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Abdulazim A, Heilig M, Rinkel G, Etminan N. Diagnosis of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage and Triggers for Intervention. Neurocrit Care 2023; 39:311-319. [PMID: 37537496 PMCID: PMC10542310 DOI: 10.1007/s12028-023-01812-3] [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: 05/25/2023] [Accepted: 07/11/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Delayed cerebral ischemia (DCI) is a major determinant for poor neurological outcome after aneurysmal subarachnoid hemorrhage (aSAH). Detection and treatment of DCI is a key component in the neurocritical care of patients with aSAH after initial aneurysm repair. METHODS Narrative review of the literature. RESULTS Over the past 2 decades, there has been a paradigm shift away from macrovascular (angiographic) vasospasm as a main diagnostic and therapeutic target. Instead, the pathophysiology of DCI is hypothesized to derive from several proischemic pathomechanisms. Clinical examination remains the most reliable means for monitoring and treatment of DCI, but its value is limited in comatose patients. In such patients, monitoring of DCI is usually based on numerous neurophysiological and/or radiological diagnostic modalities. Catheter angiography remains the gold standard for the detection of macrovascular spasm. Computed tomography (CT) angiography is increasingly used instead of catheter angiography because it is less invasive and may be combined with CT perfusion imaging. CT perfusion permits semiquantitative cerebral blood flow measurements, including the evaluation of the microcirculation. It may be used for prediction, early detection, and diagnosis of DCI, with yet-to-prove benefit on clinical outcome when used as a screening modality. Transcranial Doppler may be considered as an additional noninvasive screening tool for flow velocities in the middle cerebral artery, with limited accuracy in other cerebral arteries. Continuous electroencephalography enables detection of early signs of ischemia at a reversible stage prior to clinical manifestation. However, its widespread use is still limited because of the required infrastructure and expertise in data interpretation. Near-infrared spectroscopy, a noninvasive and continuous modality for evaluation of cerebral blood flow dynamics, has shown conflicting results and needs further validation. Monitoring techniques beyond neurological examinations may help in the detection of DCI, especially in comatose patients. However, these techniques are limited because of their invasive nature and/or restriction of measurements to focal brain areas. CONCLUSION The current literature review underscores the need for incorporating existing modalities and developing new methods to evaluate brain perfusion, brain metabolism, and overall brain function more accurately and more globally.
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Affiliation(s)
- Amr Abdulazim
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Marina Heilig
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Gabriel Rinkel
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, University Hospital Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Xu CR, Li JR, Jiang SW, Wan L, Zhang X, Xia L, Hua XM, Li ST, Chen HJ, Fu XJ, Jing CH. CD47 Blockade Accelerates Blood Clearance and Alleviates Early Brain Injury After Experimental Subarachnoid Hemorrhage. Front Immunol 2022; 13:823999. [PMID: 35281006 PMCID: PMC8915201 DOI: 10.3389/fimmu.2022.823999] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 02/07/2022] [Indexed: 01/02/2023] Open
Abstract
Aims Subarachnoid hemorrhage (SAH) is a devastating stroke subtype. Following SAH, erythrocyte lysis contributes to cell death and brain injuries. Blockage of the anti-phagocytic receptor Cluster of Differentiation 47 (CD47) enhances phagocyte clearance of erythrocytes, though it has not been well-studied post-SAH. The current study aims to determine whether anti-CD47 treatment can enhance blood clearance after experimental SAH. Methods The prechiasmatic blood injection model of SAH was used in mice. Mice were either treated with the CD47-blocking antibody or IgG as control. The effect of the anti-CD47 antibody on blood clearance and neurological function following SAH was determined. Neuroinflammation and neuronal injury were compared between the treatment and control samples on day 1 and day 7 after SAH using flow cytometry, immunofluorescence, Fluoro-Jade C, and Nissl staining, RT-PCR, and Western blot analysis. Results CD47-blocking antibody sped-up blood clearance after SAH, and resulted in less neuronal injury and neurological deficits than control samples. Microglia played a role in the anti-CD47 blockade. Following SAH Following SAH, CD47 antibody-treated mice had less neuroinflammation and lower levels of apoptosis compared to controls and both one and 7 days. Conclusions CD47 antibody treatment has a neuroprotective effect following SAH, by increasing blood clearance rate and reducing brain injury. These findings suggest CD47 antibody treatment may improve SAH patient outcomes.
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Affiliation(s)
- Chao-ran Xu
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jian-ru Li
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Shao-wei Jiang
- Department of Emergency, XinHua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Liang Wan
- Department of Neurosurgery, XinHua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xin Zhang
- Department of Neurosurgery, XinHua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Lei Xia
- Department of Neurosurgery, XinHua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xu-ming Hua
- Department of Neurosurgery, XinHua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Shi-ting Li
- Department of Neurosurgery, XinHua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Huai-jun Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiong-jie Fu
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Chao-hui Jing
- Department of Neurosurgery, XinHua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, China
- *Correspondence: Chao-hui Jing,
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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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Chamling B, Gross S, Stoffel-Wagner B, Schubert GA, Clusmann H, Coburn M, Höllig A. Early Diagnosis of Delayed Cerebral Ischemia: Possible Relevance for Inflammatory Biomarkers in Routine Clinical Practice? World Neurosurg 2017; 104:152-157. [PMID: 28512045 DOI: 10.1016/j.wneu.2017.05.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is one of the main causes of neurologic deterioration. However, it frequently evades timely detection. Early identification and effective reversal may improve the clinical outcome. In this prospective study, we evaluate several serum inflammatory markers after aneurysmal SAH with regard to the occurrence of DCI. METHODS On days 1, 4, 7, 10, and 14 after SAH, leucocyte count, C-reactive protein, interleukin 6, E-selectin, matrix metallopeptidase 9, intercellular adhesion molecule 1, and leukemia inhibitory factor were assessed in patients' serum samples. Using a Cox regression model (SPSS 21.0), associations of baseline parameters, maximum and delta (maximum minus baseline) values with occurrence of DCI were evaluated. RESULTS Considering the assessed parameters, leucocyte count (high baseline and delta values) matches most closely with occurrence of DCI. Although baseline levels of C-reactive protein are also associated with occurrence of DCI, neither maximum (only on a borderline level) nor delta levels do so. CONCLUSIONS Our data analysis identified leucocyte count as the parameter most likely associated with occurrence of DCI. However, because of its lack of specificity leucocyte count, it cannot be used as a biomarker. As hypothesized earlier, the results indicate a possible involvement of the inflammatory reaction after aneurysmal SAH in the pathomechanism of DCI.
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Affiliation(s)
- Bishwas Chamling
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany and DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
| | - Stefan Gross
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany and DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
| | - Birgit Stoffel-Wagner
- Department of Clinical Chemistry and Clinical Pharmacology, University Hospital of Bonn, Bonn, Germany
| | | | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Mark Coburn
- Department of Anesthesiology, RWTH Aachen University, Aachen, Germany
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
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Bakr A, Silva D, Cramb R, Flint G, Foroughi M. Outcomes of CSF spectrophotometry in cases of suspected subarachnoid haemorrhage with negative CT: two years retrospective review in a Birmingham hospital. Br J Neurosurg 2016; 31:223-226. [DOI: 10.1080/02688697.2016.1265089] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- A. Bakr
- Queen Elizabeth Hospital, Birmingham, UK
| | - D. Silva
- Queen Elizabeth Hospital, Birmingham, UK
| | - R. Cramb
- Queen Elizabeth Hospital, Birmingham, UK
| | - G. Flint
- Queen Elizabeth Hospital, Birmingham, UK
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Aydin HE, Özbek Z, Aydin N, Bolluk Ö, Vural M, Arslantas A, Atasoy MA. Application of Lumbar Drainage in Vasospasm After Spontaneous Subarachnoid Hemorrhage and Prevention of Late Cerebral Infarction. ACTA NEUROCHIRURGICA SUPPLEMENT 2015; 120:255-8. [DOI: 10.1007/978-3-319-04981-6_43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Abstract
Subarachnoid haemorrhage (SAH) causes early brain injury (EBI) that is mediated by effects of transient cerebral ischaemia during bleeding plus effects of the subarachnoid blood. Secondary effects of SAH include increased intracranial pressure, destruction of brain tissue by intracerebral haemorrhage, brain shift, and herniation, all of which contribute to pathology. Many patients survive these phenomena, but deteriorate days later from delayed cerebral ischaemia (DCI), which causes poor outcome or death in up to 30% of patients with SAH. DCI is thought to be caused by the combined effects of angiographic vasospasm, arteriolar constriction and thrombosis, cortical spreading ischaemia, and processes triggered by EBI. Treatment for DCI includes prophylactic administration of nimodipine, and current neurointensive care. Prompt recognition of DCI and immediate treatment by means of induced hypertension and balloon or pharmacological angioplasty are considered important by many physicians, although the evidence to support such approaches is limited. This Review summarizes the pathophysiology of DCI after SAH and discusses established treatments for this condition. Novel strategies--including drugs such as statins, sodium nitrite, albumin, dantrolene, cilostazol, and intracranial delivery of nimodipine or magnesium--are also discussed.
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Chazot PL. Editorial. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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