 10.1089/neu.2019.6513] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Cerebral microdialysis (CMD) is used in severe traumatic brain injury (TBI) in order to recover metabolites in brain extracellular fluid (ECF). To recover larger proteins and avoid fluid loss, albumin supplemented perfusion fluid (PF) has been utilized, but because of regulatory changes in the European Union, this is no longer practicable. The aim with this study was to see whether fluid, absolute (AR), and relative (RR) recovery for the novel carrier, Dextran 500, was better than conventional PF for a range of cytokines and chemokines. An in vitro setup mimicking conditions observed in the neurocritical care of TBI patients was used, utilizing 100-kDa molecular-weight cut-off CMD catheters inserted through a triple-lumen bolt cranial access device into an external solution with diluted cytokine standards in known concentrations for 48 h (divided into 6-h epochs). Samples were run on a 39-plex Luminex (Luminex Corporation, Austin, TX) assay to assess cytokine concentrations. We found that fluid recovery was inadequate in 50% of epochs with conventional PF, whereas Dextran PF overcame this limitation. The AR was higher in the Dextran PF samples for a majority of cytokines, and RR was significantly increased for macrophage colony-stimulating factor and transforming growth factor-alpha. In summary, Dextran PF improved fluid and cytokine recovery as compared to conventional PF and is a suitable alternative to albumin supplemented PF for protein microdialysis.
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Affiliation(s)
- Susan Giorgi-Coll
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Eric Peter Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Theme Neuro, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tamara Tajsic
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Keri L H Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter J A Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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38
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The immunological response to traumatic brain injury. J Neuroimmunol 2019; 332:112-125. [DOI: 10.1016/j.jneuroim.2019.04.005] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 12/30/2022]
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39
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Feng N, Jia Y, Huang X. Exosomes from adipose-derived stem cells alleviate neural injury caused by microglia activation via suppressing NF-kB and MAPK pathway. J Neuroimmunol 2019; 334:576996. [PMID: 31260950 DOI: 10.1016/j.jneuroim.2019.576996] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 06/16/2019] [Indexed: 12/16/2022]
Abstract
Activation of microglia cells play critical role in neuroinflammation after brain injury. Exosomes from adipose-derived stem cells (ADSC) possess immunoregulation effect similar with ADSC. We hypothesized that ADSC derived exosomes (ADSC-exosomes) could inhibit the activation of microglia cells and prevent neuroinflammation. We found that ADSC-exosomes could inhibit the activation of microglia cells by suppressing NF-kB and MAPK pathway. Production of inflammatory factors in lipopolysaccharide-stimulated microglia cells decreased significantly when pretreated with ADSC-exosomes. Furthermore, ADSC-exosomes could decrease the cytotoxicity of activated microglia. These results revealed that ADSC-exosomes might be a promising strategy for the therapy of neural injury.
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Affiliation(s)
- Nianhua Feng
- Medical research center, Beijing chaoyang hospital, Capital medical university, Beijing, China.
| | - Yanjun Jia
- Medical research center, Beijing chaoyang hospital, Capital medical university, Beijing, China
| | - Xiaoxi Huang
- Medical research center, Beijing chaoyang hospital, Capital medical university, Beijing, China
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40
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Dyhrfort P, Shen Q, Clausen F, Thulin M, Enblad P, Kamali-Moghaddam M, Lewén A, Hillered L. Monitoring of Protein Biomarkers of Inflammation in Human Traumatic Brain Injury Using Microdialysis and Proximity Extension Assay Technology in Neurointensive Care. J Neurotrauma 2019; 36:2872-2885. [PMID: 31017044 PMCID: PMC6761596 DOI: 10.1089/neu.2018.6320] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Traumatic brain injury (TBI) is followed by secondary injury mechanisms strongly involving neuroinflammation. To monitor the complex inflammatory cascade in human TBI, we used cerebral microdialysis (MD) and multiplex proximity extension assay (PEA) technology and simultaneously measured levels of 92 protein biomarkers of inflammation in MD samples every three hours for five days in 10 patients with severe TBI under neurointensive care. One μL MD samples were incubated with paired oligonucleotide-conjugated antibodies binding to each protein, allowing quantification by real-time quantitative polymerase chain reaction. Sixty-nine proteins were suitable for statistical analysis. We found five different patterns with either early (<48 h; e.g., CCL20, IL6, LIF, CCL3), mid (48–96 h; e.g., CCL19, CXCL5, CXCL10, MMP1), late (>96 h; e.g., CD40, MCP2, MCP3), biphasic peaks (e.g., CXCL1, CXCL5, IL8) or stable (e.g., CCL4, DNER, VEGFA)/low trends. High protein levels were observed for e.g., CXCL1, CXCL10, MCP1, MCP2, IL8, while e.g., CCL28 and MCP4 were detected at low levels. Several proteins (CCL8, -19, -20, -23, CXCL1, -5, -6, -9, -11, CST5, DNER, Flt3L, and SIRT2) have not been studied previously in human TBI. Cross-correlation analysis revealed that LIF and CXCL5 may play a central role in the inflammatory cascade. This study provides a unique data set with individual temporal trends for potential inflammatory biomarkers in patients with TBI. We conclude that the combination of MD and PEA is a powerful tool to map the complex inflammatory cascade in the injured human brain. The technique offers new possibilities of protein profiling of complex secondary injury pathways.
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Affiliation(s)
- Philip Dyhrfort
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Qiujin Shen
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Fredrik Clausen
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Måns Thulin
- Department of Statistics Uppsala University, Uppsala, Sweden.,School of Mathematics and Maxwell Institute for Mathematical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Masood Kamali-Moghaddam
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Lars Hillered
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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41
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Agoston DV, Vink R, Helmy A, Risling M, Nelson D, Prins M. How to Translate Time: The Temporal Aspects of Rodent and Human Pathobiological Processes in Traumatic Brain Injury. J Neurotrauma 2019; 36:1724-1737. [PMID: 30628544 PMCID: PMC7643768 DOI: 10.1089/neu.2018.6261] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Traumatic brain injury (TBI) triggers multiple pathobiological responses with differing onsets, magnitudes, and durations. Identifying the therapeutic window of individual pathologies is critical for successful pharmacological treatment. Dozens of experimental pharmacotherapies have been successfully tested in rodent models, yet all of them (to date) have failed in clinical trials. The differing time scales of rodent and human biological and pathological processes may have contributed to these failures. We compared rodent versus human time scales of TBI-induced changes in cerebral glucose metabolism, inflammatory processes, axonal integrity, and water homeostasis based on published data. We found that the trajectories of these pathologies run on different timescales in the two species, and it appears that there is no universal "conversion rate" between rodent and human pathophysiological processes. For example, the inflammatory process appears to have an abbreviated time scale in rodents versus humans relative to cerebral glucose metabolism or axonal pathologies. Limitations toward determining conversion rates for various pathobiological processes include the use of differing outcome measures in experimental and clinical TBI studies and the rarity of longitudinal studies. In order to better translate time and close the translational gap, we suggest 1) using clinically relevant outcome measures, primarily in vivo imaging and blood-based proteomics, in experimental TBI studies and 2) collecting data at multiple post-injury time points with a frequency exceeding the expected information content by two or three times. Combined with a big data approach, we believe these measures will facilitate the translation of promising experimental treatments into clinical use.
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Affiliation(s)
- Denes V. Agoston
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland
| | - Robert Vink
- Division of Health Science, University of South Australia, Adelaide, Australia
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Mårten Risling
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Mayumi Prins
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California
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42
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Rubin TG, Lipton ML. Sex Differences in Animal Models of Traumatic Brain Injury. J Exp Neurosci 2019; 13:1179069519844020. [PMID: 31205421 PMCID: PMC6537488 DOI: 10.1177/1179069519844020] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/25/2019] [Indexed: 12/11/2022] Open
Abstract
Traumatic brain injury (TBI) is highly prevalent and there is currently no adequate treatment. Understanding the underlying mechanisms governing TBI and recovery remains an elusive goal. The heterogeneous nature of injury and individual's response to injury have made understanding risk and susceptibility to TBI of great importance. Epidemiologic studies have provided evidence of sex-dependent differences following TBI. However, preclinical models of injury have largely focused on adult male animals. Here, we review 50 studies that have investigated TBI in both sexes using animal models. Results from these studies are highly variable and model dependent, but largely show females to have a protective advantage in behavioral outcomes and pathology following TBI. Further research of both sexes using newer models that better recapitulate mild and repetitive TBI is needed to characterize the nature of sex-dependent injury and recovery, and ultimately identifies targets for enhanced recovery.
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Affiliation(s)
- Todd G Rubin
- The Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, Rose F. Kennedy Center, Bronx, NY, USA.,Gruss Magnetic Resonance Research Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael L Lipton
- The Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, Rose F. Kennedy Center, Bronx, NY, USA.,Gruss Magnetic Resonance Research Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx NY, USA.,Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY, USA
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Goetzl EJ, Ledreux A, Granholm AC, Elahi FM, Goetzl L, Hiramoto J, Kapogiannis D. Neuron-Derived Exosome Proteins May Contribute to Progression From Repetitive Mild Traumatic Brain Injuries to Chronic Traumatic Encephalopathy. Front Neurosci 2019; 13:452. [PMID: 31133789 PMCID: PMC6517542 DOI: 10.3389/fnins.2019.00452] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 04/23/2019] [Indexed: 12/22/2022] Open
Abstract
The recent recognition that Alzheimer disease-like pathology may be found in chronic traumatic encephalopathy (CTE) even after acute mild traumatic brain injury (mTBI) has increased the urgency of elucidating mechanisms, identifying biomarkers predictive of high risk of development of CTE, and establishing biomarker profiles indicative of impactful effects of treatments. Of the many proteins that are loaded into neuron-derived exosomes (NDEs) from damaged neurons after acute TBI, the levels of prion cellular protein (PRPc), coagulation factor XIII (XIIIa), synaptogyrin-3, IL-6, and aquaporins remain elevated for months. Prolonged heightened expression of aquaporins and IL-6 may account for the persistent central nervous system edema and inflammation of CTE. PRPc, XIIIa and synaptogyrin-3 bind and concentrate neurotoxic forms of oligomeric amyloid β peptides or P-tau for delivery into neurons at or distant from the site of trauma. Our progression factor hypothesis of CTE asserts that physiological neuronal proteins, such as PRPc, XIIIa, synaptogyrin-3, IL-6 and aquaporins, that increase in concentration in neurons and NDEs for months after acute TBI, are etiological contributors to CTE by either direct actions or by recruiting neurotoxic forms of Aβ peptides or P-tau. Such progression factors also may be useful new targets for development of drugs to prevent CTE.
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Affiliation(s)
- Edward J Goetzl
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Aurélie Ledreux
- Knoebel Institute for Healthy Aging, University of Denver, Denver, CO, United States
| | | | - Fanny M Elahi
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, San Francisco, CA, United States
| | - Laura Goetzl
- Department of Obstetrics, Gynecology and Reproductive Sciences, Health Sciences Center at Houston, University of Texas, Houston, TX, United States
| | - Jade Hiramoto
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Dimitrios Kapogiannis
- Laboratory of Neurosciences, Intramural Research Program, National Institute on Aging, Baltimore, MD, United States
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Isosteviol sodium injection improves outcomes by modulating TLRs/NF-κB-dependent inflammatory responses following experimental traumatic brain injury in rats. Neuroreport 2019; 29:794-803. [PMID: 29683870 PMCID: PMC5999382 DOI: 10.1097/wnr.0000000000001033] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Supplemental Digital Content is available in the text. Previous studies have shown that isosteviol sodium (STVNa) protects against permanent cerebral ischemia injury by inhibition of the nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB)-mediated inflammatory responses. Overwhelming evidence shows that toll-like receptors (TLRs) are the upstream regulators of NF-κB. On the basis of the similarity of the pathology caused by traumatic brain injury (TBI) and stroke, we speculated that STVNa may have a therapeutic effect against TBI through regulation of the TLRs/NF-κB signaling-mediated inflammatory response. Thus, we studied the potential therapeutic effects of STVNa and the underlying mechanisms. Male rats, subjected to controlled cortical impact (CCI) injury, were injected intraperitoneally with STVNa (5, 10, 20, 40, and 80 mg/kg, daily for 3 or 7 days) after trauma. Neurobehavioral scores, relative numbers of cortical lesions, and histology were examined. We also measured the mRNA and protein expression levels of TLRs/NF-κB signaling pathway-related genes including TLR2, TLR4, and NF-κB by quantitative real-time-PCR and western blotting, respectively, and concentrations of tumor necrosis factor-α and interleukin-1β by an enzyme-linked immunosorbent assay. The results indicated that STVNa (20 mg/kg) showed significant neuroprotective effects 3 and 7 days after TBI, including the reduction of cortical lesions, improvement of the neurological severity score, significantly increased number of restored neurons, decreased number of astrocytes, and lower concentrations of tumor necrosis factor-α and interleukin-1β. Results from quantitative real-time-PCR and western blotting also show that the mRNA and protein expression levels of TLR2, TLR4, and NF-κB were significantly lower in STVNa-treated rats compared with the vehicle-treated rats. The administration of STVNa attenuates the TLR/NF-κB signaling pathway-mediated inflammatory responses in the injured rat brain, and this may be the mechanism by which STVNa improves the outcome following TBI.
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Zhao JL, Du ZY, Yuan Q, Yu J, Sun YR, Wu X, Li ZQ, Wu XH, Hu J. Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Predicting the 6-Month Outcome of Patients with Traumatic Brain Injury: A Retrospective Study. World Neurosurg 2019; 124:e411-e416. [PMID: 30610986 DOI: 10.1016/j.wneu.2018.12.107] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND Peripheral white blood cells are regularly analyzed on admission for patients with traumatic brain injury (TBI). The prognostic value of the neutrophil-to-lymphocyte ratio (NLR) in predicting the 6-month outcome of patients with TBI is unclear. METHODS We designed a single-center retrospective cohort study. Patients admitted to Fudan University Huashan Hospital within 6 hours after TBI were identified between December 2004 and December 2017. The primary outcome was 6-month Glasgow Outcome Scale score. Independent predictors of 6-month outcome were assessed using uni- and multivariate analyses. Three models based on admission characteristics were built to evaluate the prognostic value of the NLR in predicting the outcome of patients with TBI. The discriminative ability of predictive models was evaluated by the area under the curve (AUC). RESULTS A total of 1291 patients with TBI were included. Multivariate analysis showed age, Glasgow Coma Scale scores at admission, subdural hematoma, intraparenchymal hemorrhage, traumatic subarachnoid hemorrhage, NLR (P < 0.001), and coagulopathy (P = 0.028) were independent predictors of 6-month outcome. The model combining the NLR and standard variables (AUC = 0.936; 95% confidence interval [CI], 0.923-0.949) was more favorable in predicting 6-month outcome of patients with TBI than the model without the NLR (AUC = 0.901; 95% CI, 0.883-0.919) and the model based only on the NLR (AUC = 0.827; 95% CI, 0.802-0.852). CONCLUSIONS NLR is an independent prognostic factor of predicting 6-month outcome of patients with TBI. A high NLR in patients with TBI is associated with poor outcome. The prognostic value of the NLR in predicting 6-month outcome of patients with TBI is favorable.
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Affiliation(s)
- Jian-Lan Zhao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Zhuo-Ying Du
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Jian Yu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China; Department of Neurosurgery, Shigatse People's Hospital, Shigatse, Tibet Autonomous Region, P.R. China
| | - Yi-Rui Sun
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China; Department of Neurosurgery, Minhang Branch, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Xing Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Zhi-Qi Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Xue-Hai Wu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, P.R. China.
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Goetzl EJ, Elahi FM, Mustapic M, Kapogiannis D, Pryhoda M, Gilmore A, Gorgens KA, Davidson B, Granholm AC, Ledreux A. Altered levels of plasma neuron-derived exosomes and their cargo proteins characterize acute and chronic mild traumatic brain injury. FASEB J 2019; 33:5082-5088. [PMID: 30605353 DOI: 10.1096/fj.201802319r] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Neuron-derived exosomes (NDEs) were enriched by anti-L1CAM antibody immunoabsorption from plasmas of subjects ages 18-26 yr within 1 wk after a sports-related mild traumatic brain injury (acute mTBI) ( n = 18), 3 mo or longer after the last of 2-4 mTBIs (chronic mTBI) ( n = 14) and with no recent history of TBI (controls) ( n = 21). Plasma concentrations of NDEs, assessed by counts and levels of extracted exosome marker CD81, were significantly depressed by a mean of 45% in acute mTBI ( P < 0.0001), but not chronic mTBI, compared with controls. Mean CD81-normalized NDE levels of a range of functional brain proteins were significantly abnormal relative to those of controls in acute but not chronic mTBI, including ras-related small GTPase 10, 73% decrease; annexin VII, 8.8-fold increase; ubiquitin C-terminal hydrolase L1, 2.5-fold increase; AII spectrin fragments, 1.9-fold increase; claudin-5, 2.7-fold increase; sodium-potassium-chloride cotransporter-1, 2.8-fold increase; aquaporin 4, 8.9-fold increase (3.6-fold increase in chronic mTBI); and synaptogyrin-3, 3.1-fold increase (1.3-fold increase in chronic mTBI) (all acute mTBI proteins P < 0.0001). In chronic mTBI, there were elevated CD81-normalized NDE levels of usually pathologic β-amyloid peptide 1-42 (1.6-fold, P < 0.0001), P-T181-tau (2.2-fold, P < 0.0001), P-S396-tau (1.6-fold, P < 0.01), IL-6 (16-fold, P < 0.0001), and prion cellular protein (PRPc) (5.1-fold, P < 0.0001) with lesser or greater (IL-6, PRPc) increases in acute mTBI. Increases in NDE levels of most neurofunctional proteins in acute, but not chronic, mTBI, and elevations of most NDE neuropathological proteins in chronic and acute mTBI delineated phase-specificity. Longitudinal studies of more mTBI subjects may identify biomarkers predictive of and etiologically involved in mTBI-induced neurodegeneration.-Goetzl, E. J., Elahi, F. M., Mustapic, M., Kapogiannis, D., Pryhoda, M., Gilmore, A., Gorgens, K. A., Davidson, B., Granholm, A.-C., Ledreux, A. Altered levels of plasma neuron-derived exosomes and their cargo proteins characterize acute and chronic mild traumatic brain injury.
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Affiliation(s)
- Edward J Goetzl
- Department of Medicine, Memory and Aging Center, University of California, San Francisco, San Francisco, California, USA
| | - Fanny M Elahi
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, San Francisco, California, USA
| | - Maja Mustapic
- Cellular and Molecular Neurosciences Section, Laboratory of Neurosciences, National Institute on Aging, Baltimore, Maryland, USA
| | - Dimitrios Kapogiannis
- Cellular and Molecular Neurosciences Section, Laboratory of Neurosciences, National Institute on Aging, Baltimore, Maryland, USA
| | - Moira Pryhoda
- Human Dynamics Laboratory, Department of Mechanical Engineering, University of Denver, Denver, Colorado, USA
| | - Anah Gilmore
- Knoebel Institute for Healthy Aging, University of Denver, Denver, Colorado, USA; and
| | - Kimberly A Gorgens
- Graduate School of Professional Psychology, University of Denver, Denver, Colorado, USA
| | - Bradley Davidson
- Human Dynamics Laboratory, Department of Mechanical Engineering, University of Denver, Denver, Colorado, USA
| | | | - Aurélie Ledreux
- Knoebel Institute for Healthy Aging, University of Denver, Denver, Colorado, USA; and
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Gao W, Ju YN, Chen JF, Zhou Q, Song CY, Wang YZ, Cao HL, Yang WC. Adrenomedullin Reduces Secondary Injury and Improves Outcome in Rats with Fluid Percussion Brain Injury. World Neurosurg 2018; 119:e765-e773. [DOI: 10.1016/j.wneu.2018.07.265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 01/08/2023]
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Scrimgeour AG, Carrigan CT, Condlin ML, Urso ML, van den Berg RM, van Helden HP, Montain SJ, Joosen MJ. Dietary Zinc Modulates Matrix Metalloproteinases in Traumatic Brain Injury. J Neurotrauma 2018; 35:2495-2506. [DOI: 10.1089/neu.2017.5614] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Angus G. Scrimgeour
- Military Nutrition Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, Massachusetts
| | - Christopher T. Carrigan
- Military Nutrition Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, Massachusetts
| | - Michelle L. Condlin
- Military Nutrition Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, Massachusetts
| | - Maria L. Urso
- Military Performance Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, Massachusetts
| | | | | | - Scott J. Montain
- Military Nutrition Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, Massachusetts
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Clausen F, Marklund N, Hillered L. Acute Inflammatory Biomarker Responses to Diffuse Traumatic Brain Injury in the Rat Monitored by a Novel Microdialysis Technique. J Neurotrauma 2018; 36:201-211. [PMID: 29790398 DOI: 10.1089/neu.2018.5636] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Neuroinflammation is a major contributor to the progressive brain injury process induced by traumatic brain injury (TBI), and may play an important role in the pathophysiology of axonal injury. The immediate neuroinflammatory cascade cannot be characterized in the human setting. Therefore, we used the midline fluid percussion injury model of diffuse TBI in rats and a novel microdialysis (MD) method providing stable diffusion-driven biomarker sampling. Immediately post-injury, bilateral amphiphilic tri-block polymer coated MD probes (100 kDa cut off membrane) were inserted and perfused with Dextran 500 kDa-supplemented artificial cerebrospinal fluid (CSF) to optimize protein capture. Six hourly samples were analyzed for 27 inflammatory biomarkers (9 chemokines, 13 cytokines, and 5 growth factors) using a commercial multiplex biomarker kit. TBI (n = 6) resulted in a significant increase compared with sham-injured controls (n = 6) for five chemokines (eotaxin/CCL11, fractalkine/CX3CL1, LIX/CXCL5, monocyte chemoattractant protein [MCP]1α/CCL2, macrophage inflammatory protein [MIP]1α /CCL3), 10 cytokines (interleukin [IL]-1α, IL-1β, IL-4, IL-6, IL-10, IL-13, IL-17α, IL-18, interferon [IFN]-γ, tumor necrosis factor [TNF]-α), and four growth factors (epidermal growth factor [EGF], granulocyte-macrophage colony-stimulating factor [GM-CSF], leptin, vascular endothelial growth factor [VEGF]). Therefore, diffuse TBI was associated with an increased level of 18 of the 27 inflammatory biomarkers at one through six time points, during the observation period whereas the remaining 9 biomarkers were unaltered. The study shows that diffuse TBI induces an acute increase in a number of inflammatory biomarkers. The novel MD technique provides stable MD sampling suitable for further studies on the early neuroinflammatory cascade in TBI.
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Affiliation(s)
- Fredrik Clausen
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Niklas Marklund
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Lars Hillered
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
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Abstract
PRIMARY OBJECTIVE The purpose of this paper is to review the clinical and research utility and applications of blood, cerebrospinal fluid (CSF), and cerebral microdialysis biomarkers in traumatic brain injury (TBI). RESEARCH DESIGN Not applicable. METHODS AND PROCEDURES A selective review was performed on these biofluid biomarkers in TBI. MAIN OUTCOME AND RESULTS Neurofilament heavy chain protein (NF-H), glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase-L1 (UCHL1), neuron-specific enolase (NSE), myelin basic protein (MBP), tau, and s100β blood biomarkers are elevated during the acute phase of severe head trauma but have key limitations in their research and clinical applications to mild TBI (mTBI). CSF biomarkers currently provide the best reflection of the central nervous system (CNS) pathobiological processes in TBI. Both animal and human studies of TBI have demonstrated the importance of serial sampling of biofluids and suggest that CSF biomarkers may be better equipped to characterize both TBI severity and temporal profiles. CONCLUSIONS The identification of biofluid biomarkers could play a vital role in identifying, diagnosing, and treating the underlying individual pathobiological changes of TBI. CNS-derived exosomes analyzed by ultra-high sensitivity detection methods have the potential to identify blood biomarkers for the range of TBI severity and time course.
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Affiliation(s)
- Denes V Agoston
- a Department of Anatomy, Physiology and Genetics , Uniformed Services University , Bethesda , MD , USA.,b Department of Neuroscience , Karolinska Institutet , Stockholm , Sweden
| | - Andrew Shutes-David
- c VA Northwest Network Mental Illness Research, Education, and Clinical Center , Veterans Affairs Puget Sound Health Care System , Seattle , WA , USA.,d Geriatric Research, Education, and Clinical Center , Veterans Affairs Puget Sound Health Care System , Seattle , WA , USA
| | - Elaine R Peskind
- c VA Northwest Network Mental Illness Research, Education, and Clinical Center , Veterans Affairs Puget Sound Health Care System , Seattle , WA , USA.,e Department of Psychiatry and Behavioral Sciences , University of Washington , Seattle , WA , USA
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