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Revilla-González G, Varela LM, Ruiz de Azua-López Z, Amaya-Villar R, Pezzotti MR, Castro MJ, Ureña J, González-Montelongo MDC, Castellano A. Changes in Adhesion and the Expression of Adhesion Molecules in PBMCs after Aneurysmal Subarachnoid Hemorrhage: Relation to Cerebral Vasospasm. Transl Stroke Res 2024; 15:378-387. [PMID: 36814009 PMCID: PMC10891186 DOI: 10.1007/s12975-023-01136-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/17/2023] [Accepted: 01/31/2023] [Indexed: 02/24/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a neurovascular disease produced by extravasation of blood to the subarachnoid space after rupture of the cerebral vessels. After bleeding, the immune response is activated. The role of peripheral blood mononuclear cells (PBMCs) in this response is a current subject of research. We have analysed the changes in PBMCs of patients with aSAH and their interaction with the endothelium, focusing on their adhesion and the expression of adhesion molecules. Using an in vitro adhesion assay, we observed that the adhesion of PBMCs of patients with aSAH is increased. Flow cytometry analysis shows that monocytes increased significantly in patients, especially in those who developed vasospasm (VSP). In aSAH patients, the expression of CD162, CD49d, CD62L and CD11a in T lymphocytes and of CD62L in monocytes increased. However, the expression of CD162, CD43, and CD11a decreased in monocytes. Furthermore, monocytes from patients who developed arteriographic VSP had lower expression of CD62L. In conclusion, our results confirm that after aSAH, monocyte count and adhesion of PBMCs increase, especially in patients with VSP, and that the expression of several adhesion molecules is altered. These observations can help predict VSP and to improve the treatment of this pathology.
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Affiliation(s)
- Gonzalo Revilla-González
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - Lourdes María Varela
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - Zaida Ruiz de Azua-López
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- UGC de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Rosario Amaya-Villar
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- UGC de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - María Rosa Pezzotti
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - María José Castro
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Juan Ureña
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - María Del Carmen González-Montelongo
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain.
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain.
- Unidad de Investigación, Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Hospital Universitario Puerta del Mar, Cádiz, Spain.
| | - Antonio Castellano
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain.
- Dpto. Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain.
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Zhang Y, Zeng H, Zhou H, Li J, Wang T, Guo Y, Cai L, Hu J, Zhang X, Chen G. Predicting the Outcome of Patients with Aneurysmal Subarachnoid Hemorrhage: A Machine-Learning-Guided Scorecard. J Clin Med 2023; 12:7040. [PMID: 38002653 PMCID: PMC10671848 DOI: 10.3390/jcm12227040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/05/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) frequently causes long-term disability, but predicting outcomes remains challenging. Routine parameters such as demographics, admission status, CT findings, and blood tests can be used to predict aSAH outcomes. The aim of this study was to compare the performance of traditional logistic regression with several machine learning algorithms using readily available indicators and to generate a practical prognostic scorecard based on machine learning. Eighteen routinely available indicators were collected as outcome predictors for individuals with aSAH. Logistic regression (LR), random forest (RF), support vector machines (SVMs), and fully connected neural networks (FCNNs) were compared. A scorecard system was established based on predictor weights. The results show that machine learning models and a scorecard achieved 0.75~0.8 area under the curve (AUC) predicting aSAH outcomes (LR 0.739, RF 0.749, SVM 0.762~0.793, scorecard 0.794). FCNNs performed best (~0.95) but lacked interpretability. The scorecard model used only five factors, generating a clinically useful tool with a total cutoff score of ≥5, indicating poor prognosis. We developed and validated machine learning models proven to predict outcomes more accurately in individuals with aSAH. The parameters found to be the most strongly predictive of outcomes were NLR, lymphocyte count, monocyte count, hypertension status, and SEBES. The scorecard system provides a simplified means of applying predictive analytics at the bedside using a few key indicators.
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Affiliation(s)
- Yi Zhang
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310016, China
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou 310016, China
| | - Hanhai Zeng
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310016, China
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou 310016, China
| | - Hang Zhou
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310016, China
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou 310016, China
| | - Jingbo Li
- Department of Neurointensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Tingting Wang
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310016, China
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou 310016, China
| | - Yinghan Guo
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310016, China
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou 310016, China
| | - Lingxin Cai
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310016, China
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou 310016, China
| | - Junwen Hu
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310016, China
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou 310016, China
| | - Xiaotong Zhang
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310016, China
- College of Electrical Engineering, Zhejiang University, Hangzhou 310020, China
- Interdisciplinary Institute of Neuroscience and Technology, College of Biomedical Engineering & Instrument Science, Zhejiang University, Hangzhou 310020, China
- MOE Frontier Science Center for Brain Science and Brain-Machine Integration, Zhejiang University, Hangzhou 310058, China
| | - Gao Chen
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang University, Hangzhou 310016, China
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou 310016, China
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de Azúa-López ZR, Pezzotti MR, González-Díaz Á, Meilhac O, Ureña J, Amaya-Villar R, Castellano A, Varela LM. HDL anti-inflammatory function is impaired and associated with high SAA1 and low APOA4 levels in aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab 2023; 43:1919-1930. [PMID: 37357772 PMCID: PMC10676137 DOI: 10.1177/0271678x231184806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/07/2023] [Accepted: 06/02/2023] [Indexed: 06/27/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease with high morbidity and mortality rates. Within 24 hours after aSAH, monocytes are recruited and enter the subarachnoid space, where they mature into macrophages, increasing the inflammatory response and contributing, along with other factors, to delayed neurological dysfunction and poor outcomes. High-density lipoproteins (HDL) are lipid-protein complexes that exert anti-inflammatory effects but under pathological conditions undergo structural alterations that have been associated with loss of functionality. Plasma HDL were isolated from patients with aSAH and analyzed for their anti-inflammatory activity and protein composition. HDL isolated from patients lost the ability to prevent VCAM-1 expression in endothelial cells (HUVEC) and subsequent adhesion of THP-1 monocytes to the endothelium. Proteomic analysis showed that HDL particles from patients had an altered composition compared to those of healthy subjects. We confirmed by western blot that low levels of apolipoprotein A4 (APOA4) and high of serum amyloid A1 (SAA1) in HDL were associated with the lack of anti-inflammatory function observed in aSAH. Our results indicate that the study of HDL in the pathophysiology of aSAH is needed, and functional HDL supplementation could be considered a novel therapeutic approach to the treatment of the inflammatory response after aSAH.
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Affiliation(s)
- Zaida Ruiz de Azúa-López
- Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Unidad de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - M Rosa Pezzotti
- Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Departamento de Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - Ángela González-Díaz
- Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Olivier Meilhac
- Université de La Réunion, INSERM, UMR 1188 Diabète athérothombose Réunion Océan Indien (DéTROI), Saint-Pierre de La Réunion, France
- CHU de La Réunion, Saint-Pierre de la Réunion, France
| | - Juan Ureña
- Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Departamento de Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - Rosario Amaya-Villar
- Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Unidad de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Antonio Castellano
- Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Departamento de Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
| | - Lourdes M Varela
- Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Departamento de Fisiología Médica y Biofísica, Facultad de Medicina, Universidad de Sevilla, Sevilla, Spain
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Li T, Zhuang D, Xiao Y, Chen X, Zhong Y, Ou X, Peng H, Wang S, Chen W, Sheng J. A dynamic online nomogram for predicting death in hospital after aneurysmal subarachnoid hemorrhage. Eur J Med Res 2023; 28:432. [PMID: 37828549 PMCID: PMC10571411 DOI: 10.1186/s40001-023-01417-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/30/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND This study aimed to validate the efficacy the multiplication of neutrophils and monocytes (MNM) and a novel dynamic nomogram for predicting in-hospital death in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS Retrospective study was done on 986 patients with endovascular coiling for aSAH. Independent risk factors associated with in-hospital death were identified using both univariate and multivariate logistic regression analysis. In the development cohort, a dynamic nomogram of in-hospital deaths was introduced and made available online as a straightforward calculator. To predict the in-hospital death from the external validation cohort by nomogram, calibration analysis, decision curve analysis, and receiver operating characteristic analysis were carried out. RESULTS 72/687 patients (10.5%) in the development cohort and 31/299 patients (10.4%) in the validation cohort died. MNM was linked to in-hospital death in univariate and multivariate regression studies. In the development cohort, a unique nomogram demonstrated a high prediction ability for in-hospital death. According to the calibration curves, the nomogram has a reliable degree of consistency and calibration. With threshold probabilities between 10% and 90%, the nomogram's net benefit was superior to the basic model. The MNM and nomogram also exhibited good predictive values for in-hospital death in the validation cohort. CONCLUSIONS MNM is a novel predictor of in-hospital mortality in patients with aSAH. For aSAH patients, a dynamic nomogram is a useful technique for predicting in-hospital death.
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Affiliation(s)
- Tian Li
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515000, Guangdong, China
| | - Dongzhou Zhuang
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, 900 Hospital, Fuzhou, 350025, China
| | - Yong Xiao
- Department of Neurosurgery, First Affiliated Hospital, Shantou University Medical College, 57 Changping Road, Shantou, 515000, Guangdong, China
| | - Xiaoxuan Chen
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515000, Guangdong, China
| | - Yuan Zhong
- Department of Neurosurgery, First Affiliated Hospital, Shantou University Medical College, 57 Changping Road, Shantou, 515000, Guangdong, China
| | - Xurong Ou
- Department of Neurosurgery, First Affiliated Hospital, Shantou University Medical College, 57 Changping Road, Shantou, 515000, Guangdong, China
| | - Hui Peng
- Department of Neurosurgery, Affiliated Jieyang People's Hospital of Sun Yat-sen University, 107 Tianfu Road, Jieyang, 522000, China
| | - Shousen Wang
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, 900 Hospital, Fuzhou, 350025, China.
| | - Weiqiang Chen
- Department of Neurosurgery, First Affiliated Hospital, Shantou University Medical College, 57 Changping Road, Shantou, 515000, Guangdong, China.
| | - Jiangtao Sheng
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515000, Guangdong, China.
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Grossini E, Esposito T, Viretto M, Venkatesan S, Licari I, Surico D, Della Corte F, Castello L, Bruno S, Quaglia M, Comi C, Cantaluppi V, Vaschetto R. Circulating Extracellular Vesicles in Subarachnoid Hemorrhage Patients: Characterization and Cellular Effects. Int J Mol Sci 2023; 24:14913. [PMID: 37834361 PMCID: PMC10573706 DOI: 10.3390/ijms241914913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023] Open
Abstract
Circulating extracellular vesicles (EVs) may play a pathophysiological role in the onset of complications of subarachnoid hemorrhage (SAH), potentially contributing to the development of vasospasm (VP). In this study, we aimed to characterize circulating EVs in SAH patients and examine their effects on endothelial and smooth muscle cells (SMCs). In a total of 18 SAH patients, 10 with VP (VP), 8 without VP (NVP), and 5 healthy controls (HC), clinical variables were recorded at different time points. EVs isolated from plasma samples were characterized and used to stimulate human vascular endothelial cells (HUVECs) and SMCs. We found that EVs from SAH patients expressed markers of T-lymphocytes and platelets and had a larger size and a higher concentration compared to those from HC. Moreover, EVs from VP patients reduced cell viability and mitochondrial membrane potential in HUVECs and increased oxidants and nitric oxide (NO) release. Furthermore, EVs from SAH patients increased intracellular calcium levels in SMCs. Altogether, our findings reveal an altered pattern of circulating EVs in SAH patients, suggesting their pathogenic role in promoting endothelial damage and enhancing smooth muscle reactivity. These results have significant implications for the use of EVs as potential diagnostic/prognostic markers and therapeutic tools in SAH management.
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Affiliation(s)
- Elena Grossini
- Laboratory of Physiology, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Teresa Esposito
- Anesthesia and Intensive Care, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy; (T.E.); (M.V.); (I.L.); (F.D.C.); (R.V.)
- Maggiore della Carità Hospital, 28100 Novara, Italy; (D.S.); (V.C.)
| | - Michela Viretto
- Anesthesia and Intensive Care, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy; (T.E.); (M.V.); (I.L.); (F.D.C.); (R.V.)
- Maggiore della Carità Hospital, 28100 Novara, Italy; (D.S.); (V.C.)
| | - Sakthipriyan Venkatesan
- Laboratory of Physiology, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Ilaria Licari
- Anesthesia and Intensive Care, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy; (T.E.); (M.V.); (I.L.); (F.D.C.); (R.V.)
- Maggiore della Carità Hospital, 28100 Novara, Italy; (D.S.); (V.C.)
| | - Daniela Surico
- Maggiore della Carità Hospital, 28100 Novara, Italy; (D.S.); (V.C.)
- Gynecology and Obstetrics, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
| | - Francesco Della Corte
- Anesthesia and Intensive Care, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy; (T.E.); (M.V.); (I.L.); (F.D.C.); (R.V.)
- Maggiore della Carità Hospital, 28100 Novara, Italy; (D.S.); (V.C.)
| | - Luigi Castello
- Internal Medicine, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy;
| | - Stefania Bruno
- Laboratory of Translational Research, Department of Medical Sciences, University of Torino, 10126 Torino, Italy;
| | - Marco Quaglia
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy;
- Nephrology, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
| | - Cristoforo Comi
- Neurology Unit, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
- Sant’Andrea Hospital, 00189 Vercelli, Italy
| | - Vincenzo Cantaluppi
- Maggiore della Carità Hospital, 28100 Novara, Italy; (D.S.); (V.C.)
- Nephrology, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy
| | - Rosanna Vaschetto
- Anesthesia and Intensive Care, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy; (T.E.); (M.V.); (I.L.); (F.D.C.); (R.V.)
- Maggiore della Carità Hospital, 28100 Novara, Italy; (D.S.); (V.C.)
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Patsouris V, Blecharz-Lang KG, Nieminen-Kelhä M, Schneider UC, Vajkoczy P. Resolution of Cerebral Inflammation Following Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:218-228. [PMID: 37349601 PMCID: PMC10499726 DOI: 10.1007/s12028-023-01770-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/31/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Aneurismal subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke that, despite improvement through therapeutic interventions, remains a devastating cerebrovascular disorder that has a high mortality rate and causes long-term disability. Cerebral inflammation after SAH is promoted through microglial accumulation and phagocytosis. Furthermore, proinflammatory cytokine release and neuronal cell death play key roles in the development of brain injury. The termination of these inflammation processes and restoration of tissue homeostasis are of utmost importance regarding the possible chronicity of cerebral inflammation and the improvement of the clinical outcome for affected patients post SAH. Thus, we evaluated the inflammatory resolution phase post SAH and considered indications for potential tertiary brain damage in cases of incomplete resolution. METHODS Subarachnoid hemorrhage was induced through endovascular filament perforation in mice. Animals were killed 1, 7 and 14 days and 1, 2 and 3 months after SAH. Brain cryosections were immunolabeled for ionized calcium-binding adaptor molecule-1 to detect microglia/macrophages. Neuronal nuclei and terminal deoxyuridine triphosphate-nick end labeling staining was used to visualize secondary cell death of neurons. The gene expression of various proinflammatory mediators in brain samples was analyzed by quantitative polymerase chain reaction. RESULTS We observed restored tissue homeostasis due to decreased microglial/macrophage accumulation and neuronal cell death 1 month after insult. However, the messenger RNA expression levels of interleukin 6 and tumor necrosis factor α were still elevated at 1 and 2 months post SAH, respectively. The gene expression of interleukin 1β reached its maximum on day 1, whereas at later time points, no significant differences between the groups were detected. CONCLUSIONS By the herein presented molecular and histological data we provide an important indication for an incomplete resolution of inflammation within the brain parenchyma after SAH. Inflammatory resolution and the return to tissue homeostasis represent an important contribution to the disease's pathology influencing the impact on brain damage and outcome after SAH. Therefore, we consider a novel complementary or even superior therapeutic approach that should be carefully rethought in the management of cerebral inflammation after SAH. An acceleration of the resolution phase at the cellular and molecular levels could be a potential aim in this context.
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Affiliation(s)
- Victor Patsouris
- Institute of Experimental Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Kinga G Blecharz-Lang
- Institute of Experimental Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Melina Nieminen-Kelhä
- Institute of Experimental Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ulf C Schneider
- Department of Neurosurgery, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Peter Vajkoczy
- Institute of Experimental Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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7
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Ma X, Gao H, Xu L, Bi Z, Ji S, Bu B. Increased expression of cell adhesion molecules in myofasciitis. Front Neurol 2023; 14:1113404. [PMID: 37228411 PMCID: PMC10203699 DOI: 10.3389/fneur.2023.1113404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
Background Myofasciitis is a heterogeneous group of diseases pathologically characterized by inflammatory cell infiltration into the fascia. Endothelial activation plays a critical role in the pathogenesis of the inflammatory response. However, the expression of cellular adhesion molecules (CAMs) in myofasciitis has not been investigated. Methods Data on clinical features, thigh magnetic resonance imaging, and muscle pathology were collected from five patients with myofasciitis. Immunohistochemical (IHC) staining and Western blot (WB) of the muscle biopsies from patients and healthy controls were performed. Results Increased levels of serum pro-inflammatory cytokines, including IL-6, TNF-α, and IL-2R, were detected in four patients. IHC staining and WB indicated significantly increased expression of cell adhesion molecules in blood vessels or inflammatory cells within the perimysium in muscle and fascia tissues of patients with myofasciitis compared to controls. Conclusion The up-regulation of CAMs in myofasciitis indicates endothelial activation, which may be potential therapy targets for the treatment of myofasciitis.
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Affiliation(s)
- Xue Ma
- Department of Neurology, Air Force Medical University Tangdu Hospital, Xi’an, China
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huajie Gao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Xu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhuajin Bi
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suqiong Ji
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Tsentsiper LM, Dryagina NV, Terekhov IS, Aybazova MI, Rumyantseva MV, Petrov AE, Petrova AO, Kondratyev AN. Inflammatory Response in Patients with Spontaneous Intracranial Hemorrhages. MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2022. [DOI: 10.21292/2078-5658-2022-19-5-71-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Mortality and disability rates in spontaneous intracranial hemorrhages remain high despite medical advances. In recent decades, much attention has been paid to neuroinflammation as a typical response to brain damage. Inflammation plays an important role in the acute and chronic phases of the disease. The relationship between plasma and cerebrospinal fluid cytokines, as well as the factors affecting their ratios, is currently not completely clear.The objective was to study the inflammatory response to spontaneous intracranial hemorrhage.Subjects and Methods. 59 patients aged 18 to 72 years (48 ± 6) were enrolled in the study. Patients were admitted to the intensive care unit after an episode of spontaneous intracranial hemorrhage. The levels of interleukins in blood plasma were studied: 6, 8, 10, TNF-α, C-reactive protein,blood leukocytes, and procalcitonin (by a semi-quantitative method). In the cerebrospinal fluid, the following parameters were evaluated: cytosis, protein, glucose, lactate, cytokines (6, 8, 10, TNF-α). Blood samples were collected on days 1, 2, 3, 5, 7, 9, 14, 21, 28, 35, and 45.Results. Systemic inflammatory response developed in all patients from the first day of acute brain injury. The most significant response was formed by glial brain cells which was confirmed by high levels of cytokines in the cerebrospinal fluid, hundreds and thousands of times higher than blood levels of cytokines.Conclusion. Levels of pro-inflammatory cytokines are predictors of an unfavorable outcome.
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Affiliation(s)
- L. M. Tsentsiper
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
| | - N. V. Dryagina
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
| | - I. S. Terekhov
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
| | - M. I. Aybazova
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
| | - M. V. Rumyantseva
- North-Western District Scientific and Clinical Center Named after L. G. Sokolov
| | - A. E. Petrov
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
| | | | - A. N. Kondratyev
- Polenov Neurosurgical Institute, the Branch of Almazov National Medical Research Center
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Henry N, Fraser JF, Chappell J, Langley T, Roberts JM. Cannabidiol’s Multifactorial Mechanisms Has Therapeutic Potential for Aneurysmal Subarachnoid Hemorrhage: a Review. Transl Stroke Res 2022; 14:283-296. [PMID: 36109476 PMCID: PMC10160197 DOI: 10.1007/s12975-022-01080-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/08/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
AbstractSubarachnoid hemorrhage (SAH) is a major health burden that accounts for approximately 5% of all strokes. The most common cause of a non-traumatic SAH is the rupture of a cerebral aneurysm. The most common symptom associated with SAH is a headache, often described as “the worst headache of my life.” Delayed cerebral ischemia (DCI) is a major factor associated with patient mortality following SAH and is often associated with SAH-induced cerebral vasospasm (CV). Cannabidiol (CBD) is emerging as a potential drug for many therapeutic purposes, including epilepsy, anxiety, and pain relief. We aim to review the potential use of CBD as a treatment option for post-SAH critically ill patients. Through a literature review, we evaluated the known pharmacology and physiological effects of CBD and correlated those with the pathophysiological outcomes associated with cerebral vasospasm following subarachnoid hemorrhage. Although overlap exists, data were formatted into three major categories: anti-inflammatory, vascular, and neuroprotective effects. Based on the amount of information known about the actions of CBD, we hypothesize the anti-inflammatory effects are likely to be the most promising therapeutic mechanism. However, its cardiovascular effects through calcium regulation and its neuroprotective effects against cell death, excitotoxicity, and oxidative stress are all plausible mechanisms by which post-SAH critically ill patients may benefit from both early and late intervention with CBD. More research is needed to better understand if and how CBD might affect neurological and vascular functions in the brain following injury such as subarachnoid hemorrhage.
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10
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Bhimani AD, Kalagara R, Chennareddy S, Kellner CP. Exosomes in subarachnoid hemorrhage: A scoping review. J Clin Neurosci 2022; 105:58-65. [PMID: 36084567 DOI: 10.1016/j.jocn.2022.08.025] [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: 06/29/2022] [Revised: 08/07/2022] [Accepted: 08/28/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Vasospasm is a common complication following subarachnoid hemorrhage (SAH), causing increased ischemia and tissue injury, and is implicated as a major risk factor for poor outcomes. The success of current treatments for vasospasm is limited, with limited efficacy and unclear clinical benefits. Exosomes, vesicles that carry small molecules such as miRNA, have been theorized as a potential vasospasm treatment. In this study, we aim to survey the current literature discussing the role of exosomes in the setting of SAH. METHODS Following PRISMA guidelines, we performed a scoping review evaluating the role of exosomes in the treatment of SAH. The search was conducted using PubMed and Scopus, and all original research papers studying exosomal profiles of SAH research subjects or SAH therapy were eligible for inclusion. RESULTS After screening and full text review, seven papers were selected for final inclusion. Of these, two studies analyzed the expression profile of endogenous exosomes after SAH. Four papers identified and characterized miRNA-based exosomal therapies to attenuate early brain injury (EBI) after SAH. One paper discussed the role of protein overexpression in exosome delivery of miRNA for EBI after SAH. Interestingly, all identified papers studying exosomal therapy demonstrated anti-apoptotic or anti-inflammatory effects of miRNA exosomes acting via the BDNF/TrkB/CREB or HDAC3/NF-κB pathways. CONCLUSION Identified studies demonstrate potential neuroprotective benefits of miRNA-based exosomal treatment of EBI and SAH. Findings warrant further research investigating the anti-inflammatory and anti-apoptotic role of exosomal miRNA delivery in SAH models, specifically targeting the common pathway identified by the authors.
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Affiliation(s)
- Abhiraj D Bhimani
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Susmita Chennareddy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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11
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Strickland BA, Barisano G, Abedi A, Shiroishi MS, Cen S, Emanuel B, Bulic S, Kim-Tenser M, Nguyen P, Giannotta SL, Mack W, Russin J. Minocycline decreases blood-brain barrier permeability following aneurysmal subarachnoid hemorrhage: a randomized, double-blind, controlled trial. J Neurosurg 2022; 136:1251-1259. [PMID: 35349976 DOI: 10.3171/2021.6.jns211270] [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: 05/20/2021] [Accepted: 06/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH)-induced vasospasm is linked to increased inflammatory cell trafficking across a permeable blood-brain barrier (BBB). Elevations in serum levels of matrix metalloprotease 9 (MMP9), a BBB structural protein, have been implicated in the pathogenesis of vasospasm onset. Minocycline is a potent inhibitor of MMP9. The authors sought to detect an effect of minocycline on BBB permeability following aSAH. METHODS Patients presenting within 24 hours of symptom onset with imaging confirmed aSAH (Fisher grade 3 or 4) were randomized to high-dose (10 mg/kg) minocycline or placebo. The primary outcome of interest was BBB permeability as quantitated by contrast signal intensity ratios in vascular regions of interest on postbleed day (PBD) 5 magnetic resonance permeability imaging. Secondary outcomes included serum MMP9 levels and radiographic and clinical evidence of vasospasm. RESULTS A total of 11 patients were randomized to minocycline (n = 6) or control (n = 5) groups. No adverse events or complications attributable to minocycline were reported. High-dose minocycline administration was associated with significantly lower permeability indices on imaging analysis (p < 0.01). There was no significant difference with respect to serum MMP9 levels between groups, although concentrations trended upward in both cohorts. Radiographic vasospasm was noted in 6 patients (minocycline = 3, control = 3), with only 1 patient developing symptoms of clinical vasospasm in the minocycline cohort. There was no difference between cohorts with respect to Lindegaard ratios, transcranial Doppler values, or onset of vasospasm. CONCLUSIONS Minocycline at high doses is well tolerated in the ruptured cerebral aneurysm population. Minocycline curtails breakdown of the BBB following aSAH as evidenced by lower permeability indices, though minocycline did not significantly alter serum MMP9 levels. Larger randomized clinical trials are needed to assess minocycline as a neuroprotectant against aSAH-induced vasospasm. Clinical trial registration no.: NCT04876638 (clinicaltrials.gov).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Jonathan Russin
- 1Departments of Neurosurgery
- 5Neurorestoration Center, University of Southern California, Los Angeles, California
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Dayyani M, Mousavi Mohammadi E, Ashoorion V, Sadeghirad B, Javedani Yekta M, Grotta JC, Gonzalez NR, Zabihyan S. Aneurysmal subarachnoid haemorrhage-cerebral vasospasm and prophylactic ibuprofen: a randomised controlled pilot trial protocol. BMJ Open 2022; 12:e058895. [PMID: 35414560 PMCID: PMC9006795 DOI: 10.1136/bmjopen-2021-058895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Cerebral vasospasm (CVS) is the leading cause of mortality and morbidity following aneurysmal subarachnoid haemorrhage (aSAH). One of the recently implicated underlying mechanisms of CVS is inflammatory cascades. Specific feasibility objectives include determining the ability to recruit 30 participants over 24 months while at least 75% of them comply with at least 75% of the study protocol and being able to follow 85% of them for 3 months after discharge. METHODS AND ANALYSIS This is a feasibility study for a randomised controlled trial. Eligible participants are adult patients who are 18 years of age and older with an aSAH confirmed by a brain CT scan, and CT angiography, or magnetic resonance angiography, or digital subtraction angiography who admitted to the emergency department within 12 hours of the ictus. Eligible subjects will be randomised 1:1 for the administration of either ibuprofen or a placebo, while both groups will concomitantly be treated by the standard of care for 2 weeks. Care givers, patients, outcome assessors and data analysts will be blinded. This will be the first study to investigate the preventive effects of a short-acting non-steroidal anti-inflammatory drug on CVS and the key expected outcome of this pilot study is the feasibility and safety assessment of the administration of ibuprofen in patients with aSAH. The objectives of the definitive trial would be to assess the effect of ibuprofen relative to placebo on mortality, CVS, delayed cerebral ischaemia, and level of disability at 3-month follow-up. ETHICS AND DISSEMINATION This study is approved by Mashhad University of Medical Sciences ethical committee (IR.MUMS.MEDICAL.REC.1398.225). Results from the study will be submitted for publication regardless of whether or not there are significant findings. TRIAL REGISTRATION NUMBER ISRCTN14611625.
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Affiliation(s)
- Mojtaba Dayyani
- Division of Neurosurgery, City of Hope Beckman Research Institute and Medical Center, Duarte, California, USA
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Razavi Khorasan, Iran
| | - Ermia Mousavi Mohammadi
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Razavi Khorasan, Iran
| | - Vahid Ashoorion
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | | | - James C Grotta
- Mobile Stroke Unit and Stroke Research Program, Memorial Hermann Texas Medical Center, Houston, Texas, USA
| | - Nestor R Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samira Zabihyan
- Department of Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Razavi Khorasan, Iran
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Solár P, Zamani A, Lakatosová K, Joukal M. The blood-brain barrier and the neurovascular unit in subarachnoid hemorrhage: molecular events and potential treatments. Fluids Barriers CNS 2022; 19:29. [PMID: 35410231 PMCID: PMC8996682 DOI: 10.1186/s12987-022-00312-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/24/2022] [Indexed: 12/12/2022] Open
Abstract
The response of the blood-brain barrier (BBB) following a stroke, including subarachnoid hemorrhage (SAH), has been studied extensively. The main components of this reaction are endothelial cells, pericytes, and astrocytes that affect microglia, neurons, and vascular smooth muscle cells. SAH induces alterations in individual BBB cells, leading to brain homeostasis disruption. Recent experiments have uncovered many pathophysiological cascades affecting the BBB following SAH. Targeting some of these pathways is important for restoring brain function following SAH. BBB injury occurs immediately after SAH and has long-lasting consequences, but most changes in the pathophysiological cascades occur in the first few days following SAH. These changes determine the development of early brain injury as well as delayed cerebral ischemia. SAH-induced neuroprotection also plays an important role and weakens the negative impact of SAH. Supporting some of these beneficial cascades while attenuating the major pathophysiological pathways might be decisive in inhibiting the negative impact of bleeding in the subarachnoid space. In this review, we attempt a comprehensive overview of the current knowledge on the molecular and cellular changes in the BBB following SAH and their possible modulation by various drugs and substances.
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Affiliation(s)
- Peter Solár
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Pekařská 53, 656 91, Brno, Czech Republic
| | - Alemeh Zamani
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Klaudia Lakatosová
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Marek Joukal
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic.
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Cuoco JA, Guilliams EL, Klein BJ, Benko MJ, Darden JA, Olasunkanmi AL, Witcher MR, Rogers CM, Marvin EA, Patel BM, Entwistle JJ. Neutrophil Count on Admission Predicts Acute Symptomatic Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2021; 156:e338-e344. [PMID: 34555578 DOI: 10.1016/j.wneu.2021.09.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/13/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the association between immunologic counts on admission and acute symptomatic hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH). METHODS We conducted a retrospective analysis of 143 consecutive patients with aSAH. Patient demographics, clinical parameters, laboratory values, and radiographic imaging were obtained. Univariate and multivariate logistic regression analyses were performed to investigate parameters independently associated with acute symptomatic hydrocephalus. Receiver operating characteristic (ROC) curve analysis determined the best threshold value of neutrophil count to differentiate patients with and without hydrocephalus. RESULTS Overall, acute symptomatic hydrocephalus developed in 39.16% of patients. In an adjusted multivariate logistic regression model, Hunt and Hess grade 4-5 (odds ratio [OR]: 16.052, 95% confidence interval [CI]: 1.188-216.983; P = 0.037), modified Fisher score 3-4 (OR: 10.107, 95% CI: 1.715-59.572; P = 0.011), intraventricular hemorrhage (OR: 4.578, 95% CI: 1.417-14.788; P = 0.011), neutrophil count (OR: 1.183, 95% CI: 1.033-1.354; P = 0.015), and prior ischemic stroke (OR: 7.003, 95% CI: 1.293-37.929; P = 0.024) were significantly associated with hydrocephalus. ROC analysis for neutrophil count confirmed an acceptable area under the curve (AUC 0.780, 95% CI: 0.701-0.859; P < 0.001). The best threshold value of neutrophil count to predict hydrocephalus was ≥9.80 × 103/mL. Overall, 81.25% of patients who developed shunt dependence had a neutrophil count ≥9.80 × 103/mL on admission (P = 0.003). CONCLUSIONS Neutrophil count ≥9.80 × 103/mL on admission predicts acute symptomatic hydrocephalus after aSAH in an adjusted multivariate logistic regression model. Moreover, shunt dependence was associated with higher neutrophil counts.
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Affiliation(s)
- Joshua A Cuoco
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA.
| | - Evin L Guilliams
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Brendan J Klein
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Michael J Benko
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Jordan A Darden
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Adeolu L Olasunkanmi
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Mark R Witcher
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Cara M Rogers
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Eric A Marvin
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Biraj M Patel
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Neurointerventional Surgery, Department of Radiology, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - John J Entwistle
- Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
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15
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Yun S, Jun Yi H, Hoon Lee D, Hoon Sung J. Clinical significance of platelet to neutrophil ratio and platelet to lymphocyte ratio in patients with aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2021; 92:49-54. [PMID: 34509261 DOI: 10.1016/j.jocn.2021.07.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/21/2021] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Abstract
The aim of study was aimed to investigate associations of platelet-to-neutrophil ratio (PNR) and platelet-to-lymphocyte ratio (PLR) on admission with clinical outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). A retrospective analysis was performed on patients who were treated for aSAH. Unfavorable clinical outcome was defined as Modified Rankin Scale (mRS) score of 3-6 at 90-days. Receiver operating characteristic curve analysis was performed to detect optimal cutoff values of PNR and PLR for predicting clinical outcomes. Logistic regression was used to explore associations of PNR and PLR with clinical outcomes. A total of 544 patients with aSAH were enrolled. Of them, 152 (29.9%) had unfavorable clinical outcome. Optimal cutoff values of PNR and PLR to predict clinical outcomes at 90 days after aSAH were 25 and 130, respectively (P < 0.001 and <0.001, respectively). In multivariate logistic regression analysis, PNR <25 and PLR ≥ 130 were associated with unfavorable clinical outcome at 90 days after aSAH (odds ratio [OR]: 1.81; 95% confidence interval [CI]: 1.23-3.69; P = 0.018 and OR: 1.56; 95% CI: 1.18-2.62; P = 0.031, respectively). PNR and PLR as novel inflammatory biomarkers could predict the clinical outcome after aSAH. PNR <22 and PLR ≥ 130 were associated with unfavorable clinical outcome at 90 days after aSAH.
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Affiliation(s)
- Seonyong Yun
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea; Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Jun Yi
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea; Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Dong Hoon Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Verboon LN, Patel HC, Greenhalgh AD. The Immune System's Role in the Consequences of Mild Traumatic Brain Injury (Concussion). Front Immunol 2021; 12:620698. [PMID: 33679762 PMCID: PMC7928307 DOI: 10.3389/fimmu.2021.620698] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/25/2021] [Indexed: 12/14/2022] Open
Abstract
Mild traumatic brain injury (mild TBI), often referred to as concussion, is the most common form of TBI and affects millions of people each year. A history of mild TBI increases the risk of developing emotional and neurocognitive disorders later in life that can impact on day to day living. These include anxiety and depression, as well as neurodegenerative conditions such as chronic traumatic encephalopathy (CTE) and Alzheimer's disease (AD). Actions of brain resident or peripherally recruited immune cells are proposed to be key regulators across these diseases and mood disorders. Here, we will assess the impact of mild TBI on brain and patient health, and evaluate the recent evidence for immune cell involvement in its pathogenesis.
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Affiliation(s)
- Laura N. Verboon
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Hiren C. Patel
- Division of Cardiovascular Sciences, Salford Royal National Health Service Foundation Trust, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance National Health Service Group, University of Manchester, Manchester, United Kingdom
| | - Andrew D. Greenhalgh
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance National Health Service Group, University of Manchester, Manchester, United Kingdom
- Lydia Becker Institute of Immunology and Inflammation, The University of Manchester, Manchester, United Kingdom
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Zhang J, Nie Y, Pang Q, Zhang X, Wang Q, Tang J. Effects of stellate ganglion block on early brain injury in patients with subarachnoid hemorrhage: a randomised control trial. BMC Anesthesiol 2021; 21:23. [PMID: 33472582 PMCID: PMC7816408 DOI: 10.1186/s12871-020-01215-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 11/30/2020] [Indexed: 12/20/2022] Open
Abstract
Background Subarachnoid hemorrhage (SAH) is a common neurosurgical emergency, and early brain injury (EBI) plays an important role in acute brain injury of SAH. Our objective is to investigate the effect of stellate ganglion block (SGB) on the clinical prognosis of patients with SAH (registration number ChiCTR2000030910). Methods A randomized controlled trial was conducted with 102 participants. Patients with SAH were assigned to the SGB or nSGB group. Patients in the SGB group received SGB four times (once every other day starting on the day of the surgery). In contrast, patients in the nSGB group only received standard care. Data were collected on the day before surgery (T0) and on the 1st (T1), 3rd (T2) and 7th day (T3) after surgery. The primary outcomes included EBI markers (including IL-1β, IL-6, TNF-α, ET-1, NPY, NSE and S100β), the mean cerebral blood flow velocity of the middle cerebral artery (Vm-MCA) and the basilar artery (Vm-BA). All cases were followed up for 6 months after surgery. Results The levels of the EBI markers in both groups were higher at T1–T3 than at T0 (P<0.05), and the Vm-MCA and Vm-BA were also increased at the same times. However, the levels of the EBI markers were lower in the SGB group than in the nSGB group (P<0.05), and the increases of Vm-MCA and Vm-BA were also lower (P<0.05). The prognosis score and neurological deficit were better in the SGB group than in the nSGB group (P<0.05). Conclusions SGB can improve the prognosis of SAH patients by inhibiting the inflammatory response during EBI and by reducing endothelial dysfunction and relieving CVS. Trial registration Clinical trial number: ChiCTR2000030910; Registry URL: Chinese Clinical Trial Registry; Principal investigator's name: Ying Nie; Date of Trial registration: March, 2020 (retrospectively registered). Supplementary Information The online version contains supplementary material available at 10.1186/s12871-020-01215-3.
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Affiliation(s)
- Jian Zhang
- Department of Neurosurgery, 999 Brain Hospital, Guangzhou, 510515, Guangdong, China
| | - Ying Nie
- Department of Anesthesiology, 999 Brain Hospital, Guangzhou, 510515, Guangdong, China
| | - Qiongni Pang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Xubiao Zhang
- Department of Neurosurgery, 999 Brain Hospital, Guangzhou, 510515, Guangdong, China
| | - Qianting Wang
- Department of Neurosurgery, 999 Brain Hospital, Guangzhou, 510515, Guangdong, China
| | - Jing Tang
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China. .,Department of Anesthesia, Affiliated Hospital of Guangdong Medical University, Zhanjiang, 524001, Guangdong, China.
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Kim JE, Patel K, Jackson CM. The potential for immune checkpoint modulators in cerebrovascular injury and inflammation. Expert Opin Ther Targets 2021; 25:101-113. [PMID: 33356658 DOI: 10.1080/14728222.2021.1869213] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction: Neuroinflammation has been linked to poor neurologic and functional outcomes in many cerebrovascular disorders. Immune checkpoints are upregulated in the setting of traumatic brain injury, intracerebral hemorrhage, ischemic stroke, central nervous systems vasculitis, and post-hemorrhagic vasospasm, and are potential mediators of pathologic inflammation. Burgeoning evidence suggests that immune checkpoint modulation is a promising treatment strategy to decrease immune cell recruitment, cytokine secretion, brain edema, and neurodegeneration.Areas covered: This review discusses the role of immune checkpoints in neuroinflammation, and the potential for therapeutic immune checkpoint modulation in inflammatory cerebrovascular disorders. A search of Pubmed and clinicaltrials.gov was performed to find relevant literature published within the last 50 years.Expert opinion: The clinical success of immune-activating checkpoint modulators in human cancers has shown the immense clinical potential of checkpoint-based immunotherapy. Given that checkpoint blockade can also precipitate a pathologic pro-inflammatory or autoimmune response, it is plausible that these pathways may also be targeted to quell aberrant inflammation. A limited but growing number of studies suggest that immune checkpoints play a critical role in regulating the immune response in the central nervous system in a variety of contexts, and that immune-deactivating checkpoint modulators may be a promising treatment strategy for acute and chronic neuroinflammation in cerebrovascular disorders.
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Affiliation(s)
- Jennifer E Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kisha Patel
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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19
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Chen S, Xu P, Fang Y, Lenahan C. The Updated Role of the Blood Brain Barrier in Subarachnoid Hemorrhage: From Basic and Clinical Studies. Curr Neuropharmacol 2020; 18:1266-1278. [PMID: 32928088 PMCID: PMC7770644 DOI: 10.2174/1570159x18666200914161231] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke associated with high mortality and morbidity. The blood-brain-barrier (BBB) is a structure consisting primarily of cerebral microvascular endothelial cells, end feet of astrocytes, extracellular matrix, and pericytes. Post-SAH pathophysiology included early brain injury and delayed cerebral ischemia. BBB disruption was a critical mechanism of early brain injury and was associated with other pathophysiological events. These pathophysiological events may propel the development of secondary brain injury, known as delayed cerebral ischemia. Imaging advancements to measure BBB after SAH primarily focused on exploring innovative methods to predict clinical outcome, delayed cerebral ischemia, and delayed infarction related to delayed cerebral ischemia in acute periods. These predictions are based on detecting abnormal changes in BBB permeability. The parameters of BBB permeability are described by changes in computed tomography (CT) perfusion and magnetic resonance imaging (MRI). Kep seems to be a stable and sensitive indicator in CT perfusion, whereas Ktrans is a reliable parameter for dynamic contrast-enhanced MRI. Future prediction models that utilize both the volume of BBB disruption and stable parameters of BBB may be a promising direction to develop practical clinical tools. These tools could provide greater accuracy in predicting clinical outcome and risk of deterioration. Therapeutic interventional exploration targeting BBB disruption is also promising, considering the extended duration of post-SAH BBB disruption.
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Affiliation(s)
- Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - PengLei Xu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - YuanJian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - Cameron Lenahan
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA,Center for Neuroscience Research, School of Medicine, Loma Linda University, Loma Linda, CA, USA
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20
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Weyer V, Maros ME, Kronfeld A, Kirschner S, Groden C, Sommer C, Tanyildizi Y, Kramer M, Brockmann MA. Longitudinal imaging and evaluation of SAH-associated cerebral large artery vasospasm in mice using micro-CT and angiography. J Cereb Blood Flow Metab 2020; 40:2265-2277. [PMID: 31752586 PMCID: PMC7585924 DOI: 10.1177/0271678x19887052] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 10/08/2019] [Accepted: 10/11/2019] [Indexed: 11/15/2022]
Abstract
Longitudinal in vivo imaging studies characterizing subarachnoid hemorrhage (SAH)-induced large artery vasospasm (LAV) in mice are lacking. We developed a SAH-scoring system to assess SAH severity in mice using micro CT and longitudinally analysed LAV by intravenous digital subtraction angiography (i.v. DSA). Thirty female C57Bl/6J-mice (7 sham, 23 SAH) were implanted with central venous ports for repetitive contrast agent administration. SAH was induced by filament perforation. LAV was assessed up to 14 days after induction of SAH by i.v. DSA. SAH-score and neuroscore showed a highly significant positive correlation (rsp = 0.803, p < 0.001). SAH-score and survival showed a negative significant correlation (rsp = -0.71, p < 0.001). LAV peaked between days 3-5 and normalized on days 7-15. Most severe LAV was observed in the internal carotid (Δmax = 30.5%, p < 0.001), anterior cerebral (Δmax = 21.2%, p = 0.014), middle cerebral (Δmax = 28.16%, p < 0.001) and basilar artery (Δmax = 23.49%, p < 0.001). Cerebral perfusion on day 5 correlated negatively with survival time (rPe = -0.54, p = 0.04). Arterial diameter of the left MCA correlated negatively with cerebral perfusion on day 3 (rPe = -0.72, p = 0.005). In addition, pseudoaneurysms arising from the filament perforation site were visualized in three mice using i.v. DSA. Thus, micro-CT and DSA are valuable tools to assess SAH severity and to longitudinally monitor LAV in living mice.
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Affiliation(s)
- Vanessa Weyer
- Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
- Medical Faculty Mannheim, Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Máté E Maros
- Medical Faculty Mannheim, Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Andrea Kronfeld
- Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
| | - Stefanie Kirschner
- Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
- Medical Faculty Mannheim, Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
| | - Christoph Groden
- Medical Faculty Mannheim, Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Clemens Sommer
- Institute of Neuropathology, University Medical Center Mainz, Mainz, Germany
| | - Yasemin Tanyildizi
- Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
| | - Martin Kramer
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University Giessen, Giessen, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
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21
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Ateia AM, Elbassiouny A, El-Nabi SH, Fahmy NA, Ibrahim MH, El-Garawani I, Geba KM, Khalaf M. Predictive value of haptoglobin genotype as a risk of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2020; 199:106296. [PMID: 33069930 DOI: 10.1016/j.clineuro.2020.106296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study aims to investigate the genetic predisposition of haptoglobin (Hp) genotype as a predictor for cerebral vasospasm (CV) after acute subarachnoid hemorrhage (aSAH) in the Egyptian population. This permits CV risk factors stratification of patients with aSAH. Hence, it will guide the treatment plan and intensive monitoring for those patients. PATIENTS AND METHODS The study was carried out at El Matareya Teaching Hospital, Cairo, Egypt. We studied 50 patients with aSAH who were prospectively recruited and followed up by transcranial Doppler (TCD) examination for 14 days following aneurysmal rupture to early detect hemodynamic changes associated with CV and also the occurrence of delayed cerebral ischemia (DCI) as a secondary outcome. In this study, we attempted to analyze Hp genotyping as a potential predictor of CV and DCI during the acute phase of aneurysmal SAH. RESULTS As a part of result analyses, among studied patients, 34 patients (68 %) developed CV and 19 patients (38 %) developed DCI. Only history of hypertension [RR = 1.6 (OR = 4)], diabetes mellitus [RR = 1.5 (OR = 3.4)] and smoking [RR = 1.5 (OR = 3.6)] had a significant independent relationship (P < 0.05) with short term risk to develop CV following aSAH. While, Age, sex, hyperlipidemia, cardiovascular disease and peripheral vascular disease, intracranial aneurysm site and size did not achieve significant association for developing CV. Regarding the poor Fisher scale and poor Hunt and Hess score both showed significant association with CV (P < 0.05). Genotyping of Hp protein among our study cohort revealed that the relative distribution of the three haptoglobin genotypes (Hp1-1, HP2-I & HP2-2) among Egyptian patients of aSAH was 14 %, 40 % and 46 %, respectively; (gene proportion being 0.34 for Hp1 and 0.66 for Hp2). Furthermore; Hp 2 allele was associated with radiographic vasospasm detected by TCD among the studied patients (2-2 & 2-1 Vs 1-1: RR = 5.4, OR = 19.8, P < 0.001). In the regression model; Hp genotype expressing Hp-2 allele is predictive for higher risk of development of CV after aSAH. Moreover, searching for the relationship between CV & Hp genotype and the risk for development of DCI; both variables failed to achieve a significant relationship for DCI (P > 0.05). CONCLUSION The Hp genotype may determine the susceptibility to cerebral vasospasm after acute aSAH. This has the potential for use in risk stratification by allowing for the identification of those patients requiring intensive monitoring due to their inherent genetic risk for developing CV allowing for the promising selective application of aggressive treatments to those patients.
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Affiliation(s)
| | - Ahmed Elbassiouny
- Department of Intervention Neurology, Faculty of Medicine, Ain Shams University, Egypt.
| | - Sobhy Hassab El-Nabi
- Department of Zoology, Molecular Biology and Genetics Unit, Faculty of Science, Menoufia University, Egypt.
| | - Nagia Aly Fahmy
- Department of Neurology, Faculty of Medicine, Ain Shams University, Egypt.
| | | | - Islam El-Garawani
- Department of Zoology, Molecular Biology and Genetics Unit, Faculty of Science, Menoufia University, Egypt.
| | - Khaled Mohammed Geba
- Department of Zoology, Molecular Biology and Genetics Unit, Faculty of Science, Menoufia University, Egypt.
| | - Magdy Khalaf
- Department of Neurology, El Matareya Educational Hospital, Egypt.
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22
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Wallace AN, Kayan Y, Almandoz JED, Mulder M, Milner AA, Scholz JM, Stiernagle K, Contestabile E, Tipps ME. Dual antiplatelet therapy does not improve outcomes after aneurysmal subarachnoid hemorrhage compared with aspirin monotherapy. Clin Neurol Neurosurg 2020; 195:106038. [PMID: 32650208 DOI: 10.1016/j.clineuro.2020.106038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/08/2020] [Accepted: 06/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The pathophysiology of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) may include platelet activation and microthrombi formation. Antiplatelet therapy may reduce the incidence of DCI and improve clinical outcomes after aSAH. This study compared outcomes among aSAH patients receiving aspirin monotherapy versus dual antiplatelet therapy (DAPT). METHODS Aneurysmal subarachnoid hemorrhage patients treated at a single institution between November 2011 and December 2017 were divided according to whether they received aspirin monotherapy or DAPT after endovascular treatment. Baseline characteristics and outcomes of the groups were compared, including incidences of delayed cerebral ischemia, bleeding complications, symptomatic vasospasm, in-hospital mortality, and functional status 6 months after discharge. RESULTS During the study period, 142 patients met study inclusion criteria, of which 123 were treated with aspirin monotherapy (87 %) and 19 were treated with DAPT (13 %). There was no statistically significant difference between the aspirin monotherapy and DAPT groups with respect to incidences of delayed cerebral ischemia (4.9 vs 10.5 %; p = 0.32), symptomatic vasospasm (13.0 vs 15.8 %; p = 0.74), or good clinical outcome at 6-month follow up (73.3 vs 66.7 %; p = 0.56). The DAPT group experienced a higher incidence of in-hospital mortality (21 vs 5.7 %; p = 0.02), but DAPT did not remain independently predictive of this outcome on regression analysis. There was a trend toward a higher bleeding complication rate in the DAPT group (0.8 vs 5.3 %; p = 0.13). CONCLUSIONS DAPT does not reduce the incidence of DCI or improve outcomes in aSAH patients, and may increase the risk of clinically significant bleeding complications.
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Affiliation(s)
- Adam N Wallace
- Division of Neurointerventional Surgery, Ascension Columbia St. Mary's Hospital, Milwaukee, WI, USA; University of Iowa, Department of Radiology, Iowa City, IA, USA.
| | - Yasha Kayan
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Josser E Delgado Almandoz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Maximilian Mulder
- Department of Critical Care, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Anna A Milner
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Jill M Scholz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Kayla Stiernagle
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Emma Contestabile
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Megan E Tipps
- Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
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23
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Sharma T, Datta KK, Kumar M, Dey G, Khan AA, Mangalaparthi KK, Saharan P, Chinnapparaj S, Aggarwal A, Singla N, Ghosh S, Rawat A, Dhandapani S, Salunke P, Chhabra R, Singh D, Takkar A, Gupta SK, Prasad TSK, Gowda H, Mukherjee KK, Pandey A, Bhagat H. Intracranial Aneurysm Biomarker Candidates Identified by a Proteome-Wide Study. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2020; 24:483-492. [PMID: 32525733 DOI: 10.1089/omi.2020.0057] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The scientific basis of intracranial aneurysm (IA) formation, its rupture and further development of cerebral vasospasm is incompletely understood. Aberrant protein expression may drive structural alterations of vasculature found in IA. Deciphering the molecular mechanisms underlying these events will lead to identification of early detection biomarkers and in turn, improved treatment outcomes. To unravel differential protein expression in three clinical subgroups of IA patients: (1) unruptured aneurysm, (2) ruptured aneurysm without vasospasm, (3) ruptured aneurysm who developed vasospasm, we performed untargeted quantitative proteomic analysis of aneurysm tissue and serum samples from three subgroups of IA patients and control subjects. Candidate molecules were then validated in a larger cohort of patients using enzyme-linked immunosorbent assay. A total of 937 and 294 proteins were identified from aneurysm tissue and serum samples, respectively. Several proteins that are known to maintain structural integrity of vasculature were found to be dysregulated in the context of aneurysm. ORM1, a glycoprotein, was significantly upregulated in both tissue and serum samples of unruptured aneurysm patients. We employed a larger cohort of subjects (n = 26) and validated ORM1 as a potential biomarker for screening of unruptured aneurysms. Samples from ruptured aneurysms with vasospasm showed significant upregulation of MMP9, a protease, compared with ruptured aneurysms without vasospasm. We validated MMP9 as a potential biomarker for vasospasm in a larger cohort (n = 52). This study reports the first global proteomic analysis of the entire clinical spectrum of IA. Furthermore, this study suggests ORM1 and MMP9 as potential biomarkers for unruptured aneurysm and cerebral vasospasm, respectively.
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Affiliation(s)
- Tanavi Sharma
- Division of Neuroanesthesia, Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Keshava K Datta
- Institute of Bioinformatics, International Tech Park, Bangalore, India
| | - Munish Kumar
- Division of Neuroanesthesia, Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gourav Dey
- Institute of Bioinformatics, International Tech Park, Bangalore, India
| | | | | | - Poonam Saharan
- Division of Neuroanesthesia, Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shobia Chinnapparaj
- Division of Neuroanesthesia, Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Singla
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sujata Ghosh
- Department of Experimental Medicine and Biotechnology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Pediatric Allergy and Immunology Unit, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sivashanmugam Dhandapani
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pravin Salunke
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Chhabra
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Dalbir Singh
- Department of Forensic Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aastha Takkar
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil K Gupta
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thottethodi Subrahmanya Keshava Prasad
- Institute of Bioinformatics, International Tech Park, Bangalore, India.,Center for Systems Biology and Molecular Medicine, Yenepoya Research Centre, Mangalore, India
| | - Harsha Gowda
- Institute of Bioinformatics, International Tech Park, Bangalore, India.,Center for Systems Biology and Molecular Medicine, Yenepoya Research Centre, Mangalore, India.,Manipal Academy of Higher Education, Manipal, India
| | - Kanchan K Mukherjee
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Akhilesh Pandey
- Institute of Bioinformatics, International Tech Park, Bangalore, India.,Manipal Academy of Higher Education, Manipal, India.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hemant Bhagat
- Division of Neuroanesthesia, Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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24
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Darkwah Oppong M, Gembruch O, Pierscianek D, Köhrmann M, Kleinschnitz C, Deuschl C, Mönninghoff C, Kaier K, Forsting M, Sure U, Jabbarli R. Post-treatment Antiplatelet Therapy Reduces Risk for Delayed Cerebral Ischemia due to Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2020; 85:827-833. [PMID: 30544176 DOI: 10.1093/neuros/nyy550] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 10/24/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) has a strong impact on outcome of patients with aneurysmal subarachnoid hemorrhage (SAH). Positive effect of antiplatelet therapy on DCI rates has been supposed upon smaller SAH series. OBJECTIVE To analyze the benefit/risk profile of antiplatelet use in SAH patients. METHODS This retrospective case-control study was based on institutional observational cohort with 994 SAH patients treated between January 2003 and June 2016. The individuals with postcoiling antiplatelet therapy (aspirin with/without clopidogrel) were compared to a control group without antiplatelet therapy. Occurrence of DCI, major/minor bleeding events in the follow-up computed tomography scans, and favorable outcome at 6 mo after SAH (modified Rankin scale < 3) were compared in both groups. RESULTS Of 580 patients in the final analysis, 329 patients received post-treatment antiplatelet medication. There were no significant differences between the compared groups with regard to basic outcome confounders. Aspirin use was independently associated with reduced DCI risk (P < .001, adjusted odds ratio = 0.41, 95% confidence interval 0.24-0.65) and favorable outcome (P = .02, adjusted odds ratio = 1.78, 95% confidence interval 1.06-2.98). Regarding bleeding complications, aspirin was associated only with minor bleeding events (P = .02 vs P = .51 for major bleeding events). CONCLUSION Regular administration of aspirin might have a positive impact on DCI risk and outcome of SAH patients, without increasing the risk for clinically relevant bleeding events. In our SAH cohort, dual antiplatelet therapy showed no additional benefit on DCI risk, but increased the likelihood of major bleeding events.
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Affiliation(s)
- Marvin Darkwah Oppong
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Oliver Gembruch
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | | | | | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Christoph Mönninghoff
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
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25
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Coulibaly AP, Provencio JJ. Aneurysmal Subarachnoid Hemorrhage: an Overview of Inflammation-Induced Cellular Changes. Neurotherapeutics 2020; 17:436-445. [PMID: 31907877 PMCID: PMC7283430 DOI: 10.1007/s13311-019-00829-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease that leads to poor neurological outcomes and is characterized by both vascular and neural pathologies. Recent evidence demonstrates that inflammation mediates many of the vascular and neural changes observed after SAH. Although most studies focus on inflammatory mediators such as cytokines, the ultimate effectors of inflammation in SAH are parenchymal brain and peripheral immune cells. As such, the present review will summarize our current understanding of the cellular changes of both CNS parenchymal and peripheral immune cells after SAH.
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Affiliation(s)
- A P Coulibaly
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
| | - J J Provencio
- Department of Neurology, University of Virginia, Charlottesville, VA, USA.
- Department of Neuroscience, University of Virginia, Charlottesville, VA, USA.
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26
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Wang S, Head BP. Caveolin-1 in Stroke Neuropathology and Neuroprotection: A Novel Molecular Therapeutic Target for Ischemic-Related Injury. Curr Vasc Pharmacol 2020; 17:41-49. [PMID: 29412114 DOI: 10.2174/1570161116666180206112215] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 08/18/2017] [Accepted: 11/07/2017] [Indexed: 12/20/2022]
Abstract
Cardiovascular disease and associated cerebral stroke are a global epidemic attributed to genetic and epigenetic factors, such as diet, life style and an increasingly sedentary existence due to technological advances in both the developing and developed world. There are approximately 5.9 million stroke-related deaths worldwide annually. Current epidemiological data indicate that nearly 16.9 million people worldwide suffer a new or recurrent stroke yearly. In 2014 alone, 2.4% of adults in the United States (US) were estimated to experience stroke, which is the leading cause of adult disability and the fifth leading cause of death in the US There are 2 main types of stroke: Hemorrhagic (HS) and ischemic stroke (IS), with IS occurring more frequently. HS is caused by intra-cerebral hemorrhage mainly due to high blood pressure, while IS is caused by either embolic or thrombotic stroke. Both result in motor impairments, numbness or abnormal sensations, cognitive deficits, and mood disorders (e.g. depression). This review focuses on the 1) pathophysiology of stroke (neuronal cell loss, defective blood brain barrier, microglia activation, and inflammation), 2) the role of the membrane protein caveolin- 1 (Cav-1) in normal brain physiology and stroke-induced changes, and, 3) we briefly discussed the potential therapeutic role of Cav-1 in recovery following stroke.
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Affiliation(s)
- Shanshan Wang
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States.,Department of Anesthesiology, School of Medicine, University of California, San Diego, La Jolla, CA 92093, United States
| | - Brian P Head
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States.,Department of Anesthesiology, School of Medicine, University of California, San Diego, La Jolla, CA 92093, United States
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27
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Gris T, Laplante P, Thebault P, Cayrol R, Najjar A, Joannette-Pilon B, Brillant-Marquis F, Magro E, English SW, Lapointe R, Bojanowski M, Francoeur CL, Cailhier JF. Innate immunity activation in the early brain injury period following subarachnoid hemorrhage. J Neuroinflammation 2019; 16:253. [PMID: 31801576 PMCID: PMC6894125 DOI: 10.1186/s12974-019-1629-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 10/31/2019] [Indexed: 01/01/2023] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (SAH) is a catastrophic disease with devastating consequences, including a high mortality rate and severe disabilities among survivors. Inflammation is induced following SAH, but the exact role and phenotype of innate immune cells remain poorly characterized. We investigated the inflammatory components of the early brain injury in an animal model and in SAH patients. Method SAH was induced through injection of blood in the subarachnoid space of C57Bl/6 J wild-type mice. Prospective blood collections were obtained at 12 h, days 1, 2, and 7 to evaluate the systemic inflammatory consequences of SAH by flow cytometry and enzyme-linked immunosorbent-assay (ELISA). Brains were collected, enzymatically digested, or fixed to characterize infiltrating inflammatory cells and neuronal death using flow cytometry and immunofluorescence. Phenotypic evaluation was performed at day 7 using the holding time and footprint tests. We then compared the identified inflammatory proteins to the profiles obtained from the plasma of 13 human SAH patients. Results Following SAH, systemic IL-6 levels increased rapidly, whereas IL-10 levels were reduced. Neutrophils were increased both in the brain and in the blood reflecting local and peripheral inflammation following SAH. More intracerebral pro-inflammatory monocytes were found at early time points. Astrocyte and microglia activation were also increased, and mice had severe motor deficits, which were associated with an increase in the percentage of caspase-3-positive apoptotic neurons. Similarly, we found that IL-6 levels in patients were rapidly increased following SAH. ICAM-1, bFGF, IL-7, IL-12p40, and MCP-4 variations over time were different between SAH patients with good versus bad outcomes. Moreover, high levels of Flt-1 and VEGF at admission were associated with worse outcomes. Conclusion SAH induces an early intracerebral infiltration and peripheral activation of innate immune cells. Furthermore, microglia and astrocytic activation are present at later time points. Our human and mouse data illustrate that SAH is a systemic inflammatory disease and that immune cells represent potential therapeutic targets to help this population of patients in need of new treatments.
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Affiliation(s)
- Typhaine Gris
- Research Centre of Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,CRCHUM and Montreal Cancer Institute, 900 rue St-Denis, Montreal, Quebec, H2X 0A9, Canada
| | - Patrick Laplante
- Research Centre of Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,CRCHUM and Montreal Cancer Institute, 900 rue St-Denis, Montreal, Quebec, H2X 0A9, Canada
| | - Paméla Thebault
- Research Centre of Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,CRCHUM and Montreal Cancer Institute, 900 rue St-Denis, Montreal, Quebec, H2X 0A9, Canada
| | - Romain Cayrol
- Department of Pathology and Cellular Biology, Faculty of Medicine, Université de Montréal, Pavillon Roger-Gaudry, 5e étage, 2900, Boulevard Édouard-Montpetit, Montreal, Quebec, Canada
| | - Ahmed Najjar
- Department of Surgery, Division of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), 850 rue St-Denis, Montreal, Quebec, H2X 0A9, Canada
| | - Benjamin Joannette-Pilon
- Research Centre of Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,CRCHUM and Montreal Cancer Institute, 900 rue St-Denis, Montreal, Quebec, H2X 0A9, Canada
| | - Frédéric Brillant-Marquis
- Research Centre of Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,CRCHUM and Montreal Cancer Institute, 900 rue St-Denis, Montreal, Quebec, H2X 0A9, Canada
| | - Elsa Magro
- Neurosurgery Service of CHU Cavale Blanche, INSERM, Boulevard Tanguy Prigent, Finistère, 29200, Brest, Bretagne, France
| | - Shane W English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.,Departments of Medicine (Critical Care) and School of Epidemiology and Public Health, Division of Critical Care, The Ottawa Hospital, University of Ottawa, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Réjean Lapointe
- Research Centre of Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.,CRCHUM and Montreal Cancer Institute, 900 rue St-Denis, Montreal, Quebec, H2X 0A9, Canada
| | - Michel Bojanowski
- Department of Surgery, Division of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), 850 rue St-Denis, Montreal, Quebec, H2X 0A9, Canada
| | - Charles L Francoeur
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine) and Department of Anesthesiology and Critical Care, CHU de Québec-Université Laval, (Hôpital de l'Enfant-Jésus), 1401, 18e rue, Room Z-204, Québec, G1J 1Z4, Canada
| | - Jean-François Cailhier
- Research Centre of Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada. .,CRCHUM and Montreal Cancer Institute, 900 rue St-Denis, Montreal, Quebec, H2X 0A9, Canada. .,Nephrology Division, CHUM and Department of Medicine, Université de Montréal, Montreal, Quebec, Canada.
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Neutrophils mediate early cerebral cortical hypoperfusion in a murine model of subarachnoid haemorrhage. Sci Rep 2019; 9:8460. [PMID: 31186479 PMCID: PMC6560094 DOI: 10.1038/s41598-019-44906-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/28/2019] [Indexed: 02/07/2023] Open
Abstract
Cerebral hypoperfusion in the first hours after subarachnoid haemorrhage (SAH) is a major determinant of poor neurological outcome. However, the underlying pathophysiology is only partly understood. Here we induced neutropenia in C57BL/6N mice by anti-Ly6G antibody injection, induced SAH by endovascular filament perforation, and analysed cerebral cortical perfusion with laser SPECKLE contrast imaging to investigate the role of neutrophils in mediating cerebral hypoperfusion during the first 24 h post-SAH. SAH induction significantly increased the intracranial pressure (ICP), and significantly reduced the cerebral perfusion pressure (CPP). At 3 h after SAH, ICP had returned to baseline and CPP was similar between SAH and sham mice. However, in SAH mice with normal neutrophil counts cortical hypoperfusion persisted. Conversely, despite similar CPP, cortical perfusion was significantly higher at 3 h after SAH in mice with neutropenia. The levels of 8-iso-prostaglandin-F2α in the subarachnoid haematoma increased significantly at 3 h after SAH in animals with normal neutrophil counts indicating oxidative stress, which was not the case in neutropenic SAH animals. These results suggest that neutrophils are important mediators of cortical hypoperfusion and oxidative stress early after SAH. Targeting neutrophil function and neutrophil-induced oxidative stress could be a promising new approach to mitigate cerebral hypoperfusion early after SAH.
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Liu L, Zhang P, Zhang Z, Hu Q, He J, Liu H, Zhao J, Liang Y, He Z, Li X, Sun X, Guo Z. LXA4 ameliorates cerebrovascular endothelial dysfunction by reducing acute inflammation after subarachnoid hemorrhage in rats. Neuroscience 2019; 408:105-114. [DOI: 10.1016/j.neuroscience.2019.03.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 03/15/2019] [Accepted: 03/15/2019] [Indexed: 12/18/2022]
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Vadokas G, Koehler S, Weiland J, Lilla N, Stetter C, Westermaier T. Early Antiinflammatory Therapy Attenuates Brain Damage After Sah in Rats. Transl Neurosci 2019; 10:104-111. [PMID: 31098320 PMCID: PMC6487785 DOI: 10.1515/tnsci-2019-0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 03/18/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Early inflammatory processes may play an important role in the development of early brain injury (EBI) after subarachnoid hemorrhage (SAH). Experimental studies suggest that anti-inflammatory and membrane-stabilizing drugs might have beneficial effects, although the underlying mechanisms are not fully understood. The aim of this study was to investigate the effect of early treatment with methylprednisolone and minocycline on cerebral perfusion and EBI after experimental SAH. METHODS Male Sprague-Dawley rats were subjected to SAH using the endovascular filament model. 30 minutes after SAH, they were randomly assigned to receive an intravenous injection of methylprednisolone (16mg/kg body weight, n=10), minocycline (45mg/kg body weight, n=10) or saline (n=11). Mean arterial blood pressure (MABP), intracranial pressure (ICP) and local cerebral blood flow (LCBF) over both hemispheres were recorded continuously for three hours following SAH. Neurological assessment was performed after 24 hours. Hippocampal damage was analyzed by immunohistochemical staining (caspase 3). RESULTS Treatment with methylprednisolone or minocycline did not result in a significant improvement of MABP, ICP or LCBF. Animals of both treatment groups showed a non-significant trend to better neurological recovery compared to animals of the control group. Mortality was reduced and hippocampal damage significantly attenuated in both methylprednisolone and minocycline treated animals. CONCLUSION The results of this study suggest that inflammatory processes may play an important role in the pathophysiology of EBI after SAH. Early treatment with the anti-inflammatory drugs methylprednisolone or minocycline in the acute phase of SAH has the potential to reduce brain damage and exert a neuroprotective effect.
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Affiliation(s)
- Georg Vadokas
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
- Department of Urology, Canisius Wilhelmina Hospital Nijmegen, Weg door Jonkerbos 100, 6532 SZ Nijmegen, Netherlands
| | - Stefan Koehler
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Judith Weiland
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Nadine Lilla
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Christian Stetter
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Straße 11, 97080Würzburg, Germany
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Wu Y, He Q, Wei Y, Zhu J, He Z, Zhang X, Guo Z, Xu R, Cheng C, Huang Z, Sun X. The association of neutrophil-to-lymphocyte ratio and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage: possible involvement of cerebral blood perfusion. Neuropsychiatr Dis Treat 2019; 15:1001-1007. [PMID: 31118639 PMCID: PMC6499147 DOI: 10.2147/ndt.s190477] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 02/14/2019] [Indexed: 01/11/2023] Open
Abstract
Background and purpose: Emerging evidence suggests that systemic inflammation is associated with the pathophysiological process of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to investigate the association of white blood cell (WBC) count and neutrophil-to-lymphocyte ratio (NLR) with the occurrence of DCI in SAH patients. Methods: A total of 122 patients diagnosed with aSAH within 72 h of onset were retrospectively enrolled. The count of WBC, neutrophil count (NC), and lymphocyte (LC) was collected on admission. Computed tomography perfusion was performed within 7 days after SAH. The occurrence of DCI was recorded during the hospitalization. Results: Among enrolled patients, 43 (35.2%) developed DCI during hospitalization. Patients who developed DCI had a higher count of WBC, NC, and NLR as well as a lower count of LC. NC and NLR were independently associated with the occurrence of DCI, while NLR was the best predictive parameter according to the receiver operating characteristic curve. Moreover, there was a strong correlation between NLR and mean cerebral blood flow, mean transit time and mean time to peak. Conclusion: Leukocytosis is an early pathology of SAH, and NLR may be a practical predictor for the occurrence of DCI in SAH patients.
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Affiliation(s)
- Yue Wu
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Qiuguang He
- Department of Neurosurgery, Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yuling Wei
- Department of Pharmacy, Chongqing Traditional Chinese Medicine Hospital, Chongqing, People's Republic of China
| | - Ji Zhu
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Zhaohui He
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xiaodong Zhang
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Zongduo Guo
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Rui Xu
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Chongjie Cheng
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Zhijian Huang
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Xiaochuan Sun
- Department of Neurosurgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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Marenco-Hillembrand L, Alvarado-Estrada K, Chaichana KL. Contemporary Surgical Management of Deep-Seated Metastatic Brain Tumors Using Minimally Invasive Approaches. Front Oncol 2018; 8:558. [PMID: 30547010 PMCID: PMC6279910 DOI: 10.3389/fonc.2018.00558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/09/2018] [Indexed: 12/04/2022] Open
Abstract
A subset of metastatic brain tumors occurs in deep-seated locations. Accessing and resecting these lesions can be associated with significant morbidity because it involves large craniotomies, extensive white matter dissection, prolonged retraction, and risk of inadvertent tissue injury. As a result, only palliative treatment options are typically offered for these lesions including observation, needle biopsies, and/or radiation therapy. With the development of new surgical tools and techniques, minimally invasive techniques have allowed for the treatment of these lesions previously associated with significant morbidity. These minimally invasive techniques include laser interstitial thermal therapy and channel-based resections.
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33
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Quintana-Belmares R, Hernández-Pérez G, Montiel-Dávalos A, Gustafsson Å, Miranda J, Rosas-Pérez I, López-Marure R, Alfaro-Moreno E. Urban particulate matter induces the expression of receptors for early and late adhesion molecules on human monocytes. ENVIRONMENTAL RESEARCH 2018; 167:283-291. [PMID: 30077136 DOI: 10.1016/j.envres.2018.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/25/2018] [Accepted: 07/25/2018] [Indexed: 06/08/2023]
Abstract
Exposure to urban particulate matter (PM) is correlated with increases in the emergence of health services due to adverse events and deaths and is mainly related to cardiorespiratory complications. The translocation of particles from the lung into circulation has been proposed as a factor that may trigger systemic effects. Monocytes may be exposed to PM, and if the monocytes are activated, then they are likely to adhere to endothelial cells in a distant organ due to the expression of receptors for adhesion molecules. In the present study, we evaluated the expression of receptors for adhesion molecules (sLex, PSGL-1, LFA-1, VLA-4 and αVβ3) in monocytes (U937 cells) exposed for 3 or 18 h to PM10 (0.001, 0.003, 0.010, 0.030, 0.300, 3 or 30 µg/mL). Exposed cells were co-cultured with human endothelial cells that were naive or previously exposed to the same particles. When U937 cells were exposed to PM10, similar levels of expression for early and late receptors for adhesion molecules were observed from 30 ng/mL as those induced by TNF-α. Cells exposed to particles at concentrations above 30 ng/mL were more adhesive to naive or exposed human endothelial cells. Taken together, our results suggest that it is plausible that activated monocytes may play a role in systemic effects induced by PM10 due to the size distribution of the particles and the concentrations required to trigger the expression of receptors for adhesion molecules in monocytes.
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Affiliation(s)
- Raúl Quintana-Belmares
- Environmental Health Laboratory, Subdirección de Investigación Básica, Instituto Nacional de Cancerología, Mexico
| | - Guillermina Hernández-Pérez
- Environmental Health Laboratory, Subdirección de Investigación Básica, Instituto Nacional de Cancerología, Mexico
| | - Angélica Montiel-Dávalos
- Environmental Health Laboratory, Subdirección de Investigación Básica, Instituto Nacional de Cancerología, Mexico
| | - Åsa Gustafsson
- Swetox, Karolinska Institutet, Unit of Toxicology Sciences, Forskargatan 20, SE-151 36 Södertälje, Sweden
| | - Javier Miranda
- Experimental Physics Department, Institute of Physics, Universidad Nacional Autónoma de México, Ciudad Universitaria, Ciudad de México, Mexico
| | - Irma Rosas-Pérez
- Aerobiology Laboratory, Centro de Ciencias de la Atmósfera, Universidad Nacional Autónoma de México, Ciudad Universitaria, Ciudad de México, Mexico
| | - Rebeca López-Marure
- Departamento de Fisiología, Instituto Nacional de Cardiología "Ignacio Chávez", Mexico
| | - Ernesto Alfaro-Moreno
- Swetox, Karolinska Institutet, Unit of Toxicology Sciences, Forskargatan 20, SE-151 36 Södertälje, Sweden.
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Interleukin-6 Levels in Cerebrospinal Fluid and Plasma in Patients with Severe Spontaneous Subarachnoid Hemorrhage. World Neurosurg 2018; 122:e612-e618. [PMID: 30814021 DOI: 10.1016/j.wneu.2018.10.113] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/17/2018] [Accepted: 10/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Inflammatory processes play a key role in the pathophysiology of subarachnoid hemorrhage (SAH). This study evaluated whether different temporal patterns of intrathecal and systemic inflammation could be identified in the acute phase after SAH. The intensity of the inflammation was also assessed in clinical subgroups. METHODS Cerebrospinal fluid (CSF) and blood samples were collected at days 1, 4, and 10 after ictus in 44 patients with severe SAH. Interleukin-6 (IL-6) was analyzed by a routine monoclonal antibody-based method. Median IL-6 values for each day were calculated. Day 4 IL-6 values were compared in dichotomized groups (age, sex, World Federation of Neurosurgical Societies [WFNS] grade, Fisher scale grade, outcome, vasospasm, central nervous system infection and systemic infections). RESULTS CSF IL-6 levels were significantly elevated from day 1 to days 4 and 10, whereas plasma IL-6 showed a different trend at lower levels. Median CSF IL-6 concentrations for days 1, 4, and 10 were 876.5, 3361, and 1567 ng/L, whereas plasma was 26, 27.5, and 15.9 ng/L, respectively. No significant differences in CSF concentrations were observed between the subgroups, with the most prominent one being in day 4 IL-6 in the WFNS subgroups (grades 1-3 vs. 4-5, 1158.5 vs. 5538 ng/L; P = 0.056). Patients with systemic infection had significantly higher plasma IL-6 concentrations than patients without infection (31 vs. 16.05 ng/L, respectively; P = 0.028). CONCLUSIONS Distinctly different inflammatory patterns could be seen intrathecally compared with the systemic circulation. In plasma, a significant difference in the intensity of the inflammation was seen in cases with systemic infection. No other subgroup showed statistically significant differences.
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Wiśniewski K, Jóźwik-Pruska J, Bieńkowski M, Bobeff EJ, Bryl M, Kałużna-Czaplińska J, Jaskólski DJ. Isoprostanes as potential cerebral vasospasm biomarkers. Neurol Neurochir Pol 2018; 52:643-651. [PMID: 30314904 DOI: 10.1016/j.pjnns.2018.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/01/2018] [Accepted: 09/25/2018] [Indexed: 11/29/2022]
Abstract
Despite enormous progress in medicine, symptomatic cerebral vasospasm (CVS), remains an unexplained clinical problem, which leaves both physicians and patients helpless and relying on chance, due to the lack of specific marker indicative of imminent danger as well as the lack of specific treatment. In our opinion CVS occurrence depends on dynamic disbalance between free radicals' formation (oxidative stress) and antioxidant activity. Isoprostanes are products of free-radical peroxidation of polyunsaturated fatty acids, and seem to mark a promising path for the research aiming to unravel its possible mechanism. Not only are they the biomarkers of oxidative stress in vivo and in vitro, but also have manifold biological effects (including vasoactive, inflammatory and mitogenic) via activation of the thromboxane A2 receptor (TBXA2R), both in physiological and pathophysiological processes. This review addresses the importance of isoprostanes in CVS in quest of appropriate biomarkers.
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Affiliation(s)
- Karol Wiśniewski
- Department of Neurosurgery and Neurooncology, Medical University of Lodz, Barlicki University Hospital, Kopcińskiego 22, 90-153 Lodz, Poland.
| | - Jagoda Jóźwik-Pruska
- Institute of General and Ecological Chemistry, Department of Chemistry, Lodz University of Technology, Żeromskiego 116, 90-924 Lodz, Poland
| | - Michał Bieńkowski
- Department of Molecular Pathology and Neuropathology, Chair of Oncology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland
| | - Ernest J Bobeff
- Department of Neurosurgery and Neurooncology, Medical University of Lodz, Barlicki University Hospital, Kopcińskiego 22, 90-153 Lodz, Poland
| | - Maciej Bryl
- Department of Neurosurgery and Neurooncology, Medical University of Lodz, Barlicki University Hospital, Kopcińskiego 22, 90-153 Lodz, Poland
| | - Joanna Kałużna-Czaplińska
- Institute of General and Ecological Chemistry, Department of Chemistry, Lodz University of Technology, Żeromskiego 116, 90-924 Lodz, Poland
| | - Dariusz J Jaskólski
- Department of Neurosurgery and Neurooncology, Medical University of Lodz, Barlicki University Hospital, Kopcińskiego 22, 90-153 Lodz, Poland
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Barrow JW, Turan N, Wangmo P, Roy AK, Pradilla G. The role of inflammation and potential use of sex steroids in intracranial aneurysms and subarachnoid hemorrhage. Surg Neurol Int 2018; 9:150. [PMID: 30105144 PMCID: PMC6080146 DOI: 10.4103/sni.sni_88_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/15/2018] [Indexed: 12/11/2022] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) continues to be a devastating neurological condition with a high risk of associated morbidity and mortality. Inflammation has been shown to increase the risk of complications associated with aSAH such as vasospasm and brain injury in animal models and humans. The goal of this review is to discuss the inflammatory mechanisms of aneurysm formation, rupture and vasospasm and explore the role of sex hormones in the inflammatory response to aSAH. Methods A literature review was performed using PubMed using the following search terms: "intracranial aneurysm," "cerebral aneurysm," "dihydroepiandrosterone sulfate" "estrogen," "hormone replacement therapy," "inflammation," "oral contraceptive," "progesterone," "sex steroids," "sex hormones" "subarachnoid hemorrhage," "testosterone." Only studies published in English language were included in the review. Results Studies have shown that administration of sex hormones such as progesterone and estrogen at early stages in the inflammatory cascade can lower the risk and magnitude of subsequent complications. The exact mechanism by which these hormones act on the brain, as well as their role in the inflammatory cascade is not fully understood. Moreover, conflicting results have been published on the effect of hormone replacement therapy in humans. This review will scrutinize the variations in these studies to provide a more detailed understanding of sex hormones as potential therapeutic agents for intracranial aneurysms and aSAH. Conclusion Inflammation may play a role in the pathogenesis of intracranial aneurysm formation and subarachnoid hemorrhage, and administration of sex hormones as anti-inflammatory agents has been associated with improved functional outcome in experimental models. Further studies are needed to determine the therapeutic role of these hormones in the intracranial aneurysms and aSAH.
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Affiliation(s)
- Jack W Barrow
- Cerebrovascular Research Laboratory, Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Mercer University School of Medicine, Savannah, Georgia, USA
| | - Nefize Turan
- Cerebrovascular Research Laboratory, Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pasang Wangmo
- Cerebrovascular Research Laboratory, Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anil K Roy
- Cerebrovascular Research Laboratory, Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Gustavo Pradilla
- Cerebrovascular Research Laboratory, Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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González-Montelongo MDC, Egea-Guerrero JJ, Murillo-Cabezas F, González-Montelongo R, Ruiz de Azúa-López Z, Rodríguez-Rodríguez A, Vilches-Arenas A, Castellano A, Ureña J. Relation of RhoA in Peripheral Blood Mononuclear Cells With Severity of Aneurysmal Subarachnoid Hemorrhage and Vasospasm. Stroke 2018; 49:1507-1510. [DOI: 10.1161/strokeaha.117.020311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/09/2018] [Accepted: 04/12/2018] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | - Angel Vilches-Arenas
- Dpto. de Medicina Preventiva y Salud Pública, Hospital Universitario Virgen Macarena (A.V.-A.), Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Spain
| | - Antonio Castellano
- From the Dpto. de Fisiología Médica y Biofísica (M.d.C.G.-M., R.G.-M., A.C., J.U.)
| | - Juan Ureña
- From the Dpto. de Fisiología Médica y Biofísica (M.d.C.G.-M., R.G.-M., A.C., J.U.)
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Russin JJ, Montagne A, D’Amore F, He S, Shiroishi MS, Rennert RC, Depetris J, Zlokovic BV, Mack WJ. Permeability imaging as a predictor of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab 2018; 38:973-979. [PMID: 29611451 PMCID: PMC5998996 DOI: 10.1177/0271678x18768670] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Blood-brain barrier (BBB) dysfunction has been implicated in ischemic risk following aneurysmal subarachnoid hemorrhage (aSAH), but never directly imaged. We prospectively examined whether post-bleed day 4 dynamic contrast-enhanced magnetic resonance (DCE-MR) BBB permeability imaging could predict development of delayed cerebral ischemia (DCI). Global MR-derived BBB permeability ( Ktrans) was significantly higher in aSAH patients who subsequently developed DCI (five patients; 2.28 ± 0.09 × 10-3 min-1) compared to those who experienced radiographic vasospasm only (three patients; 1.85 ± 0.12 × 10-3 min-1; p < 0.05), or no vasospasm/ischemia (eight patients; 1.74 ± 0.07 × 10-3 min-1; p < 0.01). Ktrans > 2 × 10-3 min-1 predicted development of DCI (AUC = 0.98, 95% CI: 0.93-1). Global BBB dysfunction following aSAH is detectable with DCE-MR and predictive of ischemic risk.
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Affiliation(s)
- Jonathan J Russin
- USC Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Jonathan J Russin, USC Neurorestoration Center, Keck School of Medicine, University of Southern California, 1200 N State Street, Suite 3300, Los Angeles, CA 90033, USA.
| | - Axel Montagne
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Francesco D’Amore
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shuhan He
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mark S Shiroishi
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert C Rennert
- USC Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jena Depetris
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Berislav V Zlokovic
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - William J Mack
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Enzmann GU, Pavlidou S, Vaas M, Klohs J, Engelhardt B. ICAM-1 null C57BL/6 Mice Are Not Protected from Experimental Ischemic Stroke. Transl Stroke Res 2018; 9:608-621. [PMID: 29399739 DOI: 10.1007/s12975-018-0612-4] [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: 10/20/2017] [Revised: 01/19/2018] [Accepted: 01/19/2018] [Indexed: 11/29/2022]
Abstract
Accumulation of neutrophils in the brain is a hallmark of cerebral ischemia and considered central in exacerbating tissue injury. Intercellular adhesion molecule (ICAM)-1 is upregulated on brain endothelial cells after ischemic stroke and considered pivotal in neutrophil recruitment as ICAM-1-deficient mouse lines were found protected from experimental stroke. Translation of therapeutic inhibition of ICAM-1 into the clinic however failed. This prompted us to investigate stroke pathogenesis in Icam1tm1Alb C57BL/6 mutants, a true ICAM-1null mouse line. Performing transient middle cerebral artery occlusion, we found that absence of ICAM-1 did not ameliorate stroke pathology at acute time points after reperfusion. Near-infrared imaging showed comparable accumulation of neutrophils in the ischemic hemispheres of ICAM-1null and wild type C57BL/6 mice. We also isolated equal numbers of neutrophils from the ischemic brains of ICAM-1null and wild type C57BL/6 mice. Immunostaining of the brains showed neutrophils to equally accumulate in the leptomeninges and brain parenchymal vessels of ICAM-1null and wild type C57BL/6 mice. In addition, the lesion size was comparable in ICAM-1null and wild type mice. Our study demonstrates that absence of ICAM-1 neither inhibits cerebral ischemia-induced accumulation of neutrophils in the brain nor provides protection from ischemic stroke.
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Affiliation(s)
- Gaby U Enzmann
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland
| | - Sofia Pavlidou
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland
| | - Markus Vaas
- Institute for Biomedical Engineering, ETH and University of Zurich, 8093, Zurich, Switzerland.,Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Jan Klohs
- Institute for Biomedical Engineering, ETH and University of Zurich, 8093, Zurich, Switzerland.,Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Britta Engelhardt
- Theodor Kocher Institute, University of Bern, Freiestrasse 1, 3012, Bern, Switzerland.
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Höllig A, Stoffel-Wagner B, Clusmann H, Veldeman M, Schubert GA, Coburn M. Time Courses of Inflammatory Markers after Aneurysmal Subarachnoid Hemorrhage and Their Possible Relevance for Future Studies. Front Neurol 2017; 8:694. [PMID: 29312122 PMCID: PMC5744005 DOI: 10.3389/fneur.2017.00694] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 12/04/2017] [Indexed: 12/02/2022] Open
Abstract
Object Aneurysmal subarachnoid hemorrhage triggers an intense inflammatory response, which is suspected to increase the risk for secondary complications such as delayed cerebral ischemia (DCI). However, to date, the monitoring of the inflammatory response to detect secondary complications such as DCI has not become part of the clinical routine diagnostic. Here, we aim to illustrate the time courses of inflammatory parameters after aneurysmal subarachnoid hemorrhage (aSAH) and discuss the problems of inflammatory parameters as biomarkers but also their possible relevance for deeper understanding of the pathophysiology after aSAH and sophisticated planning of future studies. Materials and methods In this prospective cohort study, 109 patients with aSAH were initially included, n = 28 patients had to be excluded. Serum and—if possible—cerebral spinal fluid samples (n = 48) were retrieved at days 1, 4, 7, 10, and 14 after aSAH. Samples were analyzed for leukocyte count and C-reactive protein (CRP) (serum samples only) as well as matrix metallopeptidase 9 (MMP9), intercellular adhesion molecule 1 (ICAM1), and leukemia inhibitory factor (LIF) [both serum and cerebrospinal fluid (CSF) samples]. Time courses of the inflammatory parameters were displayed and related to the occurrence of DCI. Results We illustrate the time courses of leukocyte count, CRP, MMP9, ICAM1, and LIF in patients’ serum samples from the first until the 14th day after aSAH. Time courses of MMP9, ICAM1, and LIF in CSF samples are demonstrated. Furthermore, no significant difference was shown relating the time courses to the occurrence of DCI. Conclusion We estimate that the wide range of the measured values hampers their interpretation and usage as a biomarker. However, understanding the inflammatory response after aSAH and generating a multicenter database may facilitate further studies: realistic sample size calculations on the basis of a multicenter database will increase the quality and clinical relevance of the acquired results.
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Affiliation(s)
- Anke Höllig
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Birgit Stoffel-Wagner
- Department of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn, Germany
| | - Hans Clusmann
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Gerrit A Schubert
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Mark Coburn
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
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Turan N, Miller BA, Heider RA, Nadeem M, Sayeed I, Stein DG, Pradilla G. Neurobehavioral testing in subarachnoid hemorrhage: A review of methods and current findings in rodents. J Cereb Blood Flow Metab 2017; 37:3461-3474. [PMID: 27677672 PMCID: PMC5669338 DOI: 10.1177/0271678x16665623] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The most important aspect of a preclinical study seeking to develop a novel therapy for neurological diseases is whether the therapy produces any clinically relevant functional recovery. For this purpose, neurobehavioral tests are commonly used to evaluate the neuroprotective efficacy of treatments in a wide array of cerebrovascular diseases and neurotrauma. Their use, however, has been limited in experimental subarachnoid hemorrhage studies. After several randomized, double-blinded, controlled clinical trials repeatedly failed to produce a benefit in functional outcome despite some improvement in angiographic vasospasm, more rigorous methods of neurobehavioral testing became critical to provide a more comprehensive evaluation of the functional efficacy of proposed treatments. While several subarachnoid hemorrhage studies have incorporated an array of neurobehavioral assays, a standardized methodology has not been agreed upon. Here, we review neurobehavioral tests for rodents and their potential application to subarachnoid hemorrhage studies. Developing a standardized neurobehavioral testing regimen in rodent studies of subarachnoid hemorrhage would allow for better comparison of results between laboratories and a better prediction of what interventions would produce functional benefits in humans.
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Affiliation(s)
- Nefize Turan
- 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Brandon A Miller
- 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert A Heider
- 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Maheen Nadeem
- 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Iqbal Sayeed
- 2 Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Donald G Stein
- 2 Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Gustavo Pradilla
- 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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Effect of Progesterone on Cerebral Vasospasm and Neurobehavioral Outcomes in a Rodent Model of Subarachnoid Hemorrhage. World Neurosurg 2017; 110:e150-e159. [PMID: 29097330 DOI: 10.1016/j.wneu.2017.10.118] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/19/2017] [Accepted: 10/21/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) induces widespread inflammation leading to cellular injury, vasospasm, and ischemia. Evidence suggests that progesterone (PROG) can improve functional recovery in acute brain injury owing to its anti-inflammatory and neuroprotective properties, which could also be beneficial in SAH. We hypothesized that PROG treatment attenuates inflammation-mediated cerebral vasospasm and microglial activation, improves synaptic connectivity, and ameliorates functional recovery after SAH. METHODS We investigated the effect of PROG in a cisternal SAH model in adult male C57BL/6 mice. Neurobehavioral outcomes were evaluated using rotarod latency and grip strength tests. Basilar artery perimeter, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid glutamate receptor 1 (GluR1)/synaptophysin colocalization, and Iba-1 immunoreactivity were quantified histologically. RESULTS PROG (8 mg/kg) significantly improved rotarod latency at day 6 and grip strength at day 9. PROG-treated mice had significantly reduced basilar artery vasospasm at 24 hours. GluR1/synaptophysin colocalization, indicative of synaptic GluR1, was significantly reduced in the SAH+Vehicle group at 24 hours, and PROG treatment significantly attenuated this reduction. PROG treatment significantly reduced microglial cell activation and proliferation in cerebellum and cortex but not in the brainstem at 10 days. CONCLUSIONS PROG treatment ameliorated cerebral vasospasm, reduced microglial activation, restored synaptic GluR1 localization, and improved neurobehavioral performance in a murine model of SAH. These results provide a rationale for further translational testing of PROG therapy in SAH.
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A Propensity Score-Matched Study of the Use of Non-steroidal Anti-inflammatory Agents Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2017; 25:351-358. [PMID: 27000643 DOI: 10.1007/s12028-016-0266-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Inflammation may contribute to poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Here, we compared outcomes among propensity score-matched cohorts who did and did not receive non-steroidal anti-inflammatory drug (NSAID) use after aSAH. METHODS Propensity score-matched analysis of 413 subjects enrolled in the Clazosentan to Overcome Neurological iSChemia and Infarction OccUring after Subarachnoid hemorrhage (CONSCIOUS-1) study. Propensity score matching was performed on the basis of age, sex, baseline National Institutes of Health Stroke Scale score, World Federation of Neurological Societies grade on admission, procedure used for securing aneurysm, and SAH clot burden. RESULTS 178 patients were matched (89 received NSAIDs, 89 did not). Propensity score matching was considered acceptable. Patients who had received NSAIDs during their hospital stay had significantly lower mortality rate, and reduced duration of intensive care unit stay and total length of hospital stay (P = 0.035, P = 0.009, and P = 0.053, respectively). At 6 weeks, 80.9 % of patients treated with NSAIDs had good functional outcome compared to 68.5 % of matched controls (P = 0.083). There was no significant difference in the proportions of patients who developed delayed ischemic neurological deficits, angiographic vasospasm, or required rescue therapy. CONCLUSIONS Inflammation may play a crucial role in the poor outcomes after SAH, and that NSAIDs may be a useful therapeutic option, once validated by larger prospective studies.
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A Propensity Score Analysis of the Impact of Dexamethasone Use on Delayed Cerebral Ischemia and Poor Functional Outcomes After Subarachnoid Hemorrhage. World Neurosurg 2017; 109:e655-e661. [PMID: 29061461 DOI: 10.1016/j.wneu.2017.10.051] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE An inflammatory response occurs after aneurysmal subarachnoid hemorrhage (aSAH) and predicts poor outcomes. Glucocorticoids suppress inflammation and promote fluid retention. Dexamethasone is often administered after aSAH for postoperative cerebral edema and refractory headache. Our objective was to examine the impact of dexamethasone use on functional outcomes and delayed cerebral ischemia (DCI) after aSAH. METHODS Patients with aSAH admitted between 2010 and 2015 were included; the data source was a single-center subarachnoid hemorrhage registry. The intervention of interest was a dexamethasone taper used <7 days from ictus. The primary outcome was poor discharge functional outcome, with a modified Rankin Scale score >3. Other outcomes included DCI and infection. A propensity score for use of dexamethasone was calculated using a logistic regression model that included potential predictors of dexamethasone use and outcome. The impact of dexamethasone on outcomes of interest was calculated and the propensity score was controlled for. RESULTS A total of 440 patients with subarachnoid hemorrhage were admitted during the study period and 309 met eligibility criteria. Dexamethasone was administered in 101 patients (33%). A total of 127 patients (41%) had a discharge modified Rankin Scale score >3, 105 (34%) developed DCI, and 94 (30%) developed an infection. After propensity score analysis, dexamethasone use was associated with a significant reduction in poor functional outcomes (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.19-0.66) but showed no significant association with DCI (OR, 0.93; 95% CI, 0.53-1.64) or infection (OR, 0.60; 95% CI, 0.34-1.06). CONCLUSIONS Dexamethasone use after aSAH was associated with a reduction in poor functional outcomes at discharge but not DCI, controlling for predictors of dexamethasone use.
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Aydın MD, Kanat A, Aydın N, Kantarci A, Ayvaz MA, Rakici H, Yolas C, Kepoglu U, Demirci E. New Evidence for Causal Central Mechanism of Hyperglycemia in Subarachnoid Hemorrhage Secondary to Ischemic Degenerative Disruption of Circuitry Among Insular Cortex, Nodose Ganglion, and Pancreas: Experimental Study. World Neurosurg 2017; 106:570-577. [DOI: 10.1016/j.wneu.2017.06.176] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 12/26/2022]
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Blood free Radicals Concentration Determined by Electron Paramagnetic Resonance Spectroscopy and Delayed Cerebral Ischemia Occurrence in Patients with Aneurysmal Subarachnoid Hemorrhage. Cell Biochem Biophys 2017; 75:351-358. [PMID: 28948569 PMCID: PMC5691099 DOI: 10.1007/s12013-017-0820-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 07/29/2017] [Indexed: 12/22/2022]
Abstract
Pathophysiology of delayed cerebral ischemia and cerebral vasospasm following aneurysmal subarachnoid hemorrhage is still poorly recognized, however free radicals are postulated as one of the crucial players. This study was designed to scrutinize whether the concentration of free radicals in the peripheral venous blood is related to the occurrence of delayed cerebral ischemia associated with cerebral vasospasm. Twenty-four aneurysmal subarachnoid hemorrhage patients and seven patients with unruptured intracranial aneurysm (control group) have been studied. Free radicals in patients’ blood have been detected by the electron paramagnetic resonance (CMH.HCl spin probe, 150 K, ELEXSYS E500 spectrometer) on admission and at least 72 h from disease onset. Delayed cerebral ischemia monitoring was performed by daily neurological follow-up and transcranial color coded Doppler. Delayed cerebral ischemia observed in six aneurysmal subarachnoid hemorrhage patients was accompanied by cerebral vasospasm in all six cases. No statistically significant difference in average free radicals concentration between controls and study subgroups was noticed on admission (p = .3; Kruskal–Wallis test). After 72 h free radicals concentration in delayed cerebral ischemia patients (3.19 ± 1.52 mmol/l) differed significantly from the concentration in aneurysmal subarachnoid hemorrhage patients without delayed cerebral ischemia (0.65 ± 0.37 mmol/l) (p = .012; Mann–Whitney test). These findings are consistent with our assumptions and seem to confirm the role of free radicals in delayed cerebral ischemia development. Preliminary results presented above are promising and we need perform further investigation to establish whether blood free radicals concentration may serve as the biomarker of delayed cerebral ischemia associated with cerebral vasospasm.
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Zhou Y, Jiang Y, Peng Y, Zhang M. The Quantitative and Functional Changes of Postoperative Peripheral Blood Immune Cell Subsets Relate to Prognosis of Patients with Subarachnoid Hemorrhage: A Preliminary Study. World Neurosurg 2017; 108:206-215. [PMID: 28866066 DOI: 10.1016/j.wneu.2017.08.091] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE It has been suggested that the preoperative (PRE) and postoperative (POST) immune system alteration triggered by aneurysmal subarachnoid hemorrhage (SAH) and surgical treatment itself may affect patients' prognosis and contribute to POST complications. The mechanisms may be attributed to immune suppression-triggered infection or immune overreaction-triggered aseptic inflammation. In this study, we investigated the dynamic changes in peripheral immune cell subsets as well as the alterations of inflammatory cytokines in patients with aneurysmal SAH who received craniotomy and clipping surgery. In addition, we studied the association of those changes with POST complications and clinical prognosis. METHODS We investigated 27 patients who received craniotomy and clipping surgery for aneurysmal SAH. The operations were all performed within 24 hours after the occurrence of aneurysm rupture. Detailed immune monitoring (peripheral blood leukocytes and lymphocyte subsets and inflammatory cytokines) was performed on PRE (on admission), day 1, day 3, and day 6 after operation. RESULTS Our data showed that the percentage of CD3+, CD8+, natural killer T (NKT), CD4+, and regulatory T (Treg) cells significantly decreased and the level of interleukin 4 (IL-4), interferon γ, and IL-2 significantly increased 1 day after surgery compared with the data in PRE. On the contrary, natural killer (NK), NK group 2 (NKG2D), and B cells increased and the level of IL-10 in plasma decreased. In study of the relationship between POST fever and the change in immune cell subgroups, the fever group had a lower percentage of CD3+, CD4+, NKT, Tregs, and B cells on day 1, day 3, and day 6 after surgery compared with the patients who did not have fever, whereas the CD8+, NK, and NKG2D subsets showed the opposite trend. Furthermore, we analyzed the association between immune profile changes and the prognosis of those patients. The patients were divided into those with an unfavorable prognosis (n = 6) and those with a favorable prognosis (n = 21) according to Glasgow Outcome Scale score and postoperation (POST) coma. Our results showed that except for B cells, patients with a favorable prognosis had a relatively higher percentage of CD3+, CD4+, CD8+, NK, NKT, NKG2D, and Treg cells compared with the unfavorable prognosis group from PRE to day 6 POST. CONCLUSIONS Our results indicated that patients with aneurysmal SAH undergoing craniotomy and clipping surgery had a profound transient deterioration in immune function. In addition, the changes in immune cell subgroups had a strong association with POST fever. The changes in immune cell subgroups were also directly associated with clinical prognosis of the patients. These association findings might be attributable to a better biomarker to predict patient diagnosis.
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Affiliation(s)
- Yu Zhou
- Department of Neurosurgery, The Second Xiangya Hospital of Central South University, Furong District, Changsha, Hunan, China
| | - Yugang Jiang
- Department of Neurosurgery, The Second Xiangya Hospital of Central South University, Furong District, Changsha, Hunan, China.
| | - Yong Peng
- Department of Neurosurgery, The Second Xiangya Hospital of Central South University, Furong District, Changsha, Hunan, China
| | - Mingming Zhang
- Department of Neurosurgery, The Second Xiangya Hospital of Central South University, Furong District, Changsha, Hunan, China
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Kanat A, Aydin MD, Bayram E, Kazdal H, Aydin N, Omeroglu M, Altinkaynak K, Kabalar ME, Yolas C, Ozturk C, Kepoglu U, Calik M. A New Determinant of Poor Outcome After Spontaneous Subarachnoid Hemorrhage: Blood pH and the Disruption of Glossopharyngeal Nerve–Carotid Body Network: First Experimental Study. World Neurosurg 2017; 104:330-338. [DOI: 10.1016/j.wneu.2017.04.105] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/16/2017] [Accepted: 04/17/2017] [Indexed: 12/16/2022]
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Spitzer D, Spitzer NJ, Deininger M, Wirtz CR, König R, Burster T, Kapapa T. Activation of Cytotoxic Natural Killer Cells After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2017; 101:666-676.e1. [DOI: 10.1016/j.wneu.2017.03.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 03/05/2017] [Accepted: 03/07/2017] [Indexed: 10/20/2022]
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50
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Zheng VZ, Wong GKC. Neuroinflammation responses after subarachnoid hemorrhage: A review. J Clin Neurosci 2017; 42:7-11. [PMID: 28302352 DOI: 10.1016/j.jocn.2017.02.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/07/2017] [Indexed: 12/13/2022]
Abstract
Subarachnoid hemorrhage (SAH) is an important cause of stroke mortality and morbidity, especially in the young stroke population. Recent evidences indicate that neuroinflammation plays a critical role in both early brain injury and the delayed brain deterioration after SAH, including cellular and molecular components. Cerebral vasospasm (CV) can lead to death after SAH and independently correlated with poor outcome. Neuroinflammation is evidenced to contribute to the etiology of vasospasm. Besides, systemic inflammatory response syndrome (SIRS) commonly occurs in the SAH patients, with the presence of non-infectious fever and systematic complications. In this review, we summarize the evidences that indicate the prominent role of inflammation in the pathophysiology of SAH. That may provide the potential implications on diagnostic and therapeutic strategies.
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Affiliation(s)
- Vera Zhiyuan Zheng
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Hong Kong, China
| | - George Kwok Chu Wong
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Hong Kong, China.
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