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Muehlschlegel G, Kubicki R, Jacobs-LeVan J, Kroll J, Klemm R, Humburger F, Stiller B, Fleck T. Neurological Impact of Slower Rewarming during Bypass Surgery in Infants. Thorac Cardiovasc Surg 2024; 72:e7-e15. [PMID: 38909608 DOI: 10.1055/s-0044-1787650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
BACKGROUND Hypothermia is a neuroprotective strategy during cardiopulmonary bypass. Rewarming entailing a rapid rise in cerebral metabolism might lead to secondary neurological sequelae. In this pilot study, we aimed to validate the hypothesis that a slower rewarming rate would lower the risk of cerebral hypoxia and seizures in infants. METHODS This is a prospective, clinical, single-center study. Infants undergoing cardiac surgery in hypothermia were rewarmed either according to the standard (+1°C in < 5 minutes) or a slow (+1°C in > 5-8 minutes) rewarming strategy. We monitored electrocortical activity via amplitude-integrated electroencephalography (aEEG) and cerebral oxygenation by near-infrared spectroscopy during and after surgery. RESULTS Fifteen children in the standard rewarming group (age: 13 days [5-251]) were cooled down to 26.6°C (17.2-29.8) and compared with 17 children in the slow-rewarming group (age: 9 days [4-365]) with a minimal temperature of 25.7°C (20.1-31.4). All neonates in both groups (n = 19) exhibited suppressed patterns compared with 28% of the infants > 28 days (p < 0.05). During rewarming, only 26% of the children in the slow-rewarming group revealed suppressed aEEG traces (vs. 41%; p = 0.28). Cerebral oxygenation increased by a median of 3.5% in the slow-rewarming group versus 1.5% in the standard group (p = 0.9). Our slow-rewarming group revealed no aEEG evidence of any postoperative seizures (0 vs. 20%). CONCLUSION These results might indicate that a slower rewarming rate after hypothermia causes less suppression of electrocortical activity and higher cerebral oxygenation during rewarming, which may imply a reduced risk of postoperative seizures.
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Affiliation(s)
- Geeske Muehlschlegel
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Baden-Württemberg, Germany
| | - Rouven Kubicki
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg Bad Krozingen Freiburg Branch, Freiburg, Freiburg, Germany
| | - Julia Jacobs-LeVan
- Departments of Pediatrics and Clinical Neurosciences, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Johannes Kroll
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen Freiburg Branch, Freiburg, Baden-Württemberg, Germany
| | - Rolf Klemm
- Department of Cardiovascular Surgery, University Heart Center Freiburg Bad Krozingen, Freiburg, Baden-Württemberg, Germany
| | - Frank Humburger
- Department of Anesthesiology, University of Freiburg Medical Center Freiburg, Freiburg, Baden-Württemberg, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg Bad Krozingen Freiburg Branch, Freiburg, Freiburg, Germany
| | - Thilo Fleck
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg Bad Krozingen Freiburg Branch, Freiburg, Freiburg, Germany
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Mueller C, Sharma AA, Szaflarski JP. Peripheral and Central Nervous System Biomarkers of Inflammation in Functional Seizures: Assessment with Magnetic Resonance Spectroscopy. Neuropsychiatr Dis Treat 2023; 19:2729-2743. [PMID: 38077237 PMCID: PMC10710262 DOI: 10.2147/ndt.s437063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/21/2023] [Indexed: 02/12/2024] Open
Abstract
Purpose Inflammation may link trauma to clinical symptoms in functional seizures (FS). We compared brain temperature and metabolites in FS, psychiatric (PCs) and healthy controls (HCs) and quantified their associations with serum biomarkers of inflammation and clinical symptoms. Patients and Methods Brain temperature and metabolites were measured with whole-brain magnetic resonance spectroscopic imaging (MRSI) and compared between groups in regions of interest and the whole brain. Relationships with inflammatory biomarkers and symptoms were assessed with Pearson correlations. Results Brain temperature was higher in FS than HCs in the orbitofrontal cortex (OFC) and anterior cingulate gyrus (ACG) and lower in the occipital cortex and frontal lobe. PCs showed lower temperatures than HCs in the frontal lobe including precentral gyrus and in the cerebellum. Myo-inositol (MINO) was higher in FS than HCs in the precentral gyrus, posterior temporal gyrus, ACG and OFC, and choline (CHO) was higher in the occipital lobe. CHO was higher in PCs than HCs in the ACG and OFC, and N-acetylaspartate (NAA) was higher in the ACG. There were no significant correlations with the serum inflammatory biomarkers. In FS, brain temperature correlated with depression, quality of life, psychological symptoms, and disability, CHO correlated with disability, and MINO correlated with hostility, disability, and quality of life. Conclusion Some of the previously identified neuroimaging abnormalities in FS may be related to comorbid psychiatric symptoms, while others, such as abnormalities in sensorimotor cortex, occipital regions, and the temporo-parietal junction may be specific to FS. Overlapping MINO and temperature increases in the ACG and OFC in FS suggest neuroinflammation.
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Affiliation(s)
- Christina Mueller
- Department of Neurology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ayushe A Sharma
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jerzy P Szaflarski
- Departments of Neurology, Neurobiology, and Neurosurgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Giordano L, Perri A, Tiberi E, Sbordone A, Patti ML, D’Andrea V, Vento G. The Utility and Safety of a Continuous Glucose Monitoring System (CGMS) in Asphyxiated Neonates during Therapeutic Hypothermia. Diagnostics (Basel) 2023; 13:3018. [PMID: 37761385 PMCID: PMC10530216 DOI: 10.3390/diagnostics13183018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/26/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The present study was designed to assess the feasibility and reliability of a Continuous Glucose Monitoring System (CGMS) in a population of asphyxiated neonates during therapeutic hypothermia. METHODS This non-randomized feasibility study was conducted in the Neonatal Intensive Care Unit (NICU) facilities of Fondazione Policlinico A. Gemelli IRCSS. Infants matching the criteria for hypothermic treatment were included in this study and were connected to the CGMS (Medtronic, Northridge, CA, USA) within the first 12 h of life. Hypoglycemia was defined as a glucose value ≤ 47 mg/dL, and hyperglycemia was defined as a glucose value ≥ 180 mg/dL. Data obtained via the CGMS were compared with those obtained via a point-of-care blood glucometer (GTX). RESULTS The two measuring techniques were compared using the Modified Clarke Error Grid (MCEG). Sixteen infants were enrolled. The sensor had an average (standard deviation) duration of 93 (38) h. We collected 119 pairs of glycemia values (CGMVs) from the CGMS vs. GTX measurements. The CGMS detected twenty-five episodes of hypoglycemia and three episodes of hyperglycemia. All the CGMVs indicating hyperglycemia matched with the blood sample taken via the point-of-care glucometer. CONCLUSIONS The use of a CGMS would be useful as it could detect more episodes of disglycemia than standard care. Our data show poor results in terms of the accuracy of the CGMS in this particular setting.
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Affiliation(s)
- Lucia Giordano
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
- Department of Woman and Child Health and Public Health, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Alessandro Perri
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
| | - Eloisa Tiberi
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
| | - Annamaria Sbordone
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
| | - Maria Letizia Patti
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
| | - Vito D’Andrea
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
| | - Giovanni Vento
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.G.); (E.T.); (A.S.); (M.L.P.); (V.D.); (G.V.)
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Rationale for the Use of Cord Blood in Hypoxic-Ischaemic Encephalopathy. Stem Cells Int 2022; 2022:9125460. [PMID: 35599846 PMCID: PMC9117076 DOI: 10.1155/2022/9125460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 02/16/2022] [Accepted: 04/22/2022] [Indexed: 11/18/2022] Open
Abstract
Hypoxic-ischaemic encephalopathy (HIE) is a severe complication of asphyxia at birth. Therapeutic hypothermia, the standard method for HIE prevention, is effective in only 50% of the cases. As the understanding of the immunological basis of these changes increases, experiments have begun with the use of cord blood (CB) because of its neuroprotective properties. Mechanisms for the neuroprotective effects of CB stem cells include antiapoptotic and anti-inflammatory actions, stimulation of angiogenesis, production of trophic factors, and mitochondrial donation. In several animal models of HIE, CB decreased oxidative stress, cell death markers, CD4+ T cell infiltration, and microglial activation; restored normal brain metabolic activity; promoted neurogenesis; improved myelination; and increased the proportion of mature oligodendrocytes, neuron numbers in the motor cortex and somatosensory cortex, and brain weight. These observations translate into motor strength, limb function, gait, and cognitive function and behaviour. In humans, the efficacy and safety of CB administration were reported in a few early clinical studies which confirmed the feasibility and safety of this intervention for up to 10 years. The results of these studies showed an improvement in the developmental outcomes over hypothermia. Two phase-2 clinical studies are ongoing under the United States regulations, namely one controlled study and one blinded study.
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Nogueira ALM, Maciel ALDS, Querubino AC, Prado RT, Martins JR. Efficacy and Risks of Therapeutic Hypothermia after Pediatric Cardiac Arrest: A Systematic Review. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2022. [DOI: 10.36660/ijcs.20210246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Ishida Y, Nishiyama M, Yamaguchi H, Tomioka K, Takeda H, Tokumoto S, Toyoshima D, Maruyama A, Seino Y, Aoki K, Nozu K, Kurosawa H, Tanaka R, Iijima K, Nagase H. Early steroid pulse therapy for children with suspected acute encephalopathy: An observational study. Medicine (Baltimore) 2021; 100:e26660. [PMID: 34397692 PMCID: PMC8322503 DOI: 10.1097/md.0000000000026660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 06/25/2021] [Indexed: 01/04/2023] Open
Abstract
Steroid pulse therapy is widely used to treat virus-associated acute encephalopathy, especially the cytokine storm type; however, its effectiveness remains unknown. We sought to investigate the effectiveness of early steroid pulse therapy for suspected acute encephalopathy in the presence of elevated aspartate aminotransferase (AST) levels.We enrolled children admitted to Hyogo Children's Hospital between 2003 and 2017 with convulsions or impaired consciousness accompanied by fever (temperature >38°C). The inclusion criteria were: refractory status epilepticus or prolonged neurological abnormality or hemiplegia at 6 hours from onset, and AST elevation >90 IU/L within 6 hours of onset. We excluded patients with a neurological history. We compared the prognosis between the groups with or without steroid pulse therapy within 24 hours. A good prognosis was defined as a Pediatric Cerebral Performance Category Scale (PCPC) score of 1-2 at the last evaluation, within 30 months of onset. Moreover, we analyzed the relationship between prognosis and time from onset to steroid pulse therapy.Fifteen patients with acute encephalopathy and 5 patients with febrile seizures were included in this study. Thirteen patients received steroid pulse therapy within 24 hours. There was no between-group difference in the proportion with a good prognosis. There was no significant correlation between PCPC and timing of steroid pulse therapy (rs = 0.253, P = .405). Even after excluding 2 patients with brainstem lesions, no significant correlation between PCPC and steroid pulse therapy timing (rs = 0.583, P = .060) was noted. However, the prognosis tended to be better in patients who received steroid pulse therapy earlier.Steroid pulse therapy within 24 hours did not improve the prognosis in children with suspected acute encephalopathy associated with elevated AST. Still, even earlier administration of treatment could prevent the possible neurological sequelae of this condition.
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Affiliation(s)
- Yusuke Ishida
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Nishiyama
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Yamaguchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazumi Tomioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroki Takeda
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shoichi Tokumoto
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Daisaku Toyoshima
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Azusa Maruyama
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yusuke Seino
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kazunori Aoki
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Ryojiro Tanaka
- Department of Emergency and General Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
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Lectin-Like Oxidized Low-Density Lipoprotein Receptor-1-Related Microglial Activation in Neonatal Hypoxic-Ischemic Encephalopathy: Morphologic Consideration. THE AMERICAN JOURNAL OF PATHOLOGY 2021; 191:1303-1313. [PMID: 33964218 DOI: 10.1016/j.ajpath.2021.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/12/2021] [Accepted: 04/21/2021] [Indexed: 11/23/2022]
Abstract
Neonatal hypoxic-ischemic encephalopathy (nHIE) is a major neonatal brain injury. Despite therapeutic hypothermia, mortality and sequelae remain severe. The lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is associated with the pathophysiology of nHIE. In this study, morphologic change and microglial activation under the nHIE condition and LOX-1 treatment were investigated. The microglial activity and proliferation were assessed with a novel morphologic method, immunostaining, and quantitative PCR in the rat brains of both nHIE model and anti-LOX-1 treatment. Circumference ratio, the long diameter ratio, the cell area ratio, and the roundness of microglia were calculated. The correlation of the morphologic metrics and microglial activation in nHIE model and anti-LOX-1 treated brains was evaluated. LOX-1 was expressed in activated ameboid and round microglia in the nHIE model rat brain. In the evaluation of microglial activation, the novel morphologic metrics correlated with all scales of the nHIE-damaged and treated brains. While the circumference and long diameter ratios had a positive correlation, the cell area ratio and roundness had a negative correlation. Anti-LOX-1 treatment attenuated morphologic microglial activation and proliferation, and suppressed the subsequent production of inflammatory mediators by microglia. In human nHIE, round microglia and endothelial cells expressed LOX-1. The results indicate that LOX-1 regulates microglial activation in nHIE and anti-LOX-1 treatment attenuates brain injury by suppressing microglial activation.
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Penny TR, Pham Y, Sutherland AE, Mihelakis JG, Lee J, Jenkin G, Fahey MC, Miller SL, McDonald CA. Multiple doses of umbilical cord blood cells improve long-term brain injury in the neonatal rat. Brain Res 2020; 1746:147001. [PMID: 32585139 DOI: 10.1016/j.brainres.2020.147001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hypoxic ischemic (HI) insults during pregnancy and birth can result in neurodevelopmental disorders, such as cerebral palsy. We have previously shown that a single dose of umbilical cord blood (UCB) cells is effective at reducing short-term neuroinflammation and improves short and long-term behavioural outcomes in rat pups. A single dose of UCB was not able to modulate long-term neuroinflammation or brain tissue loss. In this study we examined whether multiple doses of UCB can modulate neuroinflammation, decrease cerebral tissue damage and improve behavioural outcomes when followed up long-term. METHODS HI injury was induced in postnatal day 10 (PND10) rat pups using the Rice-Vannucci method of carotid artery ligation. Pups received either 1 dose (PND11), or 3 doses (PND11, 13, 20) of UCB cells. Rats were followed with behavioural testing, to assess both motor and cognitive outcomes. On PND50, brains were collected for analysis. RESULTS HI brain injury in rat pups caused significant behavioural deficits. These deficits were significantly improved by multiple doses of UCB. HI injury resulted in a significant decrease in brain weight and left hemisphere tissue, which was improved by multiple doses of UCB. HI resulted in increased cerebral apoptosis, loss of neurons and upregulation of activated microglia. Multiple doses of UCB modulated these neuropathologies. A single dose of UCB at PND11 did not improve behavioural or neuropathological outcomes. CONCLUSIONS Treatment with repeated doses of UCB is more effective than a single dose for reducing tissue damage, improving brain pathology and restoring behavioural deficits following perinatal brain injury.
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Affiliation(s)
- Tayla R Penny
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Yen Pham
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Amy E Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Jamie G Mihelakis
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Joohyung Lee
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Michael C Fahey
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Courtney A McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.
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Lakatos A, Kolossváry M, Szabó M, Jermendy Á, Barta H, Gyebnár G, Rudas G, Kozák LR. Neurodevelopmental effect of intracranial hemorrhage observed in hypoxic ischemic brain injury in hypothermia-treated asphyxiated neonates - an MRI study. BMC Pediatr 2019; 19:430. [PMID: 31718607 PMCID: PMC6849254 DOI: 10.1186/s12887-019-1777-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 10/09/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Identification of early signs of hypoxic ischemic encephalopathy (HIE) with magnetic resonance imaging (MRI) has proven of prognostic significance. Yet, the importance of intracranial hemorrhage (ICH), being present concomitantly had not been investigated yet, despite the known influence of hypothermia on hemostasis. We aimed to determine whether presence of ICH on MRI alongside the signs of HIE have an impact on prognosis in neonates with the clinical diagnosis of HIE. METHODS A retrospective study of consecutively sampled 108 asphyxiated term infants admitted to a tertiary neonatal intensive care unit (between 2007 and 2016), treated with whole body hypothermia and having brain MRI within 1 week of life was conducted. Presence or absence of HIE signs on MRI (basal ganglia-thalamus, watershed pattern and total brain injury) and on MR spectroscopy (lactate peak with decreased normal metabolites measured by Lac/NAA ratio) and/or of the five major types of ICH were recorded. Neurodevelopmental outcome was measured with Bayley Scales of Infant Development-II (BSID-II) test. Death or abnormal neurodevelopment (BSID-II score < 85) was defined as poor outcome in Chi-square test. Multivariate logistic regression analysis was performed on survivors. RESULTS MRI and MR-spectroscopy (MRS) signs of HIE were present in 72% (n = 78). 36% (n = 39) of neonates had ICH, being mainly small in size. Chi-square test showed a relationship between neurodevelopmental outcome and initial MRI. Unadjusted logistic regression showed that neonates presenting MRI and MRS signs of HIE have 6.23 times higher odds for delayed mental development (OR = 6.2292; CI95% = [1.2642; 30.6934], p = 0.0246), than infants without imaging alterations; with no ICH effect on outcome. Adjustment for clinical and imaging parameters did not change the pattern of results, i.e. HIE remained an independent risk factor for delayed neurodevelopment (OR = 6.2496; CI95% = [1.2018; 32.4983], p = 0.0294), while ICH remained to have no significant effect. CONCLUSION HIE related MRI abnormalities proved to be important prognostic factors of poor outcome in cooled asphyxiated infants when present, suggesting that early MRI with MRS is beneficial for prognostication. Interestingly, ICHs present in about one third of all cases had no significant effect on neurodevelopmental outcome, despite the known hemostasis altering effects of hypothermia.
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Affiliation(s)
- Andrea Lakatos
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Balassa u. 6, Budapest, 1083, Hungary
| | - Márton Kolossváry
- MTA-SE "Lendület" Cardiovascular Imaging Research Group, Semmelweis University, Városmajor u. 68, Budapest, 1122, Hungary
| | - Miklós Szabó
- First Department of Paediatrics, Semmelweis University, Bókay u. 53-54, Budapest, 1083, Hungary
| | - Ágnes Jermendy
- First Department of Paediatrics, Semmelweis University, Bókay u. 53-54, Budapest, 1083, Hungary
| | - Hajnalka Barta
- First Department of Paediatrics, Semmelweis University, Bókay u. 53-54, Budapest, 1083, Hungary
| | - Gyula Gyebnár
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Balassa u. 6, Budapest, 1083, Hungary
| | - Gábor Rudas
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Balassa u. 6, Budapest, 1083, Hungary
| | - Lajos R Kozák
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Balassa u. 6, Budapest, 1083, Hungary.
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Nonato M, Gheler L, Balestrieri JV, Audi M, Prandini M. Selective head cooling and whole body cooling as neuroprotective agents in severe perinatal asphyxia. ACTA ACUST UNITED AC 2019; 65:1116-1121. [PMID: 31531612 DOI: 10.1590/1806-9282.65.8.1116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/09/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The possibility that hypothermia has a therapeutic role during or after resuscitation from severe perinatal asphyxia has been a longstanding focus of research. Studies designed around this fact have shown that moderate cerebral hypothermia, initiated as early as possible, has been associated with potent, long-lasting neuroprotection in perinatal patients. OBJECTIVES To review the benefits of hypothermia in improving cellular function, based on the cellular characteristics of hypoxic-ischemic cerebral injury and compare the results of two different methods of cooling the brain parenchyma. METHODS Medline, Lilacs, Scielo, and PubMed were searched for articles registered between 1990 and 2019 in Portuguese and English, focused on trials comparing the safety and effectiveness of total body cooling with selective head cooling with HIE. RESULTS We found that full-body cooling provides homogenous cooling to all brain structures, including the peripheral and central regions of the brain. Selective head cooling provides a more extensive cooling to the cortical region of the brain than to the central structures. CONCLUSIONS Both methods demonstrated to have neuroprotective properties, although full-body cooling provides a broader area of protection. Recently, head cooling combined with some body cooling has been applied, which is the most promising approach. The challenge for the future is to find ways of improving the effectiveness of the treatment.
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Affiliation(s)
- Mahara Nonato
- Estudante de Medicina, Faculdade de Medicina do ABC - FMABC, Santo André , SP , Brasil
| | - Larissa Gheler
- Estudante de Medicina, Unifai , Adamantina , SP , Brasil
| | - João Vitor Balestrieri
- Estudante de Medicina, Universidade dos Grandes Lagos -Unilago, São José do Rio Preto , SP , Brasil
| | - Marise Audi
- Neurocirurgia Pediátrica, Hospital Beneficência Portuguesa - São Paulo , SP , Brasil
| | - Mirto Prandini
- Médico - PhD - Professor Associado Livre Docente - Universidade Federal de São Paulo - Unifesp, São Paulo , SP , Brasil
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Tomioka K, Nishiyama M, Nagase H, Ishida Y, Tanaka T, Tokumoto S, Yamaguchi H, Toyoshima D, Maruyama A, Fujita K, Aoki K, Seino Y, Nozu K, Nishimura N, Kurosawa H, Iijima K. Detailed clinical course of fatal acute encephalopathy in children. Brain Dev 2019; 41:691-698. [PMID: 31337523 DOI: 10.1016/j.braindev.2019.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 03/29/2019] [Accepted: 04/16/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Although the mortality among previously healthy children with acute encephalopathy (AE) is approximately 5%, their detailed clinical course has not been clarified. The objective of the present study was to describe the detailed clinical course, in minutes, of fatal AE. METHODS We retrospectively reviewed the medical records of five patients (from 6 months to 14 years of age) who previously had no neurological disorders and were diagnosed with brain death due to AE between 2002 and 2018 at Kobe Children's Hospital. RESULTS The initial clinical symptoms were convulsion in three cases and impaired consciousness in two. The earliest noted brain imaging abnormality was 7.5 h after neurological symptom detection. Liver enzymes and creatinine levels increased at initial examination, and sodium elevated gradually. All patients met the criteria of systemic inflammatory response syndrome, disseminated intravascular coagulation, and shock within 14 h of symptom detection. High dose steroids and targeted temperature management were initiated 3.5-14 h after onset. Despite these therapies, patients were diagnosed with brain death from 16 h to 4 days after initial neurological symptoms. AE diagnoses were made between 4 h 29 min and 4 days after initial neurological symptoms and included hemorrhagic shock and encephalopathy syndromes, Reye-like syndrome, and acute necrotizing encephalopathy in two, two, and one patient(s), respectively. CONCLUSIONS We revealed the time series' of clinical events (e.g. SIRS, shock, DIC, AE diagnosis, brain death, and treatments) and laboratory findings relative to initial neurological symptom in fatal AE.
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Affiliation(s)
- Kazumi Tomioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Masahiro Nishiyama
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yusuke Ishida
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tsukasa Tanaka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shoichi Tokumoto
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Hiroshi Yamaguchi
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Daisaku Toyoshima
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Azusa Maruyama
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kyoko Fujita
- Department of Emergency and General Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kazunori Aoki
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yusuke Seino
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Noriyuki Nishimura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
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13
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Cánovas-Ahedo M, Alonso-Alconada D. [Combined therapy in neonatal hypoxic-ischaemic encephalopathy]. An Pediatr (Barc) 2019; 91:59.e1-59.e7. [PMID: 31109785 DOI: 10.1016/j.anpedi.2019.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/08/2019] [Accepted: 04/12/2019] [Indexed: 01/01/2023] Open
Abstract
Neonatal hypoxic-ischaemic encephalopathy due to the lack of oxygen at birth can have severe neurological consequences, such as cerebral palsy, or even the death of the asphyxiated newborn. Hypothermia is currently the only therapy included in intensive care neonatal units. This shows a clinical benefit in neonates suffering from hypoxic-ischaemic encephalopathy, mainly because of its ability to decrease the accumulation of excitatory amino acids and its anti-inflammatory, antioxidant, and anti-apoptotic effects. However, hypothermia is not effective in half of the cases, making it necessary to search for new, or to optimize current therapies, with the aim on reducing asphyxia-derived neurological consequences, either as single treatments or in combination with cooling. Within current potential therapies, melatonin, allopurinol, and erythropoietin stand out among the others, with clinical trials on the way. While, stem cells, N-acetylcysteine and noble gases have obtained promising pre-clinical results. Melatonin produces a powerful antioxidant and anti-inflammatory effect, acting as free radical scavenger and regulating pro-inflammatory mediators. Through the inhibition of xanthine oxidase, allopurinol can decrease oxidative stress. Erythropoietin has cell death and neurogenesis as its main therapeutic targets. Keeping in mind the whole scenario of current therapies, management of neonates suffering from neonatal asphyxia could rely on the combination of one or some of these treatments, together with therapeutic hypothermia.
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Affiliation(s)
- María Cánovas-Ahedo
- Departamento de Biología Celular e Histología, Facultad de Medicina y Enfermería, Universidad del País Vasco/Euskal Herriko Unibertsitatea (UPV/EHU), Leioa, Bizkaia, España
| | - Daniel Alonso-Alconada
- Departamento de Biología Celular e Histología, Facultad de Medicina y Enfermería, Universidad del País Vasco/Euskal Herriko Unibertsitatea (UPV/EHU), Leioa, Bizkaia, España.
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14
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Penny TR, Sutherland AE, Mihelakis JG, Paton MCB, Pham Y, Lee J, Jones NM, Jenkin G, Fahey MC, Miller SL, McDonald CA. Human Umbilical Cord Therapy Improves Long-Term Behavioral Outcomes Following Neonatal Hypoxic Ischemic Brain Injury. Front Physiol 2019; 10:283. [PMID: 30967791 PMCID: PMC6440382 DOI: 10.3389/fphys.2019.00283] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 03/04/2019] [Indexed: 01/16/2023] Open
Abstract
Background: Hypoxic ischemic (HI) insult in term babies at labor or birth can cause long-term neurodevelopmental disorders, including cerebral palsy (CP). The current standard treatment for term infants with hypoxic ischemic encephalopathy (HIE) is hypothermia. Because hypothermia is only partially effective, novel therapies are required to improve outcomes further. Human umbilical cord blood cells (UCB) are a rich source of stem and progenitor cells making them a potential treatment for neonatal HI brain injury. Recent clinical trials have shown that UCB therapy is a safe and efficacious treatment for confirmed cerebral palsy. In this study, we assessed whether early administration of UCB to the neonate could improve long-term behavioral outcomes and promote brain repair following neonatal HI brain injury. Methods: HI brain injury was induced in postnatal day (PND) 7 rat pups via permanent ligation of the left carotid artery, followed by a 90 min hypoxic challenge. UCB was administered intraperitoneally on PND 8. Behavioral tests, including negative geotaxis, forelimb preference and open field test, were performed on PND 14, 30, and 50, following brains were collected for assessment of neuropathology. Results: Neonatal HI resulted in decreased brain weight, cerebral tissue loss and apoptosis in the somatosensory cortex, as well as compromised behavioral outcomes. UCB administration following HI improved short and long-term behavioral outcomes but did not reduce long-term histological evidence of brain injury compared to HI alone. In addition, UCB following HI increased microglia activation in the somatosensory cortex compared to HI alone. Conclusion: Administration of a single dose of UCB cells 24 h after HI injury improves behavior, however, a single dose of cells does not modulate pathological evidence of long-term brain injury.
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Affiliation(s)
- Tayla R Penny
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Amy E Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Jamie G Mihelakis
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Madison C B Paton
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Yen Pham
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Joohyung Lee
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Nicole M Jones
- Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Michael C Fahey
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - Courtney A McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
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Abstract
PURPOSE OF REVIEW Neonatal encephalopathy is the most common condition in neonates encountered by child neurologists. The etiology is most often global hypoxia-ischemia due to failure of cerebral perfusion to the fetus caused by uterine, placental, or umbilical cord compromise prior to or during delivery. Other etiologies of neonatal encephalopathy include ischemic stroke and intracranial hemorrhage, infection, developmental anomalies, and inborn errors of metabolism. RECENT FINDINGS Therapeutic hypothermia is standard of care for the treatment of neonatal encephalopathy presumed to be caused by hypoxia-ischemia. The number needed to treat is approximately 6 to 7 to prevent one child from either death or disability at age 18 to 22 months. EEG monitoring and MRI are important tools in determining the etiology of encephalopathy and prognosis of the infant. SUMMARY Neonatal encephalopathy is a heterogeneous disorder that is characterized by alterations in mental status, hypotonia, seizures, and abnormalities in feeding and respiration. The most common cause of neonatal encephalopathy is hypoxic-ischemic encephalopathy, for which treatment with 72 hours of therapeutic hypothermia is associated with reduced death or disability.
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Leifsdottir K, Mehmet H, Eksborg S, Herlenius E. Fas-ligand and interleukin-6 in the cerebrospinal fluid are early predictors of hypoxic-ischemic encephalopathy and long-term outcomes after birth asphyxia in term infants. J Neuroinflammation 2018; 15:223. [PMID: 30089504 PMCID: PMC6083505 DOI: 10.1186/s12974-018-1253-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 07/12/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebral ischemia generates neuroinflammation that can induce neural cell death. This cohort study assessed whether Fas-ligand (FasL) and interleukin (IL)-6 levels in the cerebrospinal fluid (CSF) after hypoxic-ischemic encephalopathy (HIE) can serve as biomarkers of hypoxic brain injury in neonates. METHODS Term infants (> 37-week gestational age) who were admitted to the neonatal intensive care unit of Karolinska University Hospital in years 2002 to 2004 with perinatal asphyxia were enrolled prospectively. Control infants without brain pathology underwent lumbar puncture for suspected infection. FasL and IL-6 levels were measured in the CSF, by enzyme-linked immunosorbent assays. All patients underwent neurological assessment at 18 months. HIE was classified as mild, moderate, or severe (HIE I-III). Adverse neurological outcome at 18 months was defined as a mental developmental index < 85, deafness, blindness, cerebral palsy, or seizure disorder. RESULTS Of the 44 HIE patients, 14, 16, and 14 had HIE-I, HIE-II, and HIE-III, respectively. HIE-II and HIE-III patients had higher FasL and IL-6 levels than HIE-I patients and the 20 controls (all p < 0.0001). Patients with adverse outcomes had higher FasL and IL-6 levels than patients with normal outcomes and controls (both p < 0.0001). On receiver-operator curve analyses, FasL and IL-6 (alone and together) were highly predictive of HIE grade and outcome (areas under the curve range 0.86-0.94) and showed high sensitivity (66.7-100%). These biomarkers performed better than cord blood pH (areas under the curve: HIE grade = 0.80, adverse outcomes = 0.86). CONCLUSION CSF biomarkers FasL and IL-6 predicted severity of encephalopathy and long-term outcomes in post-asphyxiated infants better than a standard biomarker.
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Affiliation(s)
- Kristin Leifsdottir
- Pediatric Unit, Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, SE-171 76, Stockholm, Sweden.,Present address: Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Huseyin Mehmet
- Clinical Sciences Division, Faculty of Medicine, Imperial College London, Hammersmith Hospital Campus, Kensington, London, SW7 2AZ, UK.,Present address: Zafgen, Inc., Boston, Massachusetts, USA
| | - Staffan Eksborg
- Pediatric Unit, Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| | - Eric Herlenius
- Pediatric Unit, Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, SE-171 76, Stockholm, Sweden.
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Falck M, Osredkar D, Maes E, Flatebø T, Wood TR, Walløe L, Sabir H, Thoresen M. Hypothermia Is Neuroprotective after Severe Hypoxic-Ischaemic Brain Injury in Neonatal Rats Pre-Exposed to PAM3CSK4. Dev Neurosci 2018; 40:189-197. [PMID: 29860252 DOI: 10.1159/000487798] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/15/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Preclinical research on the neuroprotective effect of hypothermia (HT) after perinatal asphyxia has shown variable results, depending on comorbidities and insult severity. Exposure to inflammation increases vulnerability of the neonatal brain to hypoxic-ischaemic (HI) injury, and could be one explanation for those neonates whose injury is unexpectedly severe. Gram-negative type inflammatory exposure by lipopolysaccharide administration prior to a mild HI insult results in moderate brain injury, and hypothermic neuroprotection is negated. However, the neuroprotective effect of HT is fully maintained after gram-positive type inflammatory exposure by PAM3CSK4 (PAM) pre-administration in the same HI model. Whether HT is neuroprotective in severe brain injury with gram-positive inflammatory pre-exposure has not been investigated. METHODS 59 seven-day-old rat pups were subjected to a unilateral HI insult, with left carotid artery ligation followed by 90-min hypoxia (8% O2 at Trectal 36°C). An additional 196 pups received intraperitoneal 0.9% saline (control) or PAM1 mg/kg, 8 h before undergoing the same HI insult. After randomisation to 5 h normothermia (NT37°C) or HT32°C, pups survived 1 week before they were sacrificed by perfusion fixation. Brains were harvested for hemispheric and hippocampal area loss analyses at postnatal day 14, as well as immunostaining for neuron count in the HIP CA1 region. RESULTS Normothermic PAM animals (PAM-NT) had a comparable median area loss (hemispheric: 60% [95% CI 33-66]; hippocampal: 61% [95% CI 29-67]) to vehicle animals (Veh-NT) (hemispheric: 58% [95% CI 11-64]; hippocampal: 60% [95% CI 19-68]), which is defined as severe brain injury. Furthermore, mortality was low and similar in the two groups (Veh-NT 4.5% vs. PAM-NT 6.6%). HT reduced hemispheric and hippocampal injury in the Veh group by 13 and 28%, respectively (hemispheric: p = 0.048; hippocampal: p = 0.042). HT also provided neuroprotection in the PAM group, reducing hemispheric injury by 22% (p = 0.03) and hippocampal injury by 37% (p = 0.027). CONCLUSION In these experiments with severe brain injury, Toll-like receptor-2 triggering prior to HI injury does not have an additive injurious effect, and there is a small but significant neuroprotective effect of HT. HT appears to be neuroprotective over a continuum of injury severity in this model, and the effect size tapers off with increasing area loss. Our results indicate that gram-positive inflammatory exposure prior to HI injury does not negate the neuroprotective effect of HT in severe brain injury.
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Affiliation(s)
- Mari Falck
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Damjan Osredkar
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of Paediatric Neurology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Elke Maes
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Torun Flatebø
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Thomas Ragnar Wood
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Lars Walløe
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Hemmen Sabir
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of General Paediatrics, Neonatology and Paediatric Cardiology, University Children's Hospital, Heinrich Heine University, Düsseldorf, Germany.,Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marianne Thoresen
- Division of Physiology, Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Neonatal Neuroscience, Translational Medicine, University of Bristol, Bristol, United Kingdom
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Potter M, Rosenkrantz T, Fitch RH. Behavioral and neuroanatomical outcomes in a rat model of preterm hypoxic-ischemic brain Injury: Effects of caffeine and hypothermia. Int J Dev Neurosci 2018; 70:46-55. [PMID: 29476789 DOI: 10.1016/j.ijdevneu.2018.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 02/13/2018] [Accepted: 02/15/2018] [Indexed: 01/10/2023] Open
Abstract
The current study investigated behavioral and post mortem neuroanatomical outcomes in Wistar rats with a neonatal hypoxic-ischemic (HI) brain injury induced on postnatal day 6 (P6; Rice-Vannucci HI method; Rice et al., 1981). This preparation models brain injury seen in premature infants (gestational age (GA) 32-35 weeks) based on shared neurodevelopmental markers at time of insult, coupled with similar neuropathologic sequelae (Rice et al., 1981; Workman et al., 2013). Clinically, HI insult during this window is associated with poor outcomes that include attention deficit hyperactivity disorder (ADHD), motor coordination deficits, spatial memory deficits, and language/learning disabilities. To assess therapies that might offer translational potential for improved outcomes, we used a P6 HI rat model to measure the behavioral and neuroanatomical effects of two prospective preterm neuroprotective treatments - hypothermia and caffeine. Hypothermia (aka "cooling") is an approved and moderately efficacious intervention therapy for fullterm infants with perinatal hypoxic-ischemic (HI) injury, but is not currently approved for preterm use. Caffeine is a respiratory stimulant used during removal of infants from ventilation but has shown surprising long-term benefits, leading to consideration as a therapy for HI of prematurity. Current findings support caffeine as a preterm neuroprotectant; treatment significantly improved some behavioral outcomes in a P6 HI rat model and partially rescued neuropathology. Hypothermia treatment (involving core temperature reduction by 4 °C for 5 h), conversely, was found to be largely ineffective and even deleterious for some measures in both HI and sham rats. These results have important implications for therapeutic intervention in at-risk preterm populations, and promote caution in the application of hypothermia protocols to at-risk premature infants without further research.
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Affiliation(s)
- Molly Potter
- University of Connecticut Health Center, School of Medicine, Farmington, CT, United States
| | - Ted Rosenkrantz
- University of Connecticut Health Center, Dept. of Pediatrics/Neonatology, Farmington, CT, United States
| | - R Holly Fitch
- University of Connecticut, Dept. of Psychological Sciences/Behavioral Neuroscience, Storrs, CT, United States.
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Thewissen L, Caicedo A, Lemmers P, Van Bel F, Van Huffel S, Naulaers G. Measuring Near-Infrared Spectroscopy Derived Cerebral Autoregulation in Neonates: From Research Tool Toward Bedside Multimodal Monitoring. Front Pediatr 2018; 6:117. [PMID: 29868521 PMCID: PMC5960703 DOI: 10.3389/fped.2018.00117] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/11/2018] [Indexed: 12/30/2022] Open
Abstract
Introduction: Cerebral autoregulation (CAR), the ability of the human body to maintain cerebral blood flow (CBF) in a wide range of perfusion pressures, can be calculated by describing the relation between arterial blood pressure (ABP) and cerebral oxygen saturation measured by near-infrared spectroscopy (NIRS). In literature, disturbed CAR is described in different patient groups, using multiple measurement techniques and mathematical models. Furthermore, it is unclear to what extent cerebral pathology and outcome can be explained by impaired CAR. Aim and methods: In order to summarize CAR studies using NIRS in neonates, a systematic review was performed in the PUBMED and EMBASE database. To provide a general overview of the clinical framework used to study CAR, the different preprocessing methods and mathematical models are described and explained. Furthermore, patient characteristics, definition of impaired CAR and the outcome according to this definition is described organized for the different patient groups. Results: Forty-six articles were included in this review. Four patient groups were established: preterm infants during the transitional period, neonates receiving specific medication/treatment, neonates with congenital heart disease and neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia. Correlation, coherence and transfer function (TF) gain are the mathematical models most frequently used to describe CAR. The definition of impaired CAR is depending on the mathematical model used. The incidence of intraventricular hemorrhage in preterm infants is the outcome variable most frequently correlated with impaired CAR. Hypotension, disease severity, dopamine treatment, injury on magnetic resonance imaging (MRI) and long term outcome are associated with impaired CAR. Prospective interventional studies are lacking in all research areas. Discussion and conclusion: NIRS derived CAR measurement is an important research tool to improve knowledge about central hemodynamic fluctuations during the transitional period, cerebral pharmacodynamics of frequently used medication (sedatives-inotropes) and cerebral effects of specific therapies in neonatology. Uniformity regarding measurement techniques and mathematical models is needed. Multimodal monitoring databases of neonatal intensive care patients of multiple centers, together with identical outcome parameters are needed to compare different techniques and make progress in this field. Real-time bedside monitoring of CAR, together with conventional monitoring, seems a promising technique to improve individual patient care.
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Affiliation(s)
- Liesbeth Thewissen
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Alexander Caicedo
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Petra Lemmers
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank Van Bel
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Sabine Van Huffel
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Gunnar Naulaers
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Alshweki A, Pérez-Muñuzuri A, López-Suárez O, Baña A, Couce ML. Relevance of urinary S100B protein levels as a short-term prognostic biomarker in asphyxiated infants treated with hypothermia. Medicine (Baltimore) 2017; 96:e8453. [PMID: 29095291 PMCID: PMC5682810 DOI: 10.1097/md.0000000000008453] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The initial diagnosis of neonatal hypoxic-ischemic encephalopathy is based on nervous system clinical manifestations. The use of biomarkers to monitor brain injury and evaluate neuroprotective effects allows early intervention and treatment. This study was designed to determine the short-term prognostic significance of urinary S100B calcium-binding protein (S100B) in asphyxiated newborns treated with hypothermia.An observational prospective study was conducted over a period of 5 years in 31 newborns with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. The patients were divided into 2 groups: Group A (13 newborns with a normal neurological examination before discharge) and Group B (18 newborns who died during admission or had an abnormal neurologic examination before discharge). Urinary S100B was the main variable, serum S100B and neuron-specific enolase (NSE) were considered as secondary variables, and all of them were assessed on the first 3 days of life. The newborns were subsequently divided into groups with normal and abnormal electrophysiological and imaging findings.Mean urinary S100B levels were significantly higher in group B than group A on day 1 (10.58 ± 14.82 vs 4.65 ± 9.16 μg/L, P = .031) and day 2 (5.16 ± 7.63 vs 0.88 ± 2.53, P = .002). The optimal cutoff for urinary S100B on day 1 was >1.11 μg/L of (sensitivity, 100%; specificity 60%) for the prediction of neonatal death and < 0.66 μg/L (sensitivity 83% and specificity 70%) for the prediction of a normal neurological examination before discharge. It was not possible to calculate cutoffs with a similar accuracy for serum S100B or NSE. Urinary S100B on day 1 was higher in patients with abnormal magnetic resonance imaging findings (7.89 ± 8.09 vs 4.49 ± 9.14, P = .039) and abnormal positron emission tomography findings (8.60 ± 9.29 vs 4.30 ± 8.28, P = .038). There were no significant differences in S100B levels between patients with normal and abnormal electroencephalography results.Urinary S100B measured in the first days of life can predict neonatal death and short-term prognosis in asphyxiated newborns treated with hypothermia. The method is convenient, noninvasive, and has a higher sensitivity and specificity than measurement of serum S100B or NSE.
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Harriman T, Bradshaw WT, Blake SM. The Use of Whole Body Cooling in the Treatment of Hypoxic-Ischemic Encephalopathy. Neonatal Netw 2017; 36:273-279. [PMID: 28847350 DOI: 10.1891/0730-0832.36.5.273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Hypoxic-ischemic encephalopathy (HIE) is a major cause of morbidity and mortality in neonates. Hypoxic-ischemic encephalopathy occurs as a result of a perinatal hypoxic-ischemic event just prior to or during delivery. Therapeutic hypothermia using whole body cooling is the current treatment of choice to reduce brain injury and improve long-term neurodevelopmental outcomes for neonates with HIE. All English language articles published since 2005 in PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were analyzed for existing evidence-based methods for whole body cooling. Whole body cooling is effective in the treatment of HIE in term and near-term neonates. Further research is needed to investigate the use of adjunctive therapies in conjunction with whole body cooling for improved neuroprotection.
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Lakadia MJ, Abbasi H, Gunn AJ, Unsworth CP, Bennet L. Examining the effect of MgSO4 on sharp wave transient activity in the hypoxic-ischemic fetal sheep model. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:908-911. [PMID: 28268471 DOI: 10.1109/embc.2016.7590848] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hypoxic-ischemic encephalopathy (HIE) due to lack of oxygen is a debilitating disorder experienced by a significant number of preterm infants during birth. Studies show that the brain undergoes different phases of injury following hypoxic insult, but the first 6-8 hours (known as a latent phase) are the key to treatment efficacy. Cerebral hypothermia is one known treatment, and for it to be effective it must be started during the latent phase and continued for several days. In order to determine the effectiveness of treatment it is important to pinpoint the time of insult. Monitoring of sharp wave transient activity in the hypoxic-ischemic (HI) electroencephalogram (EEG) could be a predictor for time of hypoxic insult. Due to practicality, it is optimal if this monitoring is performed automatically. Further, MgSO4 is a drug given to an increasing number of women in labor, due to its neuroprotective properties. This drug may influence transient activity in the HI fetal sheep EEG, leading to further complications in predicting hypoxic insult. This paper explores the effect of MgSO4 on sharp wave transient activity in the EEG of a HI fetal sheep. Demonstrated in this paper is the usage of a Wavelet-Type-II Fuzzy classifier to detect sharp wave transients during the latent phase of a control group fetal sheep and an MgSO4-treated fetal sheep. This detection was performed with an average overall performance of 93.21%±5.49 over 660 minutes of latent phase, post occlusion. There were no significant differences in number of sharp wave transients in the early- and mid-latent phases of injury for both fetal sheep. However, in the late-latent phase the MgSO4-treated fetal sheep had significantly fewer sharp wave transients than the control fetal sheep.
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Korogod SM, Demianenko LE. Temperature Deactivation of the Depolarizing TRP Current as a Mechanism of Hypothermia-Related Inhibition of Neuronal Activity: a Model Study. NEUROPHYSIOLOGY+ 2017. [DOI: 10.1007/s11062-017-9605-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Rocha-Ferreira E, Kelen D, Faulkner S, Broad KD, Chandrasekaran M, Kerenyi Á, Kato T, Bainbridge A, Golay X, Sullivan M, Kramer BW, Robertson NJ. Systemic pro-inflammatory cytokine status following therapeutic hypothermia in a piglet hypoxia-ischemia model. J Neuroinflammation 2017; 14:44. [PMID: 28253907 PMCID: PMC5335722 DOI: 10.1186/s12974-017-0821-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 02/24/2017] [Indexed: 11/17/2022] Open
Abstract
Background Inflammatory cytokines are implicated in the pathogenesis of perinatal hypoxia-ischemia (HI). The influence of hypothermia (HT) on cytokines after HI is unclear. Our aim was to assess in a piglet asphyxia model, under normothermic (NT) and HT conditions: (i) the evolution of serum cytokines over 48 h and (ii) cerebrospinal fluid (CSF) cytokine levels at 48 h; (iii) serum pro/anti-inflammatory cytokine profile over 48 h and (iv) relation between brain injury measured by magnetic resonance spectroscopy (MRS) and brain TUNEL positive cells with serum cytokines, serum pro/anti-inflammatory cytokines and CSF cytokines. Methods Newborn piglets were randomized to NT (n = 5) or HT (n = 6) lasting 2–26 h after HI. Serum samples were obtained 4–6 h before, during and at 6–12 h intervals after HI; CSF was obtained at 48 h. Concentrations of interleukin (IL)-1β, −4, −6, −8, −10 and TNF-α were measured and pro/anti-inflammatory status compared between groups. White matter and thalamic voxel lactate/N-acetyl aspartate (Lac/NAA) (a measure of both oxidative metabolism and neuronal loss) were acquired at baseline, after HI and at 24 and 36 h. Results Lac/NAA was reduced at 36 h with HT compared to NT (p = 0.013 basal ganglia and p = 0.033 white matter). HT showed lower serum TNF-α from baseline to 12 h (p < 0.05). Time-matched (acquired within 5 h of each other) serum cytokine and MRS showed correlations between Lac/NAA and serum IL-1β and IL-10 (all p < 0.01). The pro/anti-inflammatory ratios IL-1β/IL-10, IL-6/IL-10, IL-4/IL-10 and IL-8/IL-10 were similar in NT and HT groups until 36 h (24 h for IL-6/IL-10); after this, 36 h pro/anti-inflammatory cytokine ratios in the serum were higher in HT compared to NT (p < 0.05), indicating a pro-inflammatory cytokine surge after rewarming in the HT group. In the CSF at 48 h, IL-8 was lower in the HT group (p < 0.05). At 48 h, CSF TNF-α correlated with Lac/NAA (p = 0.02) and CSF IL-8 correlated with white matter TUNEL positive cell death (p = 0.04). Conclusions Following cerebral HI, there was a systemic pro-inflammatory surge after rewarming in the HT group, which is counterintuitive to the putative neuroprotective effects of HT. While serum cytokines were variable, elevations in CSF inflammatory cytokines at 48 h were associated with MRS Lac/NAA and white matter cell death. Electronic supplementary material The online version of this article (doi:10.1186/s12974-017-0821-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eridan Rocha-Ferreira
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | - Dorottya Kelen
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.,First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Stuart Faulkner
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | - Kevin D Broad
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | | | - Áron Kerenyi
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.,First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Takenori Kato
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK
| | - Alan Bainbridge
- Department of Medical Physics and Bioengineering, and Institute of Neurology, University College London, London, UK
| | - Xavier Golay
- Institute of Neurology, University College London, London, UK
| | - Mark Sullivan
- Institute of Reproductive and Developmental Biology, Hammersmith Campus, Imperial College London, London, UK
| | - Boris W Kramer
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.,Institute of Oncology and Developmental Biology, Institute of Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Nicola J Robertson
- Institute for Women's Health, University College London, 74 Huntley Street, London, WC1E 6AU, UK.
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25
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Glucose and Intermediary Metabolism and Astrocyte–Neuron Interactions Following Neonatal Hypoxia–Ischemia in Rat. Neurochem Res 2016; 42:115-132. [DOI: 10.1007/s11064-016-2149-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 12/09/2016] [Accepted: 12/10/2016] [Indexed: 11/27/2022]
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26
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Zou R, Mu DZ. [Prevention and treatment of energy failure in neonates with hypoxic-ischemic encephalopathy]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:915-920. [PMID: 27655554 PMCID: PMC7389965 DOI: 10.7499/j.issn.1008-8830.2016.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/27/2016] [Indexed: 06/06/2023]
Abstract
Hypoxic-ischemic encephalopathy (HIE) in neonates is the brain injury caused by perinatal asphyxia or hypoxia and is a major cause of death in neonates and nervous system dysfunction in infants and young children. Although to a certain degree, mild hypothermia therapy reduces the mortality of infants with moderate to severe HIE, it cannot achieve the expected improvements in nervous system dysfunction. Hence, it is of vital importance to search for effective therapeutic methods for HIE. The search for more therapies and better preventive measures based on the pathogenesis of HIE has resulted in much research. As an important link in the course of HIE, energy failure greatly affects the development and progression of HIE. This article reviews the research advances in the treatment and prevention of energy failure in the course of HIE.
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Affiliation(s)
- Rong Zou
- Department of Pediatrics, West China Second Hospital, Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China.
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27
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Abstract
Antepartum, intrapartum, and neonatal events can result in a spectrum of long-term neurological sequelae, including cerebral palsy, cognitive delay, schizophrenia, and autism spectrum disorders [1]. Advances in obstetrical and neonatal care have led to survival at earlier gestational ages and consequently increasing numbers of periviable infants who are at significant risk for long-term neurological deficits. Therefore, efforts to decrease and prevent cerebral insults attempt not only to decrease preterm delivery but also to improve neurological outcomes in infants delivered preterm. We recently published a comprehensive review addressing the impacts of magnesium sulfate, therapeutic hypothermia, delayed cord clamping, infections, and prevention of preterm delivery on the modification of neurological risk [2]. In this review, we will briefly provide updates to the aforementioned topics as well as an expansion on avoidance of toxin and infections, specifically the Zika virus.
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Affiliation(s)
- Angie C. Jelin
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kirsten Salmeen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Dawn Gano
- Departments of Neurology & Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Irina Burd
- Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mari-Paule Thiet
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
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28
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Zhu SZ, Gu Y, Wu Z, Hu YF, Pan SY. Hypothermia followed by rapid rewarming exacerbates ischemia-induced brain injury and augments inflammatory response in rats. Biochem Biophys Res Commun 2016; 474:175-181. [DOI: 10.1016/j.bbrc.2016.04.095] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/17/2016] [Indexed: 12/25/2022]
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29
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Spankovich C, Lobarinas E, Ding D, Salvi R, Le Prell CG. Assessment of thermal treatment via irrigation of external ear to reduce cisplatin-induced hearing loss. Hear Res 2016; 332:55-60. [DOI: 10.1016/j.heares.2015.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/21/2015] [Accepted: 11/23/2015] [Indexed: 12/20/2022]
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30
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Aridas JDS, McDonald CA, Paton MCB, Yawno T, Sutherland AE, Nitsos I, Pham Y, Ditchfield M, Fahey MC, Wong F, Malhotra A, Castillo-Melendez M, Bhakoo K, Wallace EM, Jenkin G, Miller SL. Cord blood mononuclear cells prevent neuronal apoptosis in response to perinatal asphyxia in the newborn lamb. J Physiol 2015; 594:1421-35. [PMID: 26527561 DOI: 10.1113/jp271104] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 10/23/2015] [Indexed: 11/08/2022] Open
Abstract
Perinatal asphyxia is a significant cause of death or long-term neurodevelopmental impairment. Hypothermia, currently the only effective treatment, leads to modest improvements, but new therapeutic strategies are required. Umbilical cord blood (UCB) mononuclear cells have potent anti-inflammatory properties and may reduce neuropathology. This study examined whether autologous UCB mononuclear cells were neuroprotective when administered to newborn lambs at 12 h after birth asphyxia. At caesarean section, birth asphyxia was induced by clamping the umbilical cord until mean arterial blood pressure decreased to 18-20 mmHg. Asphyxia (n = 20) or control (n = 11) lambs were resuscitated and maintained, with magnetic resonance spectroscropy (MRS) performed at 12 and 72 h, and were then killed at 72 h. Cord blood was collected once the cord was clamped, and mononuclear cells were isolated and labelled fluorescently and administered to control (n = 3) or asphyxia (n = 8) lambs. Asphyxia induced a significant increase in cellular apoptosis (caspase-3 immunopositive) within all brain regions examined, including cortex, hippocampus, thalamus, striatum and subcortical white matter (P < 0.01 vs. control). Additionally, asphyxia induced significant and widespread astrogliosis and increased inflammatory cells (activated microglia and macrophages). The administration of UCB mononuclear cells (asphyxia+UCB) significantly decreased neuronal apoptosis, astrogliosis and inflammation (P < 0.05 vs. asphyxia alone). Asphyxia+UCB lambs also demonstrated decreased brain metabolites lactate:choline (P = 0.01) and lactate:N-acetylaspartate (P < 0.01) from 12 to 72 h, detected using MRS. Autologous UCB mononuclear cell treatment restores normal brain metabolism following perinatal asphyxia, and reduces brain inflammation, astrogliosis and neuronal apoptosis, supporting its use as a neuroprotective therapy following asphyxia.
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Affiliation(s)
- James D S Aridas
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Courtney A McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Madison C B Paton
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Tamara Yawno
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Amy E Sutherland
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Ilias Nitsos
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Yen Pham
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Michael Ditchfield
- Monash Children's, Monash Health, and Department of Paediatrics, Monash University, Clayton, Victoria, Australia.,Diagnostic Imaging, Monash Health, Clayton, Victoria, Australia
| | - Michael C Fahey
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Monash Children's, Monash Health, and Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Flora Wong
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Monash Children's, Monash Health, and Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Atul Malhotra
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Monash Children's, Monash Health, and Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Margie Castillo-Melendez
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Kishore Bhakoo
- Singapore Bioimaging Consortium, Agency for Science, Technology and Research (A*STAR), Biopolis Way, Singapore
| | - Euan M Wallace
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Graham Jenkin
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
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31
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Silveira RC, Procianoy RS. Hypothermia therapy for newborns with hypoxic ischemic encephalopathy. J Pediatr (Rio J) 2015; 91:S78-83. [PMID: 26354871 DOI: 10.1016/j.jped.2015.07.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 08/03/2015] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Therapeutic hypothermia reduces cerebral injury and improves the neurological outcome secondary to hypoxic ischemic encephalopathy in newborns. It has been indicated for asphyxiated full-term or near-term newborn infants with clinical signs of hypoxic-ischemic encephalopathy (HIE). SOURCES A search was performed for articles on therapeutic hypothermia in newborns with perinatal asphyxia in PubMed; the authors chose those considered most significant. SUMMARY OF THE FINDINGS There are two therapeutic hypothermia methods: selective head cooling and total body cooling. The target body temperature is 34.5 °C for selective head cooling and 33.5 °C for total body cooling. Temperatures lower than 32 °C are less neuroprotective, and temperatures below 30 °C are very dangerous, with severe complications. Therapeutic hypothermia must start within the first 6h after birth, as studies have shown that this represents the therapeutic window for the hypoxic-ischemic event. Therapy must be maintained for 72 h, with very strict control of the newborn's body temperature. It has been shown that therapeutic hypothermia is effective in reducing neurologic impairment, especially in full-term or near-term newborns with moderate hypoxic-ischemic encephalopathy. CONCLUSION Therapeutic hypothermia is a neuroprotective technique indicated for newborn infants with perinatal asphyxia and hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Rita C Silveira
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Neonatology Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Renato S Procianoy
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Neonatology Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
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32
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Hassell KJ, Ezzati M, Alonso-Alconada D, Hausenloy DJ, Robertson NJ. New horizons for newborn brain protection: enhancing endogenous neuroprotection. Arch Dis Child Fetal Neonatal Ed 2015; 100:F541-52. [PMID: 26063194 PMCID: PMC4680177 DOI: 10.1136/archdischild-2014-306284] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/28/2015] [Indexed: 01/09/2023]
Abstract
Intrapartum-related events are the third leading cause of childhood mortality worldwide and result in one million neurodisabled survivors each year. Infants exposed to a perinatal insult typically present with neonatal encephalopathy (NE). The contribution of pure hypoxia-ischaemia (HI) to NE has been debated; over the last decade, the sensitising effect of inflammation in the aetiology of NE and neurodisability is recognised. Therapeutic hypothermia is standard care for NE in high-income countries; however, its benefit in encephalopathic babies with sepsis or in those born following chorioamnionitis is unclear. It is now recognised that the phases of brain injury extend into a tertiary phase, which lasts for weeks to years after the initial insult and opens up new possibilities for therapy.There has been a recent focus on understanding endogenous neuroprotection and how to boost it or to supplement its effectors therapeutically once damage to the brain has occurred as in NE. In this review, we focus on strategies that can augment the body's own endogenous neuroprotection. We discuss in particular remote ischaemic postconditioning whereby endogenous brain tolerance can be activated through hypoxia/reperfusion stimuli started immediately after the index hypoxic-ischaemic insult. Therapeutic hypothermia, melatonin, erythropoietin and cannabinoids are examples of ways we can supplement the endogenous response to HI to obtain its full neuroprotective potential. Achieving the correct balance of interventions at the correct time in relation to the nature and stage of injury will be a significant challenge in the next decade.
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Affiliation(s)
- K Jane Hassell
- Institute for Women's Health, University College London, London, UK
| | - Mojgan Ezzati
- Institute for Women's Health, University College London, London, UK
| | | | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, NIHR University College London Hospitals Biomedical Research Centre, University College London Hospital & Medical School, London, UK
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33
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Hypothermia therapy for newborns with hypoxic ischemic encephalopathy. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2015. [DOI: 10.1016/j.jpedp.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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34
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Davidson JO, Wassink G, van den Heuij LG, Bennet L, Gunn AJ. Therapeutic Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy - Where to from Here? Front Neurol 2015; 6:198. [PMID: 26441818 PMCID: PMC4568393 DOI: 10.3389/fneur.2015.00198] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 08/31/2015] [Indexed: 11/13/2022] Open
Abstract
Hypoxia-ischemia before or around the time of birth occurs in approximately 2/1000 live births and is associated with a high risk of death or lifelong disability. Therapeutic hypothermia is now well established as standard treatment for infants with moderate to severe hypoxic-ischemic encephalopathy but is only partially effective. There is compelling preclinical and clinical evidence that hypothermia is most protective when it is started as early as possible after hypoxia-ischemia. Further improvements in outcome from therapeutic hypothermia are very likely to arise from strategies to reduce the delay before starting treatment of affected infants. In this review, we examine evidence that current protocols are reasonably close to the optimal depth and duration of cooling, but that the optimal rate of rewarming after hypothermia is unclear. The potential for combination treatments to augment hypothermic neuroprotection has considerable promise, particularly with endogenous targets such as melatonin and erythropoietin, and noble gases such as xenon. We dissect the critical importance of preclinical studies using realistic delays in treatment and clinically relevant cooling protocols when examining combination treatment, and that for many strategies overlapping mechanisms of action can substantially attenuate any effects.
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Affiliation(s)
- Joanne O Davidson
- The Department of Physiology, The University of Auckland , Auckland , New Zealand
| | - Guido Wassink
- The Department of Physiology, The University of Auckland , Auckland , New Zealand
| | | | - Laura Bennet
- The Department of Physiology, The University of Auckland , Auckland , New Zealand
| | - Alistair J Gunn
- The Department of Physiology, The University of Auckland , Auckland , New Zealand
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35
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Xu SY, Hu FY, Ren LJ, Chen L, Zhou ZQ, Zhang XJ, Li WP. Dantrolene enhances the protective effect of hypothermia on cerebral cortex neurons. Neural Regen Res 2015; 10:1279-85. [PMID: 26487856 PMCID: PMC4590241 DOI: 10.4103/1673-5374.162761] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2015] [Indexed: 01/05/2023] Open
Abstract
Therapeutic hypothermia is the most promising non-pharmacological neuroprotective strategy against ischemic injury. However, shivering is the most common adverse reaction. Many studies have shown that dantrolene is neuroprotective in in vitro and in vivo ischemic injury models. In addition to its neuroprotective effect, dantrolene neutralizes the adverse reaction of hypothermia. Dantrolene may be an effective adjunctive therapy to enhance the neuroprotection of hypothermia in treating ischemic stroke. Cortical neurons isolated from rat fetuses were exposed to 90 minutes of oxygen-glucose deprivation followed by reoxygenation. Neurons were treated with 40 μM dantrolene, hypothermia (at 33°C), or the combination of both for 12 hours. Results revealed that the combination of dantrolene and hypothermia increased neuronal survival and the mitochondrial membrane potential, and reduced intracellular active oxygen cytoplasmic histone-associated DNA fragmentation, and apoptosis. Furthermore, improvements in cell morphology were observed. The combined treatment enhanced these responses compared with either treatment alone. These findings indicate that dantrolene may be used as an effective adjunctive therapy to enhance the neuroprotective effects of hypothermia in ischemic stroke.
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Affiliation(s)
- Sui-yi Xu
- Postdoctoral Workstation, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, Guangdong Province, China
- Department of Brain Center, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, Guangdong Province, China
| | - Feng-yun Hu
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Li-jie Ren
- Department of Brain Center, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, Guangdong Province, China
| | - Lei Chen
- Department of Brain Center, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, Guangdong Province, China
| | - Zhu-qing Zhou
- Department of Brain Center, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, Guangdong Province, China
| | - Xie-jun Zhang
- Department of Brain Center, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, Guangdong Province, China
| | - Wei-ping Li
- Postdoctoral Workstation, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, Guangdong Province, China
- Department of Brain Center, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen University First Affiliated Hospital, Shenzhen, Guangdong Province, China
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36
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Sex differences in behavioral outcomes following temperature modulation during induced neonatal hypoxic ischemic injury in rats. Brain Sci 2015; 5:220-40. [PMID: 26010486 PMCID: PMC4493466 DOI: 10.3390/brainsci5020220] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 04/24/2015] [Accepted: 05/12/2015] [Indexed: 12/30/2022] Open
Abstract
Neonatal hypoxia ischemia (HI; reduced oxygen and/or blood flow to the brain) can cause various degrees of tissue damage, as well as subsequent cognitive/behavioral deficits such as motor, learning/memory, and auditory impairments. These outcomes frequently result from cardiovascular and/or respiratory events observed in premature infants. Data suggests that there is a sex difference in HI outcome, with males being more adversely affected relative to comparably injured females. Brain/body temperature may play a role in modulating the severity of an HI insult, with hypothermia during an insult yielding more favorable anatomical and behavioral outcomes. The current study utilized a postnatal day (P) 7 rodent model of HI injury to assess the effect of temperature modulation during injury in each sex. We hypothesized that female P7 rats would benefit more from lowered body temperatures as compared to male P7 rats. We assessed all subjects on rota-rod, auditory discrimination, and spatial/non-spatial maze tasks. Our results revealed a significant benefit of temperature reduction in HI females as measured by most of the employed behavioral tasks. However, HI males benefitted from temperature reduction as measured on auditory and non-spatial tasks. Our data suggest that temperature reduction protects both sexes from the deleterious effects of HI injury, but task and sex specific patterns of relative efficacy are seen.
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37
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Xie C, Zhou K, Wang X, Blomgren K, Zhu C. Therapeutic benefits of delayed lithium administration in the neonatal rat after cerebral hypoxia-ischemia. PLoS One 2014; 9:e107192. [PMID: 25211332 PMCID: PMC4161387 DOI: 10.1371/journal.pone.0107192] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/07/2014] [Indexed: 01/02/2023] Open
Abstract
Aim We have previously shown that lithium treatment immediately after hypoxia-ischemia (HI) in neonatal rats affords both short- and long-term neuroprotection. The aim of this study was to evaluate possible therapeutic benefits when lithium treatment was delayed 5 days, a time point when most cell death is over. Methods Eight-day-old male rats were subjected to unilateral HI and 2 mmol/kg lithium chloride was injected intraperitoneally 5 days after the insult. Additional lithium injections of 1 mmol/kg were administered at 24 h intervals for the next 14 days. Brain injury was evaluated 12 weeks after HI. Serum cytokine measurements and behavioral analysis were performed before sacrificing the animals. Results Brain injury, as indicated by tissue loss, was reduced by 38.7%, from 276.5±27.4 mm3 in the vehicle-treated group to 169.3±25.9 mm3 in the lithium-treated group 12 weeks after HI (p<0.01). Motor hyperactivity and anxiety-like behavior after HI were normalized by lithium treatment. Lithium treatment increased neurogenesis in the dentate gyrus as indicated by doublecortin labeling. Serum cytokine levels, including IL-1α, IL-1β, and IL-6, were still elevated as late as 5 weeks after HI, but lithium treatment normalized these cytokine levels. Conclusions Delayed lithium treatment conferred long-term neuroprotection in neonatal rats after HI, and this opens a new avenue for future development of treatment strategies for neonatal brain injury that can be administered after the acute injury phase.
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Affiliation(s)
- Cuicui Xie
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
- Department of Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Kai Zhou
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
- Department of Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Xiaoyang Wang
- Perinatal Center, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
- Department of Pediatrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Klas Blomgren
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
- Department of Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden
- Department of Pediatrics, University of Gothenburg, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Changlian Zhu
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
- Department of Pediatrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Pediatrics, Zhengzhou Children's Hospital, Zhengzhou, China
- * E-mail:
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Xu SY, Hu YF, Li WP, Wu YM, Ji Z, Wang SN, Li K, Pan SY. Intermittent hypothermia is neuroprotective in an in vitro model of ischemic stroke. Int J Biol Sci 2014; 10:873-81. [PMID: 25170301 PMCID: PMC4147221 DOI: 10.7150/ijbs.8868] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 07/14/2014] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To investigate whether the intermittent hypothermia (IH) protects neurons against ischemic insult and the potential molecular targets using an in vitro ischemic model of oxygen glucose deprivation (OGD). METHODS Fetal rat cortical neurons isolated from Day E18 rat embryos were subjected to 90-min OGD and hypothermia treatments during reoxygenation before examining the changes in microscopic morphology, cell viability, microtubule- associated protein 2 (MAP-2) release, intracellular pH value and calcium, reactive oxygen species (ROS) generation, mitochondrial membrane potential (△Ψm) and neuronal death using cell counting kit (CCK-8), enzyme-linked immunosorbent assay (ELISA), BCECF AM, Fluo-3 AM, DCFH-DA and dihydroethidium (DHE), JC-1 staining and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL), respectively. RESULTS 90-min OGD induced morphologic abnormalities, cell viability decline, MAP-2 release, intracellular acidosis, calcium overload, increased ROS generation, △Ψm decrease and cell death in primary neurons, which was partially inhibited by continuous hypothermia (CH) and intermittent hypothermia (IH). Interestingly, 6-h CH was insufficient to reduce intracellular calcium overload and stabilize mitochondrial membrane potential (△Ψm), while 12-h CH was effective in reversing the above changes. All IH treatments (6×1 h, 4×1.5 h or 3×2 h) effectively attenuated intracellular free calcium overload, inhibited ROS production, stabilized mitochondrial membrane potential (△Ψm) and reduced delayed cell death in OGD-treated cells. However, only IH intervals longer than 1.5 h appeared to be effective in preventing cell viability loss and intracellular pH decline. CONCLUSION Both CH and IH were neuroprotective in an in vitro model of ischemic stroke, and in spite of shorter hypothermia duration, IH could provide a comparable neuroprotection to CH.
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Affiliation(s)
- Sui-yi Xu
- 1. Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; ; 2. Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen University 1st Affiliated Hospital, Shenzhen 518035, China
| | - Ya-fang Hu
- 1. Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Wei-pin Li
- 2. Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen University 1st Affiliated Hospital, Shenzhen 518035, China
| | - Yong-ming Wu
- 1. Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Zhong Ji
- 1. Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Sheng-nan Wang
- 1. Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Ke Li
- 3. Research Center of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Su-yue Pan
- 1. Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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Bhat BV, Adhisivam B. Therapeutic cooling for perinatal asphyxia-Indian experience. Indian J Pediatr 2014; 81:585-91. [PMID: 24619565 DOI: 10.1007/s12098-014-1348-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 01/09/2014] [Indexed: 01/25/2023]
Abstract
Therapeutic hypothermia (TH) has been established as standard of care for term babies with perinatal asphyxia in developed countries. However, it is yet to gain momentum in India. This review summarizes some of the TH trials conducted in India and the various related issues in adapting the same for the Indian context.
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Affiliation(s)
- B Vishnu Bhat
- Neonatology Division, Department of Pediatrics, Jawaharlal, Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605 006, India,
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Ichinose M, Kamei Y, Iriyama T, Imada S, Seyama T, Toshimitsu M, Asou H, Yamamoto M, Fujii T. Hypothermia attenuates apoptosis and protects contact between myelin basic protein-expressing oligodendroglial-lineage cells and neurons against hypoxia-Ischemia. J Neurosci Res 2014; 92:1270-85. [DOI: 10.1002/jnr.23418] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 04/17/2014] [Accepted: 04/21/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Mari Ichinose
- Department of Obstetrics and Gynecology; Graduate School of Medicine, University of Tokyo; Tokyo Japan
| | - Yoshimasa Kamei
- Department of Obstetrics and Gynecology; Graduate School of Medicine, University of Tokyo; Tokyo Japan
| | - Takayuki Iriyama
- Department of Obstetrics and Gynecology; Graduate School of Medicine, University of Tokyo; Tokyo Japan
| | - Shinya Imada
- Department of Obstetrics and Gynecology; Graduate School of Medicine, University of Tokyo; Tokyo Japan
| | - Takahiro Seyama
- Department of Obstetrics and Gynecology; Graduate School of Medicine, University of Tokyo; Tokyo Japan
| | - Masatake Toshimitsu
- Department of Obstetrics and Gynecology; Graduate School of Medicine, University of Tokyo; Tokyo Japan
| | - Hiroaki Asou
- Center for Kampo Medicine, Keio University School of Medicine; Tokyo Japan
| | | | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology; Graduate School of Medicine, University of Tokyo; Tokyo Japan
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Status epilepticus after prolonged umbilical cord occlusion is associated with greater neural injury in [corrected] fetal sheep at term-equivalent. PLoS One 2014; 9:e96530. [PMID: 24797081 PMCID: PMC4010475 DOI: 10.1371/journal.pone.0096530] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 04/08/2014] [Indexed: 12/24/2022] Open
Abstract
The majority of pre-clinical studies of hypoxic-ischemic encephalopathy at term-equivalent have focused on either relatively mild insults, or on functional paradigms of cerebral ischemia or hypoxia-ischemia/hypotension. There is surprisingly little information on the responses to single, severe ‘physiological’ insults. In this study we examined the evolution and pattern of neural injury after prolonged umbilical cord occlusion (UCO). 36 chronically instrumented fetal sheep at 125–129 days gestational age (term = 147 days) were subjected to either UCO until mean arterial pressure was < = 8 mmHg (n = 29), or sham occlusion (n = 7). Surviving fetuses were killed after 72 hours for histopathologic assessment with acid-fuchsin thionine. After UCO, 11 fetuses died with intractable hypotension and 5 ewes entered labor and were euthanized. The remaining 13 fetuses showed marked EEG suppression followed by evolving seizures starting at 5.8 (6.8) hours (median (interquartile range)). 6 of 13 developed status epilepticus, which was associated with a transient secondary increase in cortical impedance (a measure of cytotoxic edema, p<0.05). All fetuses showed moderate to severe neuronal loss in the hippocampus and the basal ganglia but mild cortical cell loss (p<0.05 vs sham occlusion). Status epilepticus was associated with more severe terminal hypotension (p<0.05) and subsequently, greater neuronal loss (p<0.05). In conclusion, profound UCO in term-equivalent fetal sheep was associated with delayed seizures, secondary cytotoxic edema, and subcortical injury, consistent with the predominant pattern after peripartum sentinel events at term. It is unclear whether status epilepticus exacerbated cortical injury or was simply a reflection of a longer duration of asphyxia.
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Drury PP, Davidson JO, Mathai S, van den Heuij LG, Ji H, Bennet L, Tan S, Silverman RB, Gunn AJ. nNOS inhibition during profound asphyxia reduces seizure burden and improves survival of striatal phenotypic neurons in preterm fetal sheep. Neuropharmacology 2014; 83:62-70. [PMID: 24726307 DOI: 10.1016/j.neuropharm.2014.03.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 03/17/2014] [Accepted: 03/31/2014] [Indexed: 12/01/2022]
Abstract
Basal ganglia injury after hypoxia-ischemia remains common in preterm infants, and is closely associated with later cerebral palsy. In the present study we tested the hypothesis that a highly selective neuronal nitric oxide synthase (nNOS) inhibitor, JI-10, would improve survival of striatal phenotypic neurons after profound asphyxia, and that the subsequent seizure burden and recovery of EEG are associated with neural outcome. 24 chronically instrumented preterm fetal sheep were randomized to either JI-10 (3 ml of 0.022 mg/ml, n = 8) or saline (n = 8) infusion 15 min before 25 min complete umbilical cord occlusion, or saline plus sham-occlusion (n = 8). Umbilical cord occlusion was associated with reduced numbers of calbindin-28k-, GAD-, NPY-, PV-, Calretinin- and nNOS-positive striatal neurons (p < 0.05 vs. sham occlusion) but not ChAT-positive neurons. JI-10 was associated with increased numbers of calbindin-28k-, GAD-, nNOS-, NPY-, PV-, Calretinin- and ChAT-positive striatal neurons (p < 0.05 vs. saline + occlusion). Seizure burden was strongly associated with loss of calbindin-positive cells (p < 0.05), greater seizure amplitude was associated with loss of GAD-positive cells (p < 0.05), and with more activated microglia in the white matter tracts (p < 0.05). There was no relationship between EEG power after 7 days recovery and total striatal cell loss, but better survival of NPY-positive neurons was associated with lower EEG power. In summary, these findings suggest that selective nNOS inhibition during asphyxia is associated with protection of phenotypic striatal projection neurons and has potential to help reduce basal ganglia injury in some premature babies.
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Affiliation(s)
- Paul P Drury
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Sam Mathai
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | | | - Haitao Ji
- Department of Chemistry, Department of Molecular Biosciences, Chemistry of Life Processes Institute, Center for Molecular Innovation and Drug Discovery, Northwestern University, Evanston, IL 60208-3113, USA; Department of Chemistry, University of Utah, Salt Lake City, UT, USA
| | - Laura Bennet
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Sidhartha Tan
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, IL, USA
| | - Richard B Silverman
- Department of Chemistry, Department of Molecular Biosciences, Chemistry of Life Processes Institute, Center for Molecular Innovation and Drug Discovery, Northwestern University, Evanston, IL 60208-3113, USA
| | - Alistair J Gunn
- Department of Physiology, University of Auckland, Auckland, New Zealand.
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Bolouri H, Sävman K, Wang W, Thomas A, Maurer N, Dullaghan E, Fjell CD, Ek CJ, Hagberg H, Hancock REW, Brown KL, Mallard C. Innate defense regulator peptide 1018 protects against perinatal brain injury. Ann Neurol 2014; 75:395-410. [DOI: 10.1002/ana.24087] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 09/20/2013] [Accepted: 12/03/2013] [Indexed: 12/24/2022]
Affiliation(s)
- Hayde Bolouri
- Institute of Neuroscience and Physiology; Department of Physiology, Sahlgrenska Academy, University of Gothenburg; Gothenburg Sweden
| | - Karin Sävman
- Institute of Neuroscience and Physiology; Department of Physiology, Sahlgrenska Academy, University of Gothenburg; Gothenburg Sweden
- Department of Pediatrics, Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - Wei Wang
- Institute of Neuroscience and Physiology; Department of Physiology, Sahlgrenska Academy, University of Gothenburg; Gothenburg Sweden
| | - Anitha Thomas
- Centre for Drug Research and Development; Vancouver, British Columbia; Canada
| | - Norbert Maurer
- Centre for Drug Research and Development; Vancouver, British Columbia; Canada
| | - Edie Dullaghan
- Centre for Drug Research and Development; Vancouver, British Columbia; Canada
| | - Christopher D. Fjell
- James Hogg Research Centre; University of British Columbia at St Paul's Hospital; Vancouver British Columbia Canada
| | - C. Joakim Ek
- Institute of Neuroscience and Physiology; Department of Physiology, Sahlgrenska Academy, University of Gothenburg; Gothenburg Sweden
| | - Henrik Hagberg
- Perinatal Center, Department of Clinical Sciences; Sahlgrenska Academy, University of Gothenburg; Gothenburg Sweden
- Centre for the Developing Brain, King's College; Perinatal Imaging and Health, St Thomas' Hospital; London United Kingdom
| | - Robert E. W. Hancock
- James Hogg Research Centre; University of British Columbia at St Paul's Hospital; Vancouver British Columbia Canada
| | - Kelly L. Brown
- Department of Rheumatology and Inflammation Research; Sahlgrenska Academy, University of Gothenburg; Gothenburg Sweden
| | - Carina Mallard
- Institute of Neuroscience and Physiology; Department of Physiology, Sahlgrenska Academy, University of Gothenburg; Gothenburg Sweden
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Hypothermia is not neuroprotective after infection-sensitized neonatal hypoxic-ischemic brain injury. Resuscitation 2013; 85:567-72. [PMID: 24361672 DOI: 10.1016/j.resuscitation.2013.12.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 12/10/2013] [Accepted: 12/13/2013] [Indexed: 01/17/2023]
Abstract
BACKGROUND Therapeutic hypothermia (HT) is the standard treatment after perinatal hypoxic-ischemic (HI) injury. Infection increases vulnerability to HI injury, but the effect of HT on lipopolysaccharide (LPS) sensitized HI brain injury is unknown. DESIGN/METHODS P7 rat pups were injected either with vehicle or LPS, and after a 4h delay they were exposed to left carotid ligation followed by global hypoxia inducing a unilateral stroke-like HI injury. Pups were randomized to the following treatments: (1) vehicle treated HI-pups receiving normothermia treatment (NT) (Veh-NT; n=30); (2) LPS treated HI-pups receiving NT treatment (LPS-NT; n=35); (3) vehicle treated HI-pups receiving HT treatment (Veh-HT; n=29); or (4) LPS treated HI-pups receiving HT treatment (LPS-HT; n=46). Relative area loss of the left/right hemisphere and the areas of hippocampi were measured at P14. RESULTS Mean brain area loss in the Veh-NT group was 11.2±14%. The brain area loss in LPS-NT pups was 29.8±17%, which was significantly higher than in the Veh-NT group (p=0.002). The Veh-HT group had a significantly smaller brain area loss (5.4±6%), when compared to Veh-NT group (p=0.043). The LPS-HT group showed a brain area loss of 32.5±16%, which was significantly higher than in the Veh-HT group (p<0.001). LPS-HT group also had significantly smaller size of the left hippocampus, which was not found in other groups. LPS-sensitization significantly decreased the sizes of the right, unligated-hemispheres, independent of post-HI treatment. CONCLUSIONS Therapeutic hypothermia is not neuroprotective in this LPS-sensitized unilateral stroke-like HI brain injury model in newborn rats. Lack of neuroprotection was particularly seen in the hippocampus. Pre-insult exposure to LPS also induced brain area loss in the unligated hemisphere, which is normally not affected in this model.
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Fontes MT, McDonagh DL, Phillips-Bute B, Welsby IJ, Podgoreanu MV, Fontes ML, Stafford-Smith M, Newman MF, Mathew JP. Arterial hyperoxia during cardiopulmonary bypass and postoperative cognitive dysfunction. J Cardiothorac Vasc Anesth 2013; 28:462-6. [PMID: 23972739 DOI: 10.1053/j.jvca.2013.03.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the effect of arterial normobaric hyperoxia during cardiopulmonary bypass (CPB) on postoperative neurocognitive function. The authors hypothesized that arterial hyperoxia during CPB is associated with neurocognitive decline at 6 weeks after cardiac surgery. DESIGN Retrospective study of patients undergoing cardiac surgery with CPB. SETTING A university hospital. PARTICIPANTS One thousand eighteen patients undergoing coronary artery bypass graft (CABG) or CABG + valve surgery with CPB who previously had been enrolled in prospective cognitive trials. INTERVENTIONS A battery of neurocognitive measures was administered at baseline and 6 weeks after surgery. Anesthetic and surgical care was managed as clinically indicated. MEASUREMENTS AND MAIN RESULTS Arterial hyperoxia was assessed primarily as the area under the curve (AUC) for the duration that PaO2 exceeded 200 mmHg during CPB and secondarily as the mean PaO2 during bypass, as a PaO2 = 300 mmHg at any point and as AUC>150 mmHg. Cognitive change was assessed both as a continuous change score and a dichotomous deficit rate. Multivariate regression accounting for age, years of education, baseline cognition, date of surgery, baseline postintubation PaO2, duration of CPB, and percent change in hematocrit level from baseline to lowest level during CPB revealed no significant association between hyperoxia during CPB and postoperative neurocognitive function. CONCLUSIONS Arterial hyperoxia during CPB was not associated with neurocognitive decline after 6 weeks in cardiac surgical patients.
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Affiliation(s)
- Monique T Fontes
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - David L McDonagh
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | | | - Ian J Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Mihai V Podgoreanu
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Manuel L Fontes
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | | | - Mark F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC.
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Bao L, Xu F. Fundamental research progress of mild hypothermia in cerebral protection. SPRINGERPLUS 2013; 2:306. [PMID: 23888277 PMCID: PMC3710408 DOI: 10.1186/2193-1801-2-306] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 07/03/2013] [Indexed: 11/27/2022]
Abstract
Through the years, the clinical application of mild hypothermia has been carried out worldwide and is built from the exploration and cognition of neuroprotection mechanisms by hypothermia. However, within the last decade, extensive and fundamental researches in this area have been conducted. In addition to aspects of the previous findings, scholars have discovered several new contents and uncertain results. This article reviews and summarizes this decade’s progression of mild hypothermia in lowering the cerebral oxygen metabolism, protecting the blood–brain-barrier, regulating the inflammatory response, regulating the excessive release of neurotransmitters, inhibiting calcium overload, and reducing neuronal apoptosis. In many aspects, particularly in regulating inflammatory reverse reaction, various results have been reported and therefore guide scholars to conduct more detailed analysis and investigation in order to discover the inherent theories surrounding the effect of mild hypothermia, and for better clinical services.
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Affiliation(s)
- Long Bao
- Department of Emergency medicine, The First Affiliated Hospital of Soochow University, Suzhou, 215006 China
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Spasojevic SD, Stojanovic VD, Barisic NA, Doronjski AR, Zikic DR, Babovic SM. Neuroprotective effects of hypothermia and erythropoietin after perinatal asphyxia in newborn rats. J Matern Fetal Neonatal Med 2013; 26:1506-9. [PMID: 23528136 DOI: 10.3109/14767058.2013.789846] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Evaluation of neuroprotective effects of hypothermia, erythropoietin and their simultaneous use after perinatal asphyxia in newborn rats. METHOD Hysterectomy was performed to Wistar female rats on the last day of gestation. Perinatal asphyxia was induced by submersion of uterus containing pups in saline for 15 min. After resuscitation, pups were randomized into 4 groups, 15 animals in each: G1 - asphyxia; G2 - asphyxia + hypothermia (rectal temperature 33 °C for 1 h); G3 - asphyxia + erythropoietin (Darbepoetin-α 2.5 μg, intraperitoneally) and G4 - asphyxia + erythropoietin + hypothermia. Pups were sacrificed on 7th day of life and histopathological analysis of hippocampus was performed. RESULTS Measure of damage to dorsal, ventral and entire hippocampus was significantly lower in groups G2, G3 and G4 than in group G1 (p ~ 0.00; respectively). Measure of damage to hippocampus in group G4 was significantly lower than in group G2 (p = 0.029). CONCLUSIONS This study demonstrates that simultaneous use of hypothermia and erythropoietin has more expressed neuroprotective effects than sole use of hypothermia after perinatal asphyxia in newborn rats.
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Laptook AR, McDonald SA, Shankaran S, Stephens BE, Vohr BR, Guillet R, Higgins RD, Das A. Elevated temperature and 6- to 7-year outcome of neonatal encephalopathy. Ann Neurol 2013; 73:520-8. [PMID: 23595408 DOI: 10.1002/ana.23843] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 11/20/2012] [Accepted: 11/30/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVE A study was undertaken to determine whether higher temperature after hypoxia-ischemia is associated with death or intelligence quotient (IQ)<70 at 6 to 7 years among infants treated with intensive care without hypothermia. METHODS Control infants (noncooled, n=106) of the National Institute of Child Health and Human Development Neonatal Research Network hypothermia trial had serial esophageal and skin temperatures over 72 hours. Each infant's temperature was ranked to derive an average of the upper and lower quartile, and median of each site. Temperatures were used in logistic regressions to determine adjusted associations with death or IQ<70 at 6 to 7 years. Secondary outcomes were death, IQ<70, and moderate/severe cerebral palsy (CP). IQ and motor function were assessed with Wechsler Scales for Children and Gross Motor Function Classification System. Results are odds ratio (OR; per degree Celsius increment within the quartile or median) and 95% confidence interval (CI). RESULTS Primary outcome was available for 89 infants. At 6 to 7 years, death or IQ<70 occurred in 54 infants (37 deaths, 17 survivors with IQ<70) and moderate/severe CP in 15 infants. Death or IQ<70 was associated with the upper quartile average of esophageal (OR=7.3, 95% CI=2.0-26.3) and skin temperature (OR=3.5, 95% CI=1.2-10.4). CP was associated with the upper quartile average of esophageal (OR=12.5, 95% CI=1.02-155) and skin temperature (OR=10.3, 95% CI=1.3-80.2). INTERPRETATION Among noncooled infants of a randomized trial, elevated temperatures during the first postnatal days are associated with increased odds of a worse outcome at 6 to 7 years.
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Affiliation(s)
- Abbot R Laptook
- Alpert Medical School of Brown University and Women & Infants Hospital of Rhode Island, Providence, RI
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Motamedi GK, Lesser RP, Vicini S. Therapeutic brain hypothermia, its mechanisms of action, and its prospects as a treatment for epilepsy. Epilepsia 2013; 54:959-70. [PMID: 23551057 DOI: 10.1111/epi.12144] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 11/30/2022]
Abstract
Cooling the core body temperature to 32-35°C, is almost standard practice for conditions such as cardiac arrest in adults, and perinatal hypoxic ischemic encephalopathy in neonates. Limited clinical data, and more extensive animal experiments, indicate that hypothermia could help control seizures, and could be applied directly to the brain using implantable devices. These data have fostered further research to evaluate whether cooling would be a viable means to treat refractory epilepsy. Although the effect of temperature on cellular physiology has long been recognized, with possibly dual effects on pyramidal cells and interneurons, the exact mechanisms underlying its beneficial effects, in particular in epilepsy, are yet to be discovered. This article reviews currently available clinical and laboratory data with a focus on cellular mechanisms of action and prospects of hypothermia as a treatment for intractable seizures.
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Affiliation(s)
- Gholam K Motamedi
- Department of Neurology, Georgetown University Hospital, Washington, District of Columbia 20007, USA.
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