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Scutca AC, Nicoară DM, Mang N, Jugănaru I, Brad GF, Mărginean O. Correlation between Neutrophil-to-Lymphocyte Ratio and Cerebral Edema in Children with Severe Diabetic Ketoacidosis. Biomedicines 2023; 11:2976. [PMID: 38001976 PMCID: PMC10669654 DOI: 10.3390/biomedicines11112976] [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: 10/02/2023] [Revised: 11/02/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023] Open
Abstract
Diabetic ketoacidosis (DKA), a common onset modality of type 1 diabetes mellitus (T1DM), can lead, in rare instances, to the development of cerebral edema, which is the leading cause of mortality in T1DM. Aside from the identification of several demographic and clinical risk factors for cerebral edema, attention has also been drawn to the possible link between systemic inflammation and neuroinflammation. This single-center retrospective study of 98 children with severe DKA aimed to investigate the possible relationship between neutrophil-to-lymphocyte ratio NLR) levels and the presence of cerebral edema. Patients were classified into three groups: alert (n = 28), subclinical cerebral edema (n = 59), and overt cerebral edema (n = 11). Lower blood pH and elevated NLR and blood urea were correlated with the presence of cerebral edema (p < 0.001). After a multivariable risk adjustment for possible confounding factors, such as age, pH, corrected sodium, and BUN, the NLR remained positively associated with cerebral edema (p = 0.045). As such, NLR may be an additional instrument to help practitioners target patients with a higher risk of severe cerebral edema. These patients would benefit from more rigorous neurologic surveillance, enabling the prompt identification of early signs of cerebral edema.
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Affiliation(s)
- Alexandra-Cristina Scutca
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
- Department of Pediatrics I, Children’s Emergency Hospital “Louis Turcanu”, 300011 Timisoara, Romania
| | - Delia-Maria Nicoară
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
| | - Niculina Mang
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
- Department of Pediatrics I, Children’s Emergency Hospital “Louis Turcanu”, 300011 Timisoara, Romania
| | - Iulius Jugănaru
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
- Department of Pediatrics I, Children’s Emergency Hospital “Louis Turcanu”, 300011 Timisoara, Romania
- Research Center for Disturbances of Growth and Development in Children BELIVE, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
| | - Giorgiana-Flavia Brad
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
- Department of Pediatrics I, Children’s Emergency Hospital “Louis Turcanu”, 300011 Timisoara, Romania
| | - Otilia Mărginean
- Department XI Pediatrics, Discipline I Pediatrics, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania; (A.-C.S.); (N.M.); (I.J.); (G.-F.B.); (O.M.)
- Department of Pediatrics I, Children’s Emergency Hospital “Louis Turcanu”, 300011 Timisoara, Romania
- Research Center for Disturbances of Growth and Development in Children BELIVE, ‘Victor Babeş’ University of Medicine and Pharmacy of Timisoara, 300041 Timisoara, Romania
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Zheng Y, Zhou X, Wang C, Zhang J, Chang D, Liu W, Zhu M, Zhuang S, Shi H, Wang X, Chen Y, Cheng Z, Lin Y, Nan L, Sun Y, Min L, Liu J, Chen J, Zhang J, Huang M. Effect of Tanshinone IIA on Gut Microbiome in Diabetes-Induced Cognitive Impairment. Front Pharmacol 2022; 13:890444. [PMID: 35899118 PMCID: PMC9309808 DOI: 10.3389/fphar.2022.890444] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/09/2022] [Indexed: 01/14/2023] Open
Abstract
Diabetes-induced cognitive impairment (DCI) presents a major public health risk among the aging population. Previous clinical attempts on known therapeutic targets for DCI, such as depleted insulin secretion, insulin resistance, and hyperglycaemia have delivered poor patient outcomes. However, recent evidence has demonstrated that the gut microbiome plays an important role in DCI by modulating cognitive function through the gut–brain crosstalk. The bioactive compound tanshinone IIA (TAN) has shown to improve cognitive and memory function in diabetes mellitus models, though the pharmacological actions are not fully understood. This study aims to investigate the effect and underlying mechanism of TAN in attenuating DCI in relation to regulating the gut microbiome. Metagenomic sequencing analyses were performed on a group of control rats, rats with diabetes induced by a high-fat/high-glucose diet (HFD) and streptozotocin (STZ) (model group) and TAN-treated diabetic rats (TAN group). Cognitive and memory function were assessed by the Morris water maze test, histopathological assessment of brain tissues, and immunoblotting of neurological biomarkers. The fasting blood glucose (FBG) level was monitored throughout the experiments. The levels of serum lipopolysaccharide (LPS) and tumor necrosis factor-α (TNF-α) were measured by enzyme-linked immunoassays to reflect the circulatory inflammation level. The morphology of the colon barrier was observed by histopathological staining. Our study confirmed that TAN reduced the FBG level and improved the cognitive and memory function against HFD- and STZ-induced diabetes. TAN protected the endothelial tight junction in the hippocampus and colon, regulated neuronal biomarkers, and lowered the serum levels of LPS and TNF-α. TAN corrected the reduced abundance of Bacteroidetes in diabetic rats. At the species level, TAN regulated the abundance of B. dorei, Lachnoclostridium sp. YL32 and Clostridiodes difficile. TAN modulated the lipid metabolism and biosynthesis of fatty acids in related pathways as the main functional components. TAN significantly restored the reduced levels of isobutyric acid and butyric acid. Our results supported the use of TAN as a promising therapeutic agent for DCI, in which the underlying mechanism may be associated with gut microbiome regulation.
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Affiliation(s)
- Yanfang Zheng
- Fujian Key Laboratory of Chinese Materia Medica, College of Pharmacy, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Xian Zhou
- NICM Health Research Institute, Western Sydney University, Westmead, NSW, Australia
| | - Chenxiang Wang
- Fujian Key Laboratory of Chinese Materia Medica, College of Pharmacy, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Jialin Zhang
- College of Integrated Traditional Chinese and Western Medicine, Fu Jian University of Traditional Chinese Medicine, Fu Zhou, China
| | - Dennis Chang
- NICM Health Research Institute, Western Sydney University, Westmead, NSW, Australia
| | - Wenjing Liu
- Fujian Key Laboratory of Chinese Materia Medica, College of Pharmacy, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - MingXing Zhu
- College of Traditional Chinese, Fu Jian University of Traditional Chinese Medicine, Fu Zhou, China
| | - Shuting Zhuang
- College of Integrated Traditional Chinese and Western Medicine, Fu Jian University of Traditional Chinese Medicine, Fu Zhou, China
| | - Hong Shi
- College of Integrated Traditional Chinese and Western Medicine, Fu Jian University of Traditional Chinese Medicine, Fu Zhou, China
| | - Xiaoning Wang
- College of Integrated Traditional Chinese and Western Medicine, Fu Jian University of Traditional Chinese Medicine, Fu Zhou, China
| | - Yong Chen
- College of Integrated Traditional Chinese and Western Medicine, Fu Jian University of Traditional Chinese Medicine, Fu Zhou, China
| | - Zaixing Cheng
- Fujian Key Laboratory of Chinese Materia Medica, College of Pharmacy, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Yanxiang Lin
- Fujian Key Laboratory of Chinese Materia Medica, College of Pharmacy, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Lihong Nan
- Fujian Key Laboratory of Chinese Materia Medica, College of Pharmacy, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Yibin Sun
- Fujian Key Laboratory of Chinese Materia Medica, College of Pharmacy, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Li Min
- College of Traditional Chinese, Fu Jian University of Traditional Chinese Medicine, Fu Zhou, China
| | - Jin Liu
- Fujian Key Laboratory of Chinese Materia Medica, College of Pharmacy, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Jianyu Chen
- Fujian Key Laboratory of Chinese Materia Medica, College of Pharmacy, Fujian University of Traditional Chinese Medicine, Fuzhou, China
- *Correspondence: Jianyu Chen, ; Jieping Zhang, ; Mingqing Huang,
| | - Jieping Zhang
- College of Integrated Traditional Chinese and Western Medicine, Fu Jian University of Traditional Chinese Medicine, Fu Zhou, China
- *Correspondence: Jianyu Chen, ; Jieping Zhang, ; Mingqing Huang,
| | - Mingqing Huang
- Fujian Key Laboratory of Chinese Materia Medica, College of Pharmacy, Fujian University of Traditional Chinese Medicine, Fuzhou, China
- *Correspondence: Jianyu Chen, ; Jieping Zhang, ; Mingqing Huang,
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3
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Shalimova A, Graff B, Gąsecki D, Wolf J, Sabisz A, Szurowska E, Jodzio K, Narkiewicz K. Cognitive Dysfunction in Type 1 Diabetes Mellitus. J Clin Endocrinol Metab 2019; 104:2239-2249. [PMID: 30657922 DOI: 10.1210/jc.2018-01315] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 01/15/2019] [Indexed: 02/02/2023]
Abstract
CONTEXT We have summarized key studies assessing the epidemiology, mechanisms, and consequences of cognitive dysfunction (CD) in type 1 diabetes. EVIDENCE SYNTHESIS In a number of studies, the severity of CD in type 1 diabetes was affected by the age of onset and duration, and the presence of proliferative retinopathy and autonomic neuropathy. Diabetes-related CD has been observed, not only in adults, but also in children and adolescents. Most neuroimaging studies of patients with type 1 diabetes did not show any differences in whole brain volumes; however, they did reveal selective deficits in gray matter volume or density within the frontal, posterior, and temporal cortex and subcortical gray matter. Studies of middle-age adults with long-standing type 1 diabetes using diffusion tensor imaging have demonstrated partial lesions in the white matter and decreased fractional anisotropy in posterior brain regions. The mechanisms underlying diabetes-related CD are very complex and include factors related to diabetes per se and to diabetes-related cardiovascular disease and microvascular dysfunction, including chronic hyperglycemia, hypoglycemia, macro- and microvascular disease, and increased inflammatory cytokine expression. These mechanisms might contribute to the development and progression of both vascular dementia and Alzheimer disease. CONCLUSIONS Higher rates of CD and faster progression in type 1 diabetes can be explained by both the direct effects of altered glucose metabolism on the brain and diabetes-related cardiovascular disease. Because the presence and progression of CD significantly worsens the quality of life of patients with diabetes, further multidisciplinary studies incorporating the recent progress in both neuroimaging and type 1 diabetes management are warranted to investigate this problem.
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Affiliation(s)
- Anna Shalimova
- Department of Hypertension and Diabetology, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
| | - Beata Graff
- Department of Hypertension and Diabetology, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
| | - Dariusz Gąsecki
- Department of Adult Neurology, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
| | - Jacek Wolf
- Department of Hypertension and Diabetology, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
| | - Agnieszka Sabisz
- Department of Radiology, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
| | - Edyta Szurowska
- Department of Radiology, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
| | - Krzysztof Jodzio
- Institute of Psychology, University of Gdańsk, 80-308 Gdańsk, Poland
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdańsk, Faculty of Medicine, Gdańsk, Poland
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Coucha M, Abdelsaid M, Ward R, Abdul Y, Ergul A. Impact of Metabolic Diseases on Cerebral Circulation: Structural and Functional Consequences. Compr Physiol 2018; 8:773-799. [PMID: 29687902 DOI: 10.1002/cphy.c170019] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Metabolic diseases including obesity, insulin resistance, and diabetes have profound effects on cerebral circulation. These diseases not only affect the architecture of cerebral blood arteries causing adverse remodeling, pathological neovascularization, and vasoregression but also alter the physiology of blood vessels resulting in compromised myogenic reactivity, neurovascular uncoupling, and endothelial dysfunction. Coupled with the disruption of blood brain barrier (BBB) integrity, changes in blood flow and microbleeds into the brain rapidly occur. This overview is organized into sections describing cerebrovascular architecture, physiology, and BBB in these diseases. In each section, we review these properties starting with larger arteries moving into smaller vessels. Where information is available, we review in the order of obesity, insulin resistance, and diabetes. We also tried to include information on biological variables such as the sex of the animal models noted since most of the information summarized was obtained using male animals. © 2018 American Physiological Society. Compr Physiol 8:773-799, 2018.
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Affiliation(s)
- Maha Coucha
- South University, School of Pharmacy, Savannah, Georgia, USA
| | | | - Rebecca Ward
- Department of Neuroscience & Regenerative Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Yasir Abdul
- Charlie Norwood VA Medical Center, Augusta, Georgia, USA.,Department of Physiology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Adviye Ergul
- Charlie Norwood VA Medical Center, Augusta, Georgia, USA.,Department of Physiology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
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5
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Hoffman WH, Artlett CM, Boodhoo D, Gilliland MGF, Ortiz L, Mulder D, Tjan DHT, Martin A, Tatomir A, Rus H. Markers of immune-mediated inflammation in the brains of young adults and adolescents with type 1 diabetes and fatal diabetic ketoacidosis. Is there a difference? Exp Mol Pathol 2017; 102:505-514. [PMID: 28533125 DOI: 10.1016/j.yexmp.2017.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/18/2017] [Indexed: 12/17/2022]
Abstract
Due to the limited data on diabetic ketoacidosis and brain edema (DKA/BE) in children/adolescents and the lack of recent data on adults with type 1 diabetes (T1D), we addressed the question of whether neuroinflammation was present in the fatal DKA of adults. We performed immunohistochemistry (IHC) studies on the brains of two young adults with T1D and fatal DKA and compared them with two teenagers with poorly controlled diabetes and fatal DKA. C5b-9, the membrane attack complex (MAC) had significantly greater deposits in the grey and white matter of the teenagers than the young adults (p=0.03). CD59, a MAC assembly inhibitory protein was absent, possibly suppressed by the hyperglycemia in the teenagers but was expressed in the young adults despite comparable average levels of hyperglycemia. The receptor for advanced glycation end products (RAGE) had an average expression in the young adults significantly greater than in the teenagers (p=0.02). The autophagy marker Light Chain 3 (LC3) A/B was the predominant form of programmed cell death (PCD) in the teenage brains. The young adults had high expressions of both LC3A/B and TUNEL, an apoptotic cell marker for DNA fragmentation. BE was present in the newly diagnosed young adult with hyperglycemic hyperosmolar DKA and also in the two teenagers. Our data indicate that significant differences in neuroinflammatory components, initiated by the dysregulation of DKA and interrelated metabolic and immunologic milieu, are likely present in the brains of fatal DKA of teenagers when compared with young adults.
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Affiliation(s)
- William H Hoffman
- Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, GA 30912, United States.
| | - Carol M Artlett
- Department of Microbiology & Immunology, Drexel University College of Medicine, Philadelphia, PA 19129, United States
| | - Dallas Boodhoo
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Mary G F Gilliland
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, Greenville, NC 27858, United States
| | - Luis Ortiz
- Department of Pediatrics, Nephrology, Medical College of Georgia, Augusta University, Augusta, GA 30912, United States
| | - Dries Mulder
- Department of Pathology, Rijnstate Hospital, Arnhem, The Netherlands
| | - David H T Tjan
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Alvaro Martin
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Alexandru Tatomir
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Horea Rus
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, United States; Research Service, Veterans Administration Maryland Health Care System, MD 21201, United States.
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6
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Hardigan T, Hernandez C, Ward R, Hoda MN, Ergul A. TLR2 knockout protects against diabetes-mediated changes in cerebral perfusion and cognitive deficits. Am J Physiol Regul Integr Comp Physiol 2017; 312:R927-R937. [PMID: 28336553 DOI: 10.1152/ajpregu.00482.2016] [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] [Received: 11/09/2016] [Revised: 01/25/2017] [Accepted: 02/17/2017] [Indexed: 12/29/2022]
Abstract
The risk of cognitive decline in diabetes (Type 1 and Type 2) is significantly greater compared with normoglycemic patients, and the risk of developing dementia in diabetic patients is doubled. The etiology for this is likely multifactorial, but one mechanism that has gained increasing attention is decreased cerebral perfusion as a result of cerebrovascular dysfunction. The innate immune system has been shown to play a role in diabetic vascular complications, notably through the Toll-like receptor (TLR)-stimulated release of proinflammatory cytokines and chemokines that lead to vascular damage. TLR2 has been implicated in playing a crucial role in the development of diabetic microvascular complications, such as nephropathy, and thus, we hypothesized that TLR2-mediated cerebrovascular dysfunction leads to decreased cerebral blood flow (CBF) and cognitive impairment in diabetes. Knockout of TLR2 conferred protection from impaired CBF in early-stage diabetes and from hyperperfusion in long-term diabetes, prevented the development of endothelium-dependent vascular dysfunction in diabetes, created a hyperactive and anxiolytic phenotype, and protected against diabetes-induced impairment of long-term hippocampal and prefrontal cortex-mediated fear learning. In conclusion, these findings support the involvement of TLR2 in the pathogenesis of diabetic vascular disease and cognitive impairment.
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Affiliation(s)
- Trevor Hardigan
- Department of Physiology, University of Georgia, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Caterina Hernandez
- Department of Pharmacology and Toxicology, University of Georgia, Medical College of Georgia, Augusta University, Augusta, Georgia.,Department of Small Animal Behavior Core Facility, University of Georgia, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Rebecca Ward
- Department of Neuroscience, University of Georgia, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - M Nasrul Hoda
- Department of Medical Laboratory, Imaging and Radiologic Sciences, University of Georgia, Medical College of Georgia, Augusta University, Augusta, Georgia.,Department of Neurology, University of Georgia, Medical College of Georgia, Augusta University, Augusta, Georgia.,Program in Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Medical College of Georgia, Augusta University, Augusta, Georgia; and
| | - Adviye Ergul
- Department of Physiology, University of Georgia, Medical College of Georgia, Augusta University, Augusta, Georgia; .,Charlie Norwood Veterans Administration Medical Center, Augusta, Georgia
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7
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Hardigan T, Ward R, Ergul A. Cerebrovascular complications of diabetes: focus on cognitive dysfunction. Clin Sci (Lond) 2016; 130:1807-22. [PMID: 27634842 PMCID: PMC5599301 DOI: 10.1042/cs20160397] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 07/11/2015] [Indexed: 01/01/2023]
Abstract
The incidence of diabetes has more than doubled in the United States in the last 30 years and the global disease rate is projected to double by 2030. Cognitive impairment has been associated with diabetes, worsening quality of life in patients. The structural and functional interaction of neurons with the surrounding vasculature is critical for proper function of the central nervous system including domains involved in learning and memory. Thus, in this review we explore cognitive impairment in patients and experimental models, focusing on links to vascular dysfunction and structural changes. Lastly, we propose a role for the innate immunity-mediated inflammation in neurovascular changes in diabetes.
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Affiliation(s)
- Trevor Hardigan
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, U.S.A
| | - Rebecca Ward
- Department of Neuroscience and Regenerative Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, U.S.A
| | - Adviye Ergul
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, U.S.A. Charlie Norwood Veterans Administration Medical Center, Augusta, GA 30912, U.S.A.
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8
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Fan AP, Jahanian H, Holdsworth SJ, Zaharchuk G. Comparison of cerebral blood flow measurement with [15O]-water positron emission tomography and arterial spin labeling magnetic resonance imaging: A systematic review. J Cereb Blood Flow Metab 2016; 36:842-61. [PMID: 26945019 PMCID: PMC4853843 DOI: 10.1177/0271678x16636393] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 01/19/2016] [Accepted: 02/04/2016] [Indexed: 11/16/2022]
Abstract
Noninvasive imaging of cerebral blood flow provides critical information to understand normal brain physiology as well as to identify and manage patients with neurological disorders. To date, the reference standard for cerebral blood flow measurements is considered to be positron emission tomography using injection of the [(15)O]-water radiotracer. Although [(15)O]-water has been used to study brain perfusion under normal and pathological conditions, it is not widely used in clinical settings due to the need for an on-site cyclotron, the invasive nature of arterial blood sampling, and experimental complexity. As an alternative, arterial spin labeling is a promising magnetic resonance imaging technique that magnetically labels arterial blood as it flows into the brain to map cerebral blood flow. As arterial spin labeling becomes more widely adopted in research and clinical settings, efforts have sought to standardize the method and validate its cerebral blood flow values against positron emission tomography-based cerebral blood flow measurements. The purpose of this work is to critically review studies that performed both [(15)O]-water positron emission tomography and arterial spin labeling to measure brain perfusion, with the aim of better understanding the accuracy and reproducibility of arterial spin labeling relative to the positron emission tomography reference standard.
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Affiliation(s)
- Audrey P Fan
- Department of Radiology, Stanford University, Stanford, CA, USA
| | | | | | - Greg Zaharchuk
- Department of Radiology, Stanford University, Stanford, CA, USA
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9
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Cerebral perfusion in pediatric type 1 diabetes: relation to vascular complications, psychological and neurophysiological functions. Int J Diabetes Dev Ctries 2015. [DOI: 10.1007/s13410-014-0226-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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10
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van Golen LW, Kuijer JP, Huisman MC, IJzerman RG, Barkhof F, Diamant M, Lammertsma AA. Quantification of cerebral blood flow in healthy volunteers and type 1 diabetic patients: Comparison of MRI arterial spin labeling and [15O]H2O positron emission tomography (PET). J Magn Reson Imaging 2013; 40:1300-9. [DOI: 10.1002/jmri.24484] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 09/28/2013] [Indexed: 11/06/2022] Open
Affiliation(s)
- Larissa W. van Golen
- Diabetes Center/ Department of Internal Medicine; VU University Medical Center; Amsterdam The Netherlands
| | - Joost P.A. Kuijer
- Department of Physics and Medical Technology, Neuroscience Campus Amsterdam; VU University Medical Center; Amsterdam The Netherlands
| | - Marc C. Huisman
- Department of Radiology & Nuclear Medicine, Neuroscience Campus Amsterdam; VU University Medical Center; Amsterdam The Netherlands
| | - Richard G. IJzerman
- Diabetes Center/ Department of Internal Medicine; VU University Medical Center; Amsterdam The Netherlands
| | - Frederik Barkhof
- Department of Radiology & Nuclear Medicine, Neuroscience Campus Amsterdam; VU University Medical Center; Amsterdam The Netherlands
| | - Michaela Diamant
- Diabetes Center/ Department of Internal Medicine; VU University Medical Center; Amsterdam The Netherlands
| | - Adriaan A. Lammertsma
- Department of Radiology & Nuclear Medicine, Neuroscience Campus Amsterdam; VU University Medical Center; Amsterdam The Netherlands
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11
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van Golen LW, Huisman MC, Ijzerman RG, Hoetjes NJ, Schwarte LA, Lammertsma AA, Diamant M. Cerebral blood flow and glucose metabolism measured with positron emission tomography are decreased in human type 1 diabetes. Diabetes 2013; 62:2898-904. [PMID: 23530004 PMCID: PMC3717848 DOI: 10.2337/db12-1159] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Subclinical systemic microvascular dysfunction exists in asymptomatic patients with type 1 diabetes. We hypothesized that microangiopathy, resulting from long-standing systemic hyperglycemia and hyperinsulinemia, may be generalized to the brain, resulting in changes in cerebral blood flow (CBF) and metabolism in these patients. We performed dynamic [(15)O]H2O and [(18)F]-fluoro-2-deoxy-d-glucose brain positron emission tomography scans to measure CBF and cerebral glucose metabolism (CMRglu), respectively, in 30 type 1 diabetic patients and 12 age-matched healthy controls after an overnight fast. Regions of interest were automatically delineated on coregistered magnetic resonance images and full kinetic analysis was performed. Plasma glucose and insulin levels were higher in patients versus controls. Total gray matter CBF was 9%, whereas CMRglu was 21% lower in type 1 diabetic subjects versus control subjects. We conclude that at real-life fasting glucose and insulin levels, type 1 diabetes is associated with decreased resting cerebral glucose metabolism, which is only partially explained by the decreased CBF. These findings suggest that mechanisms other than generalized microangiopathy account for the altered CMRglu observed in well-controlled type 1 diabetes.
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Affiliation(s)
- Larissa W. van Golen
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
- Corresponding author: Larissa W. van Golen,
| | - Marc C. Huisman
- Department of Nuclear Medicine and Positron Emission Tomography Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Richard G. Ijzerman
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Nikie J. Hoetjes
- Department of Nuclear Medicine and Positron Emission Tomography Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Lothar A. Schwarte
- Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Adriaan A. Lammertsma
- Department of Nuclear Medicine and Positron Emission Tomography Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Michaela Diamant
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
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Abstract
Cognitive dysfunction in type 1 and type 2 diabetes share many similarities, but important differences do exist. A primary distinguishing feature of type 2 diabetes is that people with this disorder often (but not invariably) do poorly on measures of learning and memory, whereas deficits in these domains are rarely seen in people with type 1 diabetes. Chronic hyperglycaemia and microvascular disease contribute to cognitive dysfunction in both type 1 and type 2 diabetes, and both disorders are associated with mental and motor slowing and decrements of similar magnitude on measures of attention and executive functioning. Additionally, both types are characterised by neural slowing, increased cortical atrophy, microstructural abnormalities in white matter tracts, and similar, but not identical, changes in concentrations of brain neurometabolites. Disconcertingly, the rapid rise in obesity and type 2 diabetes in all age groups might result in a substantial increase in prevalence of diabetes-related cognitive dysfunction.
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Affiliation(s)
- Rory J McCrimmon
- Medical Research Institute, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK.
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13
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Cerebral edema in diabetic ketoacidosis: time to go with the (cerebral blood) flow? Pediatr Crit Care Med 2011; 12:687-9. [PMID: 22067822 DOI: 10.1097/pcc.0b013e3182231248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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van Elderen SGC, Brandts A, van der Grond J, Westenberg JJM, Kroft LJM, van Buchem MA, Smit JWA, de Roos A. Cerebral perfusion and aortic stiffness are independent predictors of white matter brain atrophy in type 1 diabetic patients assessed with magnetic resonance imaging. Diabetes Care 2011; 34:459-63. [PMID: 21216862 PMCID: PMC3024367 DOI: 10.2337/dc10-1446] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To identify vascular mechanisms of brain atrophy in type 1 diabetes mellitus (DM) patients by investigating the relationship between brain volumes and cerebral perfusion and aortic stiffness using magnetic resonance imaging (MRI). RESEARCH DESIGN AND METHODS Approval from the local institutional review board was obtained, and patients gave informed consent. Fifty-one type 1 DM patients (30 men; mean age 44 ± 11 years; mean DM duration 23 ± 12 years) and 34 age- and sex-matched healthy control subjects were prospectively enrolled. Exclusion criteria comprised hypertension, stroke, aortic disease, and standard MRI contraindications. White matter (WM) and gray matter (GM) brain volumes, total cerebral blood flow (tCBF), total brain perfusion, and aortic pulse wave velocity (PWV) were assessed using MRI. Multivariable linear regression analysis was used for statistics, with covariates age, sex, mean arterial pressure, BMI, smoking, heart rate, DM duration, and HbA(1c). RESULTS Both WM and GM brain volumes were decreased in type 1 DM patients compared with control subjects (WM P = 0.04; respective GM P = 0.03). Total brain perfusion was increased in type 1 DM compared with control subjects (β = -0.219, P < 0.05). Total CBF and aortic PWV predicted WM brain volume (β = 0.352, P = 0.024 for tCBF; respective β = -0.458, P = 0.016 for aortic PWV) in type 1 DM. Age was the independent predictor of GM brain volume (β = -0.695, P < 0.001). CONCLUSIONS Type 1 DM patients without hypertension showed WM and GM volume loss compared with control subjects concomitant with a relative increased brain perfusion. Total CBF and stiffness of the aorta independently predicted WM brain atrophy in type 1 DM. Only age predicted GM brain atrophy.
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Abstract
Diabetic encephalopathies are now accepted complications of diabetes. They appear to differ in type 1 and type 2 diabetes as to underlying mechanisms and the nature of resulting cognitive deficits. The increased incidence of Alzheimer's disease in type 2 diabetes is associated with insulin resistance, hyperinsulinemia and hyperglycemia, and commonly accompanying attributes such as hypercholesterolemia, hypertension and obesity. The relevance of these disorders as to the emergence of dementia and Alzheimer's disease is discussed based on epidemiological studies. The pathobiology of accumulation of β-amyloid and tau the hallmarks of Alzheimer's disease are discussed based on experimental data. Type 1 diabetic encephalopathy is likely to increase as a result of the global increase in the incidence of type 1 diabetes and its occurrence in increasingly younger patients. Alzheimer-like changes and dementia are not prominently increased in type 1 diabetes. Instead, the type 1 diabetic encephalopathy involves learning abilities, intelligence development and memory retrieval resulting in impaired school and professional performances. The major underlying component here appears to be insulin deficiency with downstream effects on the expression of neurotrophic factors, neurotransmitters, oxidative and apoptotic stressors resulting in defects in neuronal integrity, connectivity and loss commonly occurring in the still developing brain. Recent experimental data emphasize the role of impaired central insulin action and provide information as to potential therapies. Therefore, the underlying mechanisms resulting in diabetic encephalopathies are complex and appear to differ between the two types of diabetes. Major headway has been made in our understanding of their pathobiology; however, many questions remain to be clarified. In view of the increasing incidence of both type 1 and type 2 diabetes, intensified investigations are called for to expand our understanding of these complications and to find therapeutic means by which these disastrous consequences can be prevented and modified.
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MESH Headings
- Amyloid/metabolism
- Animals
- Brain Diseases, Metabolic/diagnosis
- Brain Diseases, Metabolic/epidemiology
- Brain Diseases, Metabolic/etiology
- Diabetes Complications/diagnosis
- Diabetes Complications/epidemiology
- Diabetes Complications/psychology
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/epidemiology
- Diabetes Mellitus, Type 1/psychology
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/epidemiology
- Diabetes Mellitus, Type 2/psychology
- Disease Models, Animal
- Humans
- Models, Biological
- tau Proteins/metabolism
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Affiliation(s)
- Anders A F Sima
- Department of Pathology, Wayne State University, Detroit, MI 48201, USA.
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16
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Northam EA, Lin A. Hypoglycaemia in childhood onset type 1 diabetes--part villain, but not the only one. Pediatr Diabetes 2010; 11:134-41. [PMID: 19538515 DOI: 10.1111/j.1399-5448.2009.00545.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Elisabeth A Northam
- Department of Psychology, Royal Children's Hospital, Parkville, Victoria 3052, Australia.
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17
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Abstract
AbstractDiabetes is a chronic metabolic disease which can lead to numerous complications. One of these disturbances is cognitive function impairment. A group of 62 patients with type 1 and type 2 diabetes. There is a correlation between certain clinical features among diabetic patients and cognitive functions. Negative influence on cognitive functions have a higher level of total cholesterol, a higher level of LDL cholesterol, a lower level of HDL cholesterol concentration in the blood, a higher level of glucose after meals, a higher level of basic insulin dose and insulin dose taken just before the examination, longer duration of the diabetes and a lot of hypoglycemic episodes. There is no influence on cognitive functions from glucose levels before meals, the type of the insulin therapy, or the number of hyperglycemic episodes and value rate of hemoglobin HbA1C.
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Glaser N. Cerebral injury and cerebral edema in children with diabetic ketoacidosis: could cerebral ischemia and reperfusion injury be involved? Pediatr Diabetes 2009; 10:534-41. [PMID: 19821944 DOI: 10.1111/j.1399-5448.2009.00511.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA 95817, USA.
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Glaser NS, Marcin JP, Wootton-Gorges SL, Buonocore MH, Rewers A, Strain J, DiCarlo J, Neely EK, Barnes P, Kuppermann N. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr 2008; 153:541-6. [PMID: 18589447 DOI: 10.1016/j.jpeds.2008.04.048] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Revised: 03/18/2008] [Accepted: 04/14/2008] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine clinical and biochemical factors influencing cerebral edema formation during diabetic ketoacidosis (DKA) in children. STUDY DESIGN We used magnetic resonance diffusion-weighted imaging to quantify edema formation. We measured the apparent diffusion coefficient (ADC) of brain water during and after DKA treatment in 26 children and correlated ADC changes with clinical and biochemical variables. RESULTS Mean ADC values were elevated during DKA treatment compared with baseline (8.13 +/- 0.47 vs 7.74 +/- 0.49 x 10(-4) mm(2)/sec, difference in means 0.40, 95% CI: 0.25 to 0.55, P < .001). Children with altered mental status during DKA had greater elevation in ADC. ADC elevation during DKA was positively correlated with initial serum urea nitrogen concentration (correlation coefficient 0.41, P = .03) and initial respiratory rate (correlation coefficient 0.61, P < .001). ADC elevation was not significantly correlated with initial serum glucose, sodium or effective osmolality, nor with changes in glucose, sodium or osmolality during treatment. Multivariable analyses identified the initial urea nitrogen concentration and respiratory rate as independently associated with ADC elevation. CONCLUSIONS The degree of edema formation during DKA in children is correlated with the degree of dehydration and hyperventilation at presentation, but not with factors related to initial osmolality or osmotic changes during treatment. These data support the hypothesis that CE is related to cerebral hypoperfusion during DKA, and that osmotic fluctuations during DKA treatment do not play a primary causal role.
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Affiliation(s)
- Nicole S Glaser
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA 95817, USA.
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Yuen N, Anderson SE, Glaser N, Tancredi DJ, O'Donnell ME. Cerebral blood flow and cerebral edema in rats with diabetic ketoacidosis. Diabetes 2008; 57:2588-94. [PMID: 18633109 PMCID: PMC2551666 DOI: 10.2337/db07-1410] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 07/03/2008] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Cerebral edema (CE) is a potentially life-threatening complication of diabetic ketoacidosis (DKA) in children. Osmotic fluctuations during DKA treatment have been considered responsible, but recent data instead suggest that cerebral hypoperfusion may be involved and that activation of cerebral ion transporters may occur. Diminished cerebral blood flow (CBF) during DKA, however, has not been previously demonstrated. We investigated CBF and edema formation in a rat model of DKA and determined the effects of bumetanide, an inhibitor of Na-K-Cl cotransport. RESEARCH DESIGN AND METHODS Juvenile rats with streptozotocin-induced DKA were treated with intravenous saline and insulin, similar to human treatment protocols. CBF was determined by magnetic resonance (MR) perfusion-weighted imaging before and during treatment, and CE was assessed by determining apparent diffusion coefficients (ADCs) using MR diffusion-weighted imaging. RESULTS CBF was significantly reduced in DKA and was responsive to alterations in pCO(2). ADC values were reduced, consistent with cell swelling. The reduction in ADCs correlated with dehydration, as reflected in blood urea nitrogen concentrations. Bumetanide caused a rapid rise in ADCs of DKA rats without significantly changing CBF, while saline/insulin caused a rapid rise in CBF and a gradual rise in ADCs. DKA rats treated with bumetanide plus saline/insulin showed a trend toward more rapid rise in cortical ADCs and a larger rise in striatal CBF than those observed with saline/insulin alone. CONCLUSIONS These data demonstrate that CE in DKA is accompanied by cerebral hypoperfusion before treatment and suggest that blocking Na-K-Cl cotransport may reduce cerebral cell swelling.
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Affiliation(s)
- Natalie Yuen
- Department of Physiology and Membrane Biology, University of California, Davis, California
| | - Steven E. Anderson
- Department of Physiology and Membrane Biology, University of California, Davis, California
| | - Nicole Glaser
- Department of Pediatrics, University of California, Davis, California
| | | | - Martha E. O'Donnell
- Department of Physiology and Membrane Biology, University of California, Davis, California
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Tiehuis AM, Vincken KL, van den Berg E, Hendrikse J, Manschot SM, Mali WPTM, Kappelle LJ, Biessels GJ. Cerebral perfusion in relation to cognitive function and type 2 diabetes. Diabetologia 2008; 51:1321-6. [PMID: 18488188 PMCID: PMC2440938 DOI: 10.1007/s00125-008-1041-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 04/04/2008] [Indexed: 11/29/2022]
Abstract
AIM/HYPOTHESIS Underlying mechanisms for decreased cognitive functioning in patients with type 2 diabetes are unclear. In the general population, cerebral hypoperfusion is a risk factor for cognitive dysfunction and dementia. Reduced cerebral perfusion may account for cognitive impairments in diabetic patients relative to controls. METHODS A total of 98 patients with type 2 diabetes and 47 control participants underwent neuropsychological evaluation. Total cerebral blood flow (CBF) was assessed non-invasively by measuring the volume flow in the internal carotid arteries and basilar artery with two-dimensional phase-contrast magnetic resonance angiography. Relative total CBF, a measure of mean total cerebral perfusion, was obtained by expressing total CBF per 100 ml brain parenchyma volume. RESULTS Patients with type 2 diabetes performed worse on neuropsychological tests (p < 0.05). Total CBF per 100 ml brain parenchyma volume did not differ between participants with and without diabetes (difference -2.3 ml min(-1) 100 ml(-1); 95% CI -6.0, 1.3). In the entire group, total CBF per 100 ml brain parenchyma volume was positively associated with cognitive functioning (0.09 SD increase in composite z score per 10 ml min(-1) 100 ml(-1) increase in relative total CBF). This association was not affected by type 2 diabetes. CONCLUSIONS/INTERPRETATION Although total CBF per 100 ml brain parenchyma volume was associated with cognitive functioning, it did not explain cognitive impairments in patients with type 2 diabetes relative to controls.
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Affiliation(s)
- A M Tiehuis
- Department of Radiology and Image Sciences Institute, University Medical Center Utrecht, Utrecht, the Netherlands.
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Wessels AM, Scheltens P, Barkhof F, Heine RJ. Hyperglycaemia as a determinant of cognitive decline in patients with type 1 diabetes. Eur J Pharmacol 2008; 585:88-96. [PMID: 18396273 DOI: 10.1016/j.ejphar.2007.11.080] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 09/12/2007] [Accepted: 11/14/2007] [Indexed: 12/31/2022]
Abstract
Individuals with type 1 diabetes show mild performance deficits in a range of neuropsychological tests compared to healthy controls, but the mechanisms underlying this cognitive deterioration are still poorly understood. Basically, two diabetes-related mechanisms can be postulated: recurrent severe hypoglycaemia and/or chronic hyperglycaemia. Intensive insulin therapy in type 1 diabetes, resulting in a durable improvement of glycaemic control, has been shown to lower the risk of long-term microvascular and macrovascular complications. The down side of striving for strict glycaemic control is the considerably elevated risk of severe hypoglycaemia, sometimes leading to seizure or coma. While retrospective studies in adult patients with type 1 diabetes have suggested an association between a history of recurrent severe hypoglycaemia and a modest or even severe degree of cognitive impairment, large prospective studies have failed to confirm this association. Only fairly recently, better appreciation of the possible deleterious effects of chronic hyperglycaemia on brain function and structure is emerging. In addition, it can be hypothesized that hyperglycaemia associated microvascular changes in the brain are responsible for the cognitive decline in patients with type 1 diabetes. This review presents various pathophysiological considerations concerning the cognitive decline in patients with type 1 diabetes.
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Affiliation(s)
- Alette M Wessels
- Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands.
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24
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Mlynarski W, Tarasov AI, Gach A, Girard CA, Pietrzak I, Zubcevic L, Kusmierek J, Klupa T, Malecki MT, Ashcroft FM. Sulfonylurea improves CNS function in a case of intermediate DEND syndrome caused by a mutation in KCNJ11. ACTA ACUST UNITED AC 2007; 3:640-5. [PMID: 17982434 DOI: 10.1038/ncpneuro0640] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 08/23/2007] [Indexed: 12/25/2022]
Abstract
BACKGROUND A 12-week-old female presented with neonatal diabetes. Insulin therapy alleviated the diabetes, but the patient showed marked motor and mental developmental delay. The patient underwent genetic evaluation at the age of 6 years, prompted by reports that mutations in the KCNJ11 gene caused neonatal diabetes. INVESTIGATIONS Genomic sequencing of the ATP-sensitive potassium (K(ATP)) channel gene KCNJ11 and in vitro functional analysis of the channel defect, and single-photon emission CT imaging before and after glibenclamide therapy. DIAGNOSIS Genetic evaluation revealed a missense mutation (His46Leu) in KCNJ11, which encodes the Kir6.2 subunit of the K(ATP) channel, conferring reduced ATP sensitivity. Functional studies demonstrated that the mutant channels were strongly inhibited by the sulfonylurea tolbutamide. MANAGEMENT Sulfonylurea (glibenclamide) treatment led to both improved glucose homeostasis and an increase in mental and motor function.
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Abstract
The object of this review is to provide the definitions and criteria for diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS), and convey current knowledge of the causes of permanent disability or mortality from complications of these conditions, of the risk factors for DKA and HHS, and of early indicators and contemporary treatment of suspected cerebral edema. The frequency of DKA at onset of type 1 diabetes mellitus (DM1) varies from 10-70%, depending on availability of health care and frequency of diabetes. At the onset of type 2 diabetes (DM2), DKA occurs in 5-52%. One study reported HHS in approximately 4% of new patients with DM2. Recurrent DKA rates are equally dependent on variability in medical services and socio-economic circumstances, and are estimated to be eight episodes per 100 patient years, with 20% of patients accounting for 80% of the episodes. Mortality for each episode of DKA internationally varies from 0.15-0.31%, with idiopathic cerebral edema accounting for two-thirds or more of this mortality. Other causes of death or disability include untreated DKA or HHS, hypokalemia, hypophosphatemia, hypoglycemia, other intracerebral complications, peripheral venous thrombosis, mucormycosis, rhabdomyolysis, acute pancreatitis, acute renal failure, sepsis, aspiration pneumonia, and other pulmonary complications. Population-based studies from the UK, Australia, the USA, and Canada report cerebral edema incidence in DKA of 0.5-2.0%. Published information does not support the notion that treatment factors are causal in cerebral edema. Younger age, greater severity of acidosis, degree of hypocapnia, and severity of dehydration have been suggested as risk factors in several studies. Bimodal distribution of the time of onset of cerebral edema and wide variation in brain imaging findings suggest the variability and likely multiple causation of the clinical picture. Functional brain scanning has indicated that DKA is accompanied by increased cerebral blood flow suggesting that the predominant mechanism of edema formation is a vasogenic process. A method of monitoring for diagnostic and major and minor signs of cerebral edema has been proposed and tested which indicates that intervention will be required in five individuals to provide early intervention for a single case of cerebral edema. The preferred intervention of mannitol infusion has typically been accompanied by intubation and hyperventilation, but recent evidence indicates outcome is adversely affected by aggressive hyperventilation. The prevention of DKA and HHS at the onset of diabetes mellitus requires a high degree of awareness and suspicion by primary care providers; prevention of recurrent DKA necessitates a diligent team effort.
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Affiliation(s)
- Arlan L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Children's Medical Services Center, 1701 SW 16th Avenue, Gainesville 32608, USA.
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Affiliation(s)
- Christopher M Ryan
- University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA.
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Ryan CM. Why is cognitive dysfunction associated with the development of diabetes early in life? The diathesis hypothesis. Pediatr Diabetes 2006; 7:289-97. [PMID: 17054452 DOI: 10.1111/j.1399-5448.2006.00206.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Christopher M Ryan
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Rosenbloom AL. Hyperglycemic comas in children: new insights into pathophysiology and management. Rev Endocr Metab Disord 2005; 6:297-306. [PMID: 16311948 DOI: 10.1007/s11154-005-6188-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Arlan L Rosenbloom
- Division of Endocrinology, Department of Pediatrics, College of Medicine, Children's Medical Services Center, University of Florida, 1701 SW 16th Avenue, Gainesville, 32608, USA.
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