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Lee HY, Mamadjonov N, Jung YH, Jeung KW, Kim TH, Kim JW, Kim HJ, Gumucio JA, Salcido DD. Relationships of Jugular Bulb Parameters with Cerebral Perfusion and Metabolism After Resuscitation from Cardiac Arrest: A Post-Hoc Analysis of Experimental Studies Using a Minipig Model. Neurocrit Care 2024:10.1007/s12028-024-02084-1. [PMID: 39117965 DOI: 10.1007/s12028-024-02084-1] [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: 03/18/2024] [Accepted: 07/26/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Cerebral blood flow (CBF) decreases in the first few hours or days following resuscitation from cardiac arrest, increasing the risk of secondary cerebral injury. Using data from experimental studies performed in minipigs, we investigated the relationships of parameters derived from arterial and jugular bulb blood gas analyses and lactate levels (jugular bulb parameters), which have been used as indicators of cerebral perfusion and metabolism, with CBF and the cerebral lactate to creatine ratio measured with dynamic susceptibility contrast magnetic resonance imaging and proton magnetic resonance spectroscopy, respectively. METHODS We retrospectively analyzed 36 sets of the following data obtained during the initial hours following resuscitation from cardiac arrest: percent of measured CBF relative to that at the prearrest baseline (%CBF), cerebral lactate to creatine ratio, and jugular bulb parameters, including jugular bulb oxygen saturation, jugular bulb lactate, arterial-jugular bulb oxygen content difference, cerebral extraction of oxygen, jugular bulb-arterial lactate content difference, lactate oxygen index, estimated respiratory quotient, and arterial-jugular bulb hydrogen ion content difference. Linear mixed-effects models were constructed to examine the effects of each jugular bulb parameter on the %CBF and cerebral lactate to creatine ratio. RESULTS The arterial-jugular bulb oxygen content difference (P = 0.047) and cerebral extraction of oxygen (P = 0.030) had a significant linear relationship with %CBF, but they explained only 12.0% (95% confidence interval [CI] 0.002-0.371) and 14.2% (95% CI 0.005-0.396) of the total %CBF variance, respectively. The arterial-jugular bulb hydrogen ion content difference had a significant linear relationship with cerebral lactate to creatine ratio (P = 0.037) but explained only 13.8% (95% CI 0.003-0.412) of the total variance in the cerebral lactate to creatine ratio. None of the other jugular bulb parameters were related to the %CBF or cerebral lactate to creatine ratio. CONCLUSIONS In conclusion, none of the jugular bulb parameters appeared to provide sufficient information on cerebral perfusion and metabolism in this setting.
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Affiliation(s)
- Hyoung Youn Lee
- Trauma Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Najmiddin Mamadjonov
- Department of Medical Science, Chonnam National University Graduate School, Gwangju, Republic of Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Medical School, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Medical School, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea.
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Tae-Hoon Kim
- Medical Convergence Research Center, Wonkwang University, Iksan, Republic of Korea
| | - Jin Woong Kim
- Department of Radiology, Chosun University Hospital, Gwangju, Republic of Korea
- Department of Radiology, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Hyung Joong Kim
- Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Jorge Antonio Gumucio
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David D Salcido
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Lavrentev SN, Petrova AS, Serova OF, Vishnyakova P, Kondratev MV, Gryzunova AS, Zakharova NI, Zubkov VV, Silachev DN. Ultrasound Diagnosis and Near-Infrared Spectroscopy in the Study of Encephalopathy in Neonates Born under Asphyxia: Narrative Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:591. [PMID: 38790586 PMCID: PMC11119551 DOI: 10.3390/children11050591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024]
Abstract
Brain injury resulting from adverse events during pregnancy and delivery is the leading cause of neonatal morbidity and disability. Surviving neonates often suffer long-term motor, sensory, and cognitive impairments. Birth asphyxia is among the most common causes of neonatal encephalopathy. The integration of ultrasound, including Doppler ultrasound, and near-infrared spectroscopy (NIRS) offers a promising approach to understanding the pathology and diagnosis of encephalopathy in this special patient population. Ultrasound diagnosis can be very helpful for the assessment of structural abnormalities associated with neonatal encephalopathy such as alterations in brain structures (intraventricular hemorrhage, infarcts, hydrocephalus, white matter injury) and evaluation of morphologic changes. Doppler sonography is the most valuable method as it provides information about blood flow patterns and outcome prediction. NIRS provides valuable insight into the functional aspects of brain activity by measuring tissue oxygenation and blood flow. The combination of ultrasonography and NIRS may produce complementary information on structural and functional aspects of the brain. This review summarizes the current state of research, discusses advantages and limitations, and explores future directions to improve applicability and efficacy.
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Affiliation(s)
- Simeon N. Lavrentev
- The State Budgetary Institution, Moscow Regional Perinatal Center, 143912 Balashikha, Russia; (S.N.L.); (A.S.P.); (O.F.S.); (M.V.K.); (A.S.G.)
- Research Clinical Institute of Childhood of the Moscow Region, 115093 Moscow, Russia; (N.I.Z.); (V.V.Z.)
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of the Russian Federation, 117997 Moscow, Russia;
| | - Anastasia S. Petrova
- The State Budgetary Institution, Moscow Regional Perinatal Center, 143912 Balashikha, Russia; (S.N.L.); (A.S.P.); (O.F.S.); (M.V.K.); (A.S.G.)
- Research Clinical Institute of Childhood of the Moscow Region, 115093 Moscow, Russia; (N.I.Z.); (V.V.Z.)
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of the Russian Federation, 117997 Moscow, Russia;
| | - Olga F. Serova
- The State Budgetary Institution, Moscow Regional Perinatal Center, 143912 Balashikha, Russia; (S.N.L.); (A.S.P.); (O.F.S.); (M.V.K.); (A.S.G.)
| | - Polina Vishnyakova
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of the Russian Federation, 117997 Moscow, Russia;
- Research Institute of Molecular and Cellular Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
| | - Maxim V. Kondratev
- The State Budgetary Institution, Moscow Regional Perinatal Center, 143912 Balashikha, Russia; (S.N.L.); (A.S.P.); (O.F.S.); (M.V.K.); (A.S.G.)
- Research Clinical Institute of Childhood of the Moscow Region, 115093 Moscow, Russia; (N.I.Z.); (V.V.Z.)
| | - Anastasia S. Gryzunova
- The State Budgetary Institution, Moscow Regional Perinatal Center, 143912 Balashikha, Russia; (S.N.L.); (A.S.P.); (O.F.S.); (M.V.K.); (A.S.G.)
- Research Clinical Institute of Childhood of the Moscow Region, 115093 Moscow, Russia; (N.I.Z.); (V.V.Z.)
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of the Russian Federation, 117997 Moscow, Russia;
| | - Nina I. Zakharova
- Research Clinical Institute of Childhood of the Moscow Region, 115093 Moscow, Russia; (N.I.Z.); (V.V.Z.)
| | - Victor V. Zubkov
- Research Clinical Institute of Childhood of the Moscow Region, 115093 Moscow, Russia; (N.I.Z.); (V.V.Z.)
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of the Russian Federation, 117997 Moscow, Russia;
| | - Denis N. Silachev
- V.I. Kulakov National Medical Research Center for Obstetrics Gynecology and Perinatology, Ministry of Healthcare of the Russian Federation, 117997 Moscow, Russia;
- A.N. Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia
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Jung YH, Lee HY, Lee BK, Choi BK, Kim TH, Kim JW, Kim HC, Kim HJ, Jeung KW. Feasibility of Magnetic Resonance-Based Conductivity Imaging as a Tool to Estimate the Severity of Hypoxic-Ischemic Brain Injury in the First Hours After Cardiac Arrest. Neurocrit Care 2024; 40:538-550. [PMID: 37353670 DOI: 10.1007/s12028-023-01776-4] [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: 01/25/2023] [Accepted: 06/05/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Early identification of the severity of hypoxic-ischemic brain injury (HIBI) after cardiac arrest can be used to help plan appropriate subsequent therapy. We evaluated whether conductivity of cerebral tissue measured using magnetic resonance-based conductivity imaging (MRCI), which provides contrast derived from the concentration and mobility of ions within the imaged tissue, can reflect the severity of HIBI in the early hours after cardiac arrest. METHODS Fourteen minipigs were resuscitated after 5 min or 12 min of untreated cardiac arrest. MRCI was performed at baseline and at 1 h and 3.5 h after return of spontaneous circulation (ROSC). RESULTS In both groups, the conductivity of cerebral tissue significantly increased at 1 h after ROSC compared with that at baseline (P = 0.031 and 0.016 in the 5-min and 12-min groups, respectively). The increase was greater in the 12-min group, resulting in significantly higher conductivity values in the 12-min group (P = 0.030). At 3.5 h after ROSC, the conductivity of cerebral tissue in the 12-min group remained increased (P = 0.022), whereas that in the 5-min group returned to its baseline level. CONCLUSIONS The conductivity of cerebral tissue was increased in the first hours after ROSC, and the increase was more prominent and lasted longer in the 12-min group than in the 5-min group. Our findings suggest the promising potential of MRCI as a tool to estimate the severity of HIBI in the early hours after cardiac arrest.
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Affiliation(s)
- Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hyoung Youn Lee
- Trauma Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Bup Kyung Choi
- Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Medical Convergence Research Center, Wonkwang University, Iksan, Republic of Korea
| | - Jin Woong Kim
- Department of Radiology, Chosun University Hospital, Gwangju, Republic of Korea
| | - Hyun Chul Kim
- Department of Radiology, Chosun University Hospital, Gwangju, Republic of Korea
| | - Hyung Joong Kim
- Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea.
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea.
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Kirschen MP, Ouyang M, Patel B, Berman JI, Burnett R, Berg RA, Diaz-Arrastia R, Topjian A, Huang H, Vossough A. Association between ASL MRI-derived cerebral blood flow and outcomes after pediatric cardiac arrest. Resuscitation 2024; 196:110128. [PMID: 38280508 PMCID: PMC10923119 DOI: 10.1016/j.resuscitation.2024.110128] [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: 10/05/2023] [Revised: 01/08/2024] [Accepted: 01/19/2024] [Indexed: 01/29/2024]
Abstract
AIM Cerebral blood flow (CBF) is dysregulated after cardiac arrest. It is unknown if post-arrest CBF is associated with outcome. We aimed to determine the association of CBF derived from arterial spin labelling (ASL) MRI with outcome after pediatric cardiac arrest. METHODS Retrospective observational study of patients ≤18 years who had a clinically obtained brain MRI within 7 days of cardiac arrest between June 2005 and December 2019. Primary outcome was unfavorable neurologic status: change in Pediatric Cerebral Performance Category (PCPC) ≥1 from pre-arrest that resulted in hospital discharge PCPC 3-6. We measured CBF in whole brain and regions of interest (ROIs) including frontal, parietal, and temporal cortex, caudate, putamen, thalamus, and brainstem using pulsed ASL. We compared CBF between outcome groups using Wilcoxon Rank-Sum and performed logistic regression to associate each region's CBF with outcome, accounting for age, sex, and time between arrest and MRI. RESULTS Forty-eight patients were analyzed (median age 2.8 [IQR 0.95, 8.8] years, 65% male). Sixty-nine percent had unfavorable outcome. Time from arrest to MRI was 4 [3,5] days and similar between outcome groups (p = 0.39). Whole brain median CBF was greater for unfavorable compared to favorable groups (28.3 [20.9,33.0] vs. 19.6 [15.3,23.1] ml/100 g/min, p = 0.007), as was CBF in individual ROIs. Greater CBF in the whole brain and individual ROIs was associated with higher odds of unfavorable outcome after controlling for age, sex, and days from arrest to MRI (aOR for whole brain 19.08 [95% CI 1.94, 187.41]). CONCLUSION CBF measured 3-5 days after pediatric cardiac arrest by ASL MRI was independently associated with unfavorable outcome.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Minhui Ouyang
- Department of Radiology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Bhavesh Patel
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey I Berman
- Department of Radiology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Burnett
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Hao Huang
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Arastoo Vossough
- Department of Radiology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Lee HY, Jung YH, Mamadjonov N, Jeung KW, Lee BK, Kim T, Kim HJ, Gumucio JA, Salcido DD. Assessment of the Effects of Sodium Nitroprusside Administered Via Intracranial Subdural Catheters on the Cerebral Blood Flow and Lactate Using Dynamic Susceptibility Contrast Magnetic Resonance Imaging and Proton Magnetic Resonance Spectroscopy in a Pig Cardiac Arrest Model. J Am Heart Assoc 2023; 12:e029774. [PMID: 37776216 PMCID: PMC10727238 DOI: 10.1161/jaha.123.029774] [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: 03/02/2023] [Accepted: 08/29/2023] [Indexed: 10/02/2023]
Abstract
Background Cerebral blood flow (CBF) is impaired in the early phase after return of spontaneous circulation. Sodium nitroprusside (SNP) administration via intracranial subdural catheters improves cerebral cortical microcirculation. We determined whether the SNP treatment improves CBF in the subcortical tissue and evaluated the effects of this treatment on cerebral lactate. Methods and Results Sixty minutes after return of spontaneous circulation following 14 minutes of untreated cardiac arrest, 14 minipigs randomly received 4 mg SNP or saline via intracranial subdural catheters. CBF was measured in regions of interest within the cerebrum and thalamus using dynamic susceptibility contrast-magnetic resonance imaging. After return of spontaneous circulation, CBF was expressed as a percentage of the baseline value. In the saline group, the %CBF in the regions of interest within the cerebrum remained at approximately 50% until 3.5 hours after return of spontaneous circulation, whereas %CBF in the thalamic regions of interest recovered to approximately 73% at this time point. The percentages of the baseline values in the cortical gray matter and subcortical white matter were higher in the SNP group (group effect P=0.026 and 0.025, respectively) but not in the thalamus. The cerebral lactate/creatine ratio measured using magnetic resonance spectroscopy increased over time in the saline group but not in the SNP group (group-time interaction P=0.035). The thalamic lactate/creatine ratio was similar in the 2 groups. Conclusions SNP administered via intracranial subdural catheters improved CBF not only in the cortical gray matter but also in the subcortical white matter. The CBF improvement by SNP was accompanied by a decrease in cerebral lactate.
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Affiliation(s)
- Hyoung Youn Lee
- Trauma CenterChonnam National University HospitalGwangjuRepublic of Korea
| | - Yong Hun Jung
- Department of Emergency MedicineChonnam National University HospitalGwangjuRepublic of Korea
- Department of Emergency MedicineChonnam National University Medical SchoolGwangjuRepublic of Korea
| | - Najmiddin Mamadjonov
- Department of Medical ScienceChonnam National University Graduate SchoolGwangjuRepublic of Korea
| | - Kyung Woon Jeung
- Department of Emergency MedicineChonnam National University HospitalGwangjuRepublic of Korea
- Department of Emergency MedicineChonnam National University Medical SchoolGwangjuRepublic of Korea
| | - Byung Kook Lee
- Department of Emergency MedicineChonnam National University HospitalGwangjuRepublic of Korea
- Department of Emergency MedicineChonnam National University Medical SchoolGwangjuRepublic of Korea
| | - Tae‐Hoon Kim
- Medical Convergence Research CenterWonkwang UniversityIksanRepublic of Korea
| | - Hyung Joong Kim
- Medical Science Research InstituteKyung Hee University HospitalSeoulRepublic of Korea
| | - Jorge Antonio Gumucio
- Department of Emergency MedicineSchool of Medicine University of PittsburghPittsburghPAUSA
| | - David D. Salcido
- Department of Emergency MedicineSchool of Medicine University of PittsburghPittsburghPAUSA
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Justice CN, Halperin HR, Vanden Hoek TL, Geocadin RG. Extracorporeal cardiopulmonary resuscitation (eCPR) and cerebral perfusion: A narrative review. Resuscitation 2023; 182:109671. [PMID: 36549433 PMCID: PMC9877198 DOI: 10.1016/j.resuscitation.2022.12.009] [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: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.
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Affiliation(s)
- Cody N Justice
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Henry R Halperin
- Departments of Medicine, Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Terry L Vanden Hoek
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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Oghifobibi OA, Toader AE, Nicholas MA, Nelson BP, Alindogan NG, Wolf MS, Kline AE, Nouraie SM, Bondi CO, Iordanova B, Clark RS, Bayır H, Loughran PA, Watkins SC, St Croix CM, Kochanek PM, Vazquez AL, Manole MD. Resuscitation with epinephrine worsens cerebral capillary no-reflow after experimental pediatric cardiac arrest: An in vivo multiphoton microscopy evaluation. J Cereb Blood Flow Metab 2022; 42:2255-2269. [PMID: 35854408 PMCID: PMC9670003 DOI: 10.1177/0271678x221113022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Epinephrine is the principal resuscitation therapy for pediatric cardiac arrest (CA). Clinical data suggest that although epinephrine increases the rate of resuscitation, it fails to improve neurological outcome, possibly secondary to reductions in microvascular flow. We characterized the effect of epinephrine vs. placebo administered at resuscitation from pediatric asphyxial CA on microvascular and macrovascular cortical perfusion assessed using in vivo multiphoton microscopy and laser speckle flowmetry, respectively, and on brain tissue oxygenation (PbO2), behavioral outcomes, and neuropathology in 16-18-day-old rats. Epinephrine-treated rats had a more rapid return of spontaneous circulation and brisk immediate cortical reperfusion during 1-3 min post-CA vs. placebo. However, at the microvascular level, epinephrine-treated rats had penetrating arteriole constriction and increases in both capillary stalling (no-reflow) and cortical capillary transit time 30-60 min post-CA vs. placebo. Placebo-treated rats had increased capillary diameters post-CA. The cortex was hypoxic post-CA in both groups. Epinephrine treatment worsened reference memory performance vs. shams. Hippocampal neuron counts did not differ between groups. Resuscitation with epinephrine enhanced immediate reperfusion but produced microvascular alterations during the first hour post-resuscitation, characterized by vasoconstriction, capillary stasis, prolonged cortical transit time, and absence of compensatory cortical vasodilation. Targeted therapies mitigating the deleterious microvascular effects of epinephrine are needed.
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Affiliation(s)
- Onome A Oghifobibi
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA
| | - Andrew E Toader
- Department of Electrical and Computer Engineering, University of Pittsburgh, Pittsburgh, USA
| | - Melissa A Nicholas
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA
| | - Brittany P Nelson
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA
| | - Nicole G Alindogan
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA
| | - Michael S Wolf
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Anthony E Kline
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, USA
| | - Seyed M Nouraie
- Department of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Corina O Bondi
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, USA
| | - Bistra Iordanova
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, USA
| | - Robert Sb Clark
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.,Children's Neuroscience Institute, UPMC Children's Hospital, Pittsburgh, USA
| | - Hülya Bayır
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.,Children's Neuroscience Institute, UPMC Children's Hospital, Pittsburgh, USA
| | | | - Simon C Watkins
- Department of Cell Biology, Center for Biologic Imaging University of Pittsburgh, Pittsburgh, USA
| | - Claudette M St Croix
- Department of Cell Biology, Center for Biologic Imaging University of Pittsburgh, Pittsburgh, USA
| | - Patrick M Kochanek
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.,Children's Neuroscience Institute, UPMC Children's Hospital, Pittsburgh, USA
| | - Alberto L Vazquez
- Department of Radiology, University of Pittsburgh, Pittsburgh, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, USA
| | - Mioara D Manole
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, USA.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, USA.,Children's Neuroscience Institute, UPMC Children's Hospital, Pittsburgh, USA
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8
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Smida T, Menegazzi JJ, Crowe RP, Weiss LS, Salcido DD. Association of prehospital hypotension depth and dose with survival following out-of-hospital cardiac arrest. Resuscitation 2022; 180:99-107. [PMID: 36191809 DOI: 10.1016/j.resuscitation.2022.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Hypotension following resuscitation from out-of-hospital cardiac arrest (OHCA) may cause harm by exacerbating secondary brain injury; however, limited research has explored this relationship. Our objective was to examine the association between duration and depth of prehospital post return of spontaneous circulation (ROSC) hypotension and survival. METHODS We utilized the 2019 and 2020 ESO Data Collaborative public use research data sets for this study (ESO, Austin, TX). Hypotension dose (mmHg*min.), average prehospital systolic blood pressure (SBP), and lowest recorded prehospital SBP were calculated. The association of these measures with survival to home (STH) and rearrest were explored using multivariable logistic regression. Time to hypotension resolution analyses by hypotension management strategy (push dose vasopressors, vasopressor infusion, or fluid only) were conducted using adjusted Cox proportional hazards models. RESULTS 17,280 OHCA patients met inclusion criteria, of which 3,345 had associated hospital outcome data. Over one-third (37.8%; 6,526/17,280) of all patients had at least one recorded SBP below 90 mmHg. When modeled continuously, average prehospital SBP (1.19 [1.15, 1.23] per 10 mmHg), lowest prehospital SBP (1.20 [1.17, 1.24] per 10 mmHg), and hypotension dose (0.995 [0.993, 0.996] per mmHg*min.) were independently associated with STH. Differences in hypotension management were not associated with differences in survival or time to hypotension resolution. CONCLUSION Severity and duration of hypotension were significantly associated with worse outcomes in this dataset. Defining a threshold for hypotension requiring treatment above the classical SBP threshold of 90 mmHg may be warranted in the setting of prehospital post-resuscitation care.
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Affiliation(s)
- Tanner Smida
- West Virginia University MD/PhD Program, Morgantown, WV, United States.
| | - James J Menegazzi
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, PA, United States
| | | | - Leonard S Weiss
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, PA, United States
| | - David D Salcido
- University of Pittsburgh School of Medicine, Department of Emergency Medicine, Pittsburgh, PA, United States
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9
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Dietz RM, Dingman AL, Herson PS. Cerebral ischemia in the developing brain. J Cereb Blood Flow Metab 2022; 42:1777-1796. [PMID: 35765984 PMCID: PMC9536116 DOI: 10.1177/0271678x221111600] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/29/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022]
Abstract
Brain ischemia affects all ages, from neonates to the elderly population, and is a leading cause of mortality and morbidity. Multiple preclinical rodent models involving different ages have been developed to investigate the effect of ischemia during different times of key brain maturation events. Traditional models of developmental brain ischemia have focused on rodents at postnatal day 7-10, though emerging models in juvenile rodents (postnatal days 17-25) indicate that there may be fundamental differences in neuronal injury and functional outcomes following focal or global cerebral ischemia at different developmental ages, as well as in adults. Here, we consider the timing of injury in terms of excitation/inhibition balance, oxidative stress, inflammatory responses, blood brain barrier integrity, and white matter injury. Finally, we review translational strategies to improve function after ischemic brain injury, including new ideas regarding neurorestoration, or neural repair strategies that restore plasticity, at delayed time points after ischemia.
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Affiliation(s)
- Robert M Dietz
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
- Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Andra L Dingman
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Neuronal Injury Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Paco S Herson
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
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10
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Lee RHC, Wu CYC, Citadin CT, Couto E Silva A, Possoit HE, Clemons GA, Acosta CH, de la Llama VA, Neumann JT, Lin HW. Activation of Neuropeptide Y2 Receptor Can Inhibit Global Cerebral Ischemia-Induced Brain Injury. Neuromolecular Med 2022; 24:97-112. [PMID: 34019239 PMCID: PMC8606017 DOI: 10.1007/s12017-021-08665-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/07/2021] [Indexed: 12/17/2022]
Abstract
Cardiopulmonary arrest (CA) can greatly impact a patient's life, causing long-term disability and death. Although multi-faceted treatment strategies against CA have improved survival rates, the prognosis of CA remains poor. We previously reported asphyxial cardiac arrest (ACA) can cause excessive activation of the sympathetic nervous system (SNS) in the brain, which contributes to cerebral blood flow (CBF) derangements such as hypoperfusion and, consequently, neurological deficits. Here, we report excessive activation of the SNS can cause enhanced neuropeptide Y levels. In fact, mRNA and protein levels of neuropeptide Y (NPY, a 36-amino acid neuropeptide) in the hippocampus were elevated after ACA-induced SNS activation, resulting in a reduced blood supply to the brain. Post-treatment with peptide YY3-36 (PYY3-36), a pre-synaptic NPY2 receptor agonist, after ACA inhibited NPY release and restored brain circulation. Moreover, PYY3-36 decreased neuroinflammatory cytokines, alleviated mitochondrial dysfunction, and improved neuronal survival and neurological outcomes. Overall, NPY is detrimental during/after ACA, but attenuation of NPY release via PYY3-36 affords neuroprotection. The consequences of PYY3-36 inhibit ACA-induced 1) hypoperfusion, 2) neuroinflammation, 3) mitochondrial dysfunction, 4) neuronal cell death, and 5) neurological deficits. The present study provides novel insights to further our understanding of NPY's role in ischemic brain injury.
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Affiliation(s)
- Reggie Hui-Chao Lee
- Department of Neurology, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, USA
| | - Celeste Yin-Chieh Wu
- Department of Neurology, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, USA
| | - Cristiane T Citadin
- Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alexandre Couto E Silva
- Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Harlee E Possoit
- Department of Neurology, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, USA
| | - Garrett A Clemons
- Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Christina H Acosta
- Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Victoria A de la Llama
- Department of Neurology, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, USA
| | - Jake T Neumann
- Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Hung Wen Lin
- Department of Neurology, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, USA.
- Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, USA.
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11
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Lee HY, Jung YH, Mamadjonov N, Jeung KW, Kim MC, Lim KS, Jeon CY, Lee Y, Kim HJ. Effects of Sodium Nitroprusside Administered Via a Subdural Intracranial Catheter on the Microcirculation, Oxygenation, and Electrocortical Activity of the Cerebral Cortex in a Pig Cardiac Arrest Model. J Am Heart Assoc 2022; 11:e025400. [PMID: 35624079 PMCID: PMC9238727 DOI: 10.1161/jaha.122.025400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Postischemic cerebral hypoperfusion has been indicated as an important contributing factor to secondary cerebral injury after cardiac arrest. We evaluated the effects of sodium nitroprusside administered via a subdural intracranial catheter on the microcirculation, oxygenation, and electrocortical activity of the cerebral cortex in the early postresuscitation period using a pig model of cardiac arrest. Methods and Results Twenty‐nine pigs were resuscitated with closed cardiopulmonary resuscitation after 14 minutes of untreated ventricular fibrillation. Thirty minutes after restoration of spontaneous circulation, 24 pigs randomly received either 4 mg of sodium nitroprusside (IT‐SNP group) or saline placebo (IT‐saline group) via subdural intracranial catheters and were observed for 5 hours. The same dose of sodium nitroprusside was administered intravenously in another 5 pigs. Compared with the IT‐saline group, the IT‐SNP group had larger areas under the curve for tissue oxygen tension and percent changes of arteriole diameter and number of perfused microvessels from baseline (all P<0.05) monitored on the cerebral cortex during the 5‐hour period, without severe hemodynamic instability. This group also showed faster recovery of electrocortical activity measured using amplitude‐integrated electroencephalography. Repeated‐measures analysis of variance revealed significant group–time interactions for these parameters. Intravenously administered sodium nitroprusside caused profound hypotension but did not appear to increase the cerebral parameters. Conclusions Sodium nitroprusside administered via a subdural intracranial catheter increased post–restoration of spontaneous circulation cerebral cortical microcirculation and oxygenation and hastened electrocortical activity recovery in a pig model of cardiac arrest. Further studies are required to determine its impact on the long‐term neurologic outcomes.
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Affiliation(s)
- Hyoung Youn Lee
- Trauma Center Chonnam National University Hospital Gwangju Republic of Korea
| | - Yong Hun Jung
- Department of Emergency Medicine Chonnam National University Hospital Gwangju Republic of Korea.,Department of Emergency Medicine Chonnam National University Medical School Gwangju Republic of Korea
| | - Najmiddin Mamadjonov
- Department of Medical Science Chonnam National University Graduate School Gwangju Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine Chonnam National University Hospital Gwangju Republic of Korea.,Department of Emergency Medicine Chonnam National University Medical School Gwangju Republic of Korea
| | - Min Chul Kim
- Division of Cardiology Department of Internal Medicine Chonnam National University Hospital Gwangju Republic of Korea
| | - Kyung Seob Lim
- Futuristic Animal Resource & Research Center Korea Research Institute of Bioscience and Biotechnology Ochang Republic of Korea
| | - Chang-Yeop Jeon
- National Primate Research CenterKorea Research Institute of Bioscience and Biotechnology Ochang Republic of Korea
| | - Youngjeon Lee
- National Primate Research CenterKorea Research Institute of Bioscience and Biotechnology Ochang Republic of Korea
| | - Hyung Joong Kim
- Medical Science Research InstituteKyung Hee University Hospital Seoul Republic of Korea
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12
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An Exploratory Assessment of Serum Biomarkers of Post-Cardiac Arrest Syndrome in Children. Resuscitation 2021; 167:307-316. [PMID: 34271122 DOI: 10.1016/j.resuscitation.2021.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/08/2021] [Accepted: 07/01/2021] [Indexed: 11/23/2022]
Abstract
AIM We hypothesized that serum biomarkers of inflammation including chemokine, cytokine, pituitary hormones, and growth factors following cardiac arrest in children would independently associate with 6-month neurologic outcome. METHODS In this prospective observational single center study of children with in-hospital and out-of-hospital cardiac arrest surviving to intensive care unit admission, serum was obtained twice per 24h period between 0h and 96h and once at approximately 196h post-cardiac arrest. Inflammatory mediators, hormones, and growth factors were analyzed by Luminex Multiplex Bead Immunoassay. We recorded demographics, resuscitation characteristics, and Pediatric Cerebral Performance Category (PCPC) at 6 months. We analyzed the association and area under the curve (AUC) of biomarker levels with favorable (PCPC 1-3) or unfavorable (PCPC 4-6, or >1 increase from baseline) outcome. RESULTS Forty-two children (50% female; median age of 2.5 [IQR: 0.4-10.2]) were enrolled and 18 (42%) died prior to 6-month follow up. Receiver operator curves for initial levels of ciliary neurotrophic factor (CNTF, AUC 0.84, 95% CI 0.73-0.96, p<0.001) and interleukin (IL-17, AUC 0.84, 95% CI 0.73-0.97, p<0.001) best classified favorable versus unfavorable 6-month outcome. In multivariable analysis, initial levels of CNTF and IL-17 remained associated with 6-month PCPC. Peak levels of interferon-γ-inducible protein 10 (IP-10), CNTF, and hepatocyte growth factor (HGF) were also independently associated with outcome. CONCLUSION Increased serum concentrations of CNTF and IL-17 associated with unfavorable 6-month neurologic outcome of children surviving cardiac arrest. Further investigation of the prognostic utility and roles of CNTF and IL-17 in the pathophysiology of post-cardiac arrest syndrome are warranted.
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13
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Hoiland RL, Griesdale DE, Sekhon MS. Invasive neuromonitoring post-cardiac arrest: Key considerations. Resuscitation 2021; 164:144-146. [PMID: 34000353 DOI: 10.1016/j.resuscitation.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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14
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Jung YH, Shamsiev K, Mamadjonov N, Jeung KW, Lee HY, Lee BK, Kang BS, Heo T, Min YI. Relationship of common hemodynamic and respiratory target parameters with brain tissue oxygen tension in the absence of hypoxemia or hypotension after cardiac arrest: A post-hoc analysis of an experimental study using a pig model. PLoS One 2021; 16:e0245931. [PMID: 33539360 PMCID: PMC7861448 DOI: 10.1371/journal.pone.0245931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/08/2021] [Indexed: 11/18/2022] Open
Abstract
Brain tissue oxygen tension (PbtO2)-guided care, a therapeutic strategy to treat or prevent cerebral hypoxia through modifying determinants of cerebral oxygen delivery, including arterial oxygen tension (PaO2), end-tidal carbon dioxide (ETCO2), and mean arterial pressure (MAP), has recently been introduced. Studies have reported that cerebral hypoxia occurs after cardiac arrest in the absence of hypoxemia or hypotension. To obtain preliminary information on the degree to which PbtO2 is responsive to changes in the common target variables for PbtO2-guided care in conditions without hypoxemia or hypotension, we investigated the relationships between the common target variables for PbtO2-guided care and PbtO2 using data from an experimental study in which the animals did not experience hypoxemia or hypotension after resuscitation. We retrospectively analyzed 170 sets of MAP, ETCO2, PaO2, PbtO2, and cerebral microcirculation parameters obtained during the 60-min post-resuscitation period in 10 pigs resuscitated from ventricular fibrillation cardiac arrest. PbtO2 and cerebral microcirculation parameters were measured on parietal cortices exposed through burr holes. Multiple linear mixed effect models were used to test the independent effects of each variable on PbtO2. Despite the absence of arterial hypoxemia or hypotension, seven (70%) animals experienced cerebral hypoxia (defined as PbtO2 <20 mmHg). Linear mixed effect models revealed that neither MAP nor ETCO2 were related to PbtO2. PaO2 had a significant linear relationship with PbtO2 after adjusting for significant covariates (P = 0.030), but it could explain only 17.5% of the total PbtO2 variance (semi-partial R2 = 0.175; 95% confidence interval, 0.086-0.282). In conclusion, MAP and ETCO2 were not significantly related to PbtO2 in animals without hypoxemia or hypotension during the early post-resuscitation period. PaO2 had a significant linear association with PbtO2, but its ability to explain PbtO2 variance was small.
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Affiliation(s)
- Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Kamoljon Shamsiev
- Department of Medical Science, Chonnam National University Graduate School, Gwangju, Republic of Korea
| | - Najmiddin Mamadjonov
- Department of Medical Science, Chonnam National University Graduate School, Gwangju, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- * E-mail:
| | - Hyoung Youn Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Byung Soo Kang
- Department of Medical Science, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Tag Heo
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Yong Il Min
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
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15
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Kleuskens DG, Gonçalves Costa F, Annink KV, van den Hoogen A, Alderliesten T, Groenendaal F, Benders MJN, Dudink J. Pathophysiology of Cerebral Hyperperfusion in Term Neonates With Hypoxic-Ischemic Encephalopathy: A Systematic Review for Future Research. Front Pediatr 2021; 9:631258. [PMID: 33604320 PMCID: PMC7884860 DOI: 10.3389/fped.2021.631258] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/07/2021] [Indexed: 01/07/2023] Open
Abstract
Worldwide neonatal hypoxic-ischemic encephalopathy (HIE) is a common cause of mortality and neurologic disability, despite the implementation of therapeutic hypothermia treatment. Advances toward new neuroprotective interventions have been limited by incomplete knowledge about secondary injurious processes such as cerebral hyperperfusion commonly observed during the first 1-5 days after asphyxia. Cerebral hyperperfusion is correlated with adverse neurodevelopmental outcome and it is a process that remains poorly understood. In order to provide an overview of the existing knowledge on the pathophysiology and highlight the gaps in current understanding of cerebral hyperperfusion in term animals and neonates with HIE, we performed a systematic research. We included papers scoping for study design, population, number of participants, study technique and relevant findings. Methodological quality was assessed using the checklist for cohort studies from The Joanna Briggs Institute. Out of 2,690 results, 34 studies were included in the final review-all prospective cohort studies. There were 14 studies of high, 17 moderate and 3 of low methodological quality. Data from the literature were analyzed in two main subjects: (1) Hemodynamic Changes subdivided into macro- and microscopic hemodynamic changes, and (2) Endogenous Pathways which was subdivided into N-methyl-D-aspartate/Mitogen activated protein kinase (NDMA/MAPK), Nitric Oxide (NO), prostanoids and other endogenous studies. Cerebral hyperperfusion in term neonates with HIE was found to be present 10-30 min after the hypoxic-ischemic event and was still present around day 10 and up to 1 month after birth. Cerebral hyperperfusion was also characterized by angiogenesis and cerebral vasodilation. Additionally, cerebral vasodilation was mediated by endogenous pathways such as MAPK through urokinase Plasminogen Activator (uPA), by neuronal NO synthase following NMDA and by prostanoid synthesis. Future research should elucidate the precise role of NMDA, MAPK and prostanoids in cerebral hyperperfusion. Moreover, research should focus on possible interventions and the effect of hypothermia on hyperperfusion. These findings should be taken into account simultaneously with brain imagining techniques, becoming a valuable asset in assessing the impact in neurodevelopmental outcome.
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Affiliation(s)
- Dianne G Kleuskens
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Filipe Gonçalves Costa
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Kim V Annink
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Agnes van den Hoogen
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Thomas Alderliesten
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Manon J N Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Jeroen Dudink
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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16
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Kang C, Lee IH, Park JS, You Y, Jeong W, Ahn HJ, Min JH. Measuring global impairment of cerebral perfusion using dynamic susceptibility contrast perfusion-weighted imaging in out-of-hospital cardiac arrest survivors: A prospective preliminary study. J Neuroradiol 2020; 48:379-384. [PMID: 33340642 DOI: 10.1016/j.neurad.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/25/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE This study aimed to assess the global impairment and prognostic performance of cerebral perfusions (CP) measured by dynamic susceptibility contrast perfusion-weighted imaging (DSC-PWI) in out-of-hospital cardiac arrest (OHCA) patients after sustained restoration of spontaneous circulation (ROSC). MATERIALS AND METHODS This is a single-centre, prospective observational study. OHCA patients performed DSC-PWI within 8 h after ROSC were enrolled. We quantified the CP parameters, such as cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), time to peak (TTP), and time to maximum of the residue function (Tmax) either by normalization or arterial input function (AIF). The primary and secondary outcomes were survival to discharge and comparison of prognostic performance between CP parameters and serum neuron-specific enolase (NSE) using area under the receiver operating characteristic (AUROC) and sensitivity values. RESULTS Thirty-one patients were included in this study. CBV and TTP quantified by normalization, and MTT and Tmax quantified by AIF showed significantly higher CP values in the non-survival group (p = 0.02, 0.03, 0.02, and <0.01, respectively). Their AUROCs and 100% specific sensitivities were 0.74/25.0%, 0.60/33.3%, 0.75/56.3%, and 0.79/43.8%, respectively. MTT quantified by AIF showed sensitivity in predicting mortality at an early stage of PCA care, comparable with NSE. CONCLUSION Hyperaemia and delayed CP were generally observed in OHCA patients regardless of outcomes. MTT and Tmax quantified by AIF have prognostic performance in predicting mortality, comparable with NSE. Further prospective multicentre studies are required to confirm our results.
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Affiliation(s)
- Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - In Ho Lee
- Department of Radiology, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea.
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea; Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
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17
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Linardi D, Walpoth B, Mani R, Murari A, Tessari M, Hoxha S, Anderloni M, Decimo I, Dolci S, Nicolato E, Bontempi P, Merigo F, Luciani GB, Faggian G, Rungatscher A. Slow versus fast rewarming after hypothermic circulatory arrest: effects on neuroinflammation and cerebral oedema. Eur J Cardiothorac Surg 2020; 58:792-800. [DOI: 10.1093/ejcts/ezaa143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 01/08/2023] Open
Abstract
AbstractOBJECTIVESAmong the factors that could determine neurological outcome after hypothermic circulatory arrest (HCA) rewarming is rarely considered. The optimal rewarming rate is still unknown. The goal of this study was to investigate the effects of 2 different protocols for rewarming after HCA on neurological outcome in an experimental animal model.METHODSForty-four Sprague Dawley rats were cooled to 19 ± 1°C body core temperature by cardiopulmonary bypass (CPB). HCA was maintained for 60 min. Animals were randomized to receive slow (90 min) or fast (45 min) assisted rewarming with CPB to a target temperature of 35°C. After a total of 90 min of reperfusion in both groups, brain samples were collected and analysed immunohistochemically and with immunofluorescence. In 10 rats, magnetic resonance imaging was performed after 2 and after 24 h to investigate cerebral perfusion and cerebral oedema.RESULTSInterleukin 6, chemokine (C-C motif) ligand 5, intercellular adhesion molecule 1 and tumour necrosis factor α in the hippocampus are significantly less expressed in the slow rewarming group, and microglia cells are significantly less activated in the slow rewarming group. Magnetic resonance imaging analysis demonstrated better cerebral perfusion and less water content in brains that underwent slow rewarming at 2 and 24 h.CONCLUSIONSSlow rewarming after HCA might be superior to fast rewarming in neurological outcome. The present experimental study demonstrated reduction in the inflammatory response, reduction of inflammatory cell activation in the brain, enhancement of cerebral blood flow and reduction of cerebral oedema when slow rewarming was applied.
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Affiliation(s)
- Daniele Linardi
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Beat Walpoth
- Department of Cardiovascular Surgery, University of Geneva, Geneva, Switzerland
| | - Romel Mani
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Angela Murari
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | | | - Stiljan Hoxha
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Marco Anderloni
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Ilaria Decimo
- Department of Pharmacology, University of Verona, Verona, Italy
| | - Sissi Dolci
- Department of Pharmacology, University of Verona, Verona, Italy
| | - Elena Nicolato
- Department of Anatomy, University of Verona, Verona, Italy
| | | | - Flavia Merigo
- Department of Anatomy, University of Verona, Verona, Italy
| | | | - Giuseppe Faggian
- Department of Cardiac Surgery, University of Verona, Verona, Italy
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18
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Hwang M, Sridharan A, Darge K, Riggs B, Sehgal C, Flibotte J, Huisman TAGM. Novel Quantitative Contrast-Enhanced Ultrasound Detection of Hypoxic Ischemic Injury in Neonates and Infants: Pilot Study 1. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2025-2038. [PMID: 30560547 DOI: 10.1002/jum.14892] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/05/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To investigate whether quantitative contrast-enhanced ultrasound (CEUS) can accurately identify neonates and infants with hypoxic ischemic brain injury. METHODS In this prospective cohort study, 8 neonates and infants with a suspicion of hypoxic ischemic injury were evaluated with CEUS. RESULTS An interesting trend was observed in the central gray nuclei-to-cortex perfusion ratios. The ratios at the peak enhancement, wash-in area under the curve, perfusion index, and maximum wash-in slopes were lower in all of the affected cases compared to the normal group but not statistically significant given the small sample size (P = .0571). Additionally, when the central gray nuclei-to-cortex perfusion ratio was plotted for all time points along the time-intensity curve, it was observed that the affected cases showed a trend that was qualitatively different from that of the normal cases. In the affected cases, the ratio time-intensity curves either stayed below 1.0 for the entire enhancement period or reached 1.0 close to peak wash-in before falling just below 1.0 for the remaining period of enhancement. However, in the unaffected patients, there was a steep wash-in that crossed the 1.0 threshold and remained above 1.0 for most of the enhancement period. CONCLUSIONS Bedside CEUS is an easily obtainable brain-imaging modality that has the potential to effectively identify infants and neonates with evolving brain injury. A larger prospective study evaluating the correlation between CEUS findings and the reference standard of diffusion- and perfusion-weighted magnetic resonance imaging is needed to establish it as a diagnostic tool.
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Affiliation(s)
- Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kassa Darge
- Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Becky Riggs
- Department of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Chandra Sehgal
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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19
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Lee RHC, Couto E Silva A, Possoit HE, Lerner FM, Chen PY, Azizbayeva R, Citadin CT, Wu CYC, Neumann JT, Lin HW. Palmitic acid methyl ester is a novel neuroprotective agent against cardiac arrest. Prostaglandins Leukot Essent Fatty Acids 2019; 147:6-14. [PMID: 30514597 PMCID: PMC6533160 DOI: 10.1016/j.plefa.2018.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 01/13/2023]
Abstract
We previously discovered that palmitic acid methyl ester (PAME) is a potent vasodilator first identified and released from the superior cervical ganglion and remain understudied. Thus, we investigated PAME's role in modulating cerebral blood flow (CBF) and neuroprotection after 6 min of cardiac arrest (model of global cerebral ischemia). Our results suggest that PAME can enhance CBF under normal physiological conditions, while administration of PAME (0.02 mg/kg) immediately after cardiopulmonary resuscitation can also enhance CBF in vivo. Additionally, functional learning and spatial memory assessments (via T-maze) 3 days after asphyxial cardiac arrest (ACA) suggest that PAME-treated rats have improved learning and memory recovery versus ACA alone. Furthermore, improved neuronal survival in the CA1 region of the hippocampus were observed in PAME-treated, ACA-induced rats. Altogether, our findings suggest that PAME can enhance CBF, alleviate neuronal cell death, and promote functional outcomes in the presence of ACA.
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Affiliation(s)
- Reggie Hui-Chao Lee
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA, USA; Center for Brain Health, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Alexandre Couto E Silva
- Center for Brain Health, Louisiana State University Health Sciences Center, Shreveport, LA, USA; Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - HarLee E Possoit
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA, USA; Center for Brain Health, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Francesca M Lerner
- Department of Neurology, Cerebral Vascular Disease Research Laboratories, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Po-Yi Chen
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA, USA; Center for Brain Health, Louisiana State University Health Sciences Center, Shreveport, LA, USA; Department of Pharmacology and Toxicology, Tzu Chi University, Hualien, Taiwan
| | - Rinata Azizbayeva
- Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, WV, USA
| | - Cristiane T Citadin
- Center for Brain Health, Louisiana State University Health Sciences Center, Shreveport, LA, USA; Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Celeste Yin-Chieh Wu
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA, USA; Center for Brain Health, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Jake T Neumann
- Department of Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, WV, USA
| | - Hung Wen Lin
- Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA, USA; Center for Brain Health, Louisiana State University Health Sciences Center, Shreveport, LA, USA; Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, LA, USA.
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20
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The Burden of Brain Hypoxia and Optimal Mean Arterial Pressure in Patients With Hypoxic Ischemic Brain Injury After Cardiac Arrest*. Crit Care Med 2019; 47:960-969. [DOI: 10.1097/ccm.0000000000003745] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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21
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Li L, Poloyac SM, Watkins SC, St. Croix CM, Alexander H, Gibson GA, Loughran PA, Kirisci L, Clark RSB, Kochanek PM, Vazquez AL, Manole MD. Cerebral microcirculatory alterations and the no-reflow phenomenon in vivo after experimental pediatric cardiac arrest. J Cereb Blood Flow Metab 2019; 39:913-925. [PMID: 29192562 PMCID: PMC6501505 DOI: 10.1177/0271678x17744717] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/29/2017] [Accepted: 10/25/2017] [Indexed: 01/02/2023]
Abstract
Decreased cerebral blood flow (CBF) after cardiac arrest (CA) contributes to secondary ischemic injury in infants and children. We previously reported cortical hypoperfusion with tissue hypoxia early in a pediatric rat model of asphyxial CA. In order to identify specific alterations as potential therapeutic targets to improve cortical hypoperfusion post-CA, we characterize the CBF alterations at the cortical microvascular level in vivo using multiphoton microscopy. We hypothesize that microvascular constriction and disturbances of capillary red blood cell (RBC) flow contribute to cortical hypoperfusion post-CA. After resuscitation from 9 min asphyxial CA, transient dilation of capillaries and venules at 5 min was followed by pial arteriolar constriction at 30 and 60 min (19.6 ± 1.3, 19.3 ± 1.2 µm at 30, 60 min vs. 22.0 ± 1.2 µm at baseline, p < 0.05). At the capillary level, microcirculatory disturbances were highly heterogeneous, with RBC stasis observed in 25.4% of capillaries at 30 min post-CA. Overall, the capillary plasma mean transit time was increased post-CA by 139.7 ± 51.5%, p < 0.05. In conclusion, pial arteriolar constriction, the no-reflow phenomenon and increased plasma transit time were observed post-CA. Our results detail the microvascular disturbances in a pediatric asphyxial CA model and provide a powerful platform for assessing specific vascular-targeted therapies.
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Affiliation(s)
- Lingjue Li
- Center of Clinical Pharmaceutical
Sciences,
University
of Pittsburgh, PA, USA
- School of Pharmacy,
University
of Pittsburgh, PA, USA
| | - Samuel M Poloyac
- Center of Clinical Pharmaceutical
Sciences,
University
of Pittsburgh, PA, USA
- School of Pharmacy,
University
of Pittsburgh, PA, USA
| | - Simon C Watkins
- Center for Biologic Imaging,
University
of Pittsburgh, PA, USA
| | | | - Henry Alexander
- Safar Center for Resuscitation Research,
University
of Pittsburgh, PA, USA
| | | | | | | | - Robert SB Clark
- Safar Center for Resuscitation Research,
University
of Pittsburgh, PA, USA
- Department of Critical Care Medicine,
University
of Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research,
University
of Pittsburgh, PA, USA
- Department of Critical Care Medicine,
University
of Pittsburgh, PA, USA
- Department of Pediatrics,
University
of Pittsburgh, PA, USA
| | | | - Mioara D Manole
- Safar Center for Resuscitation Research,
University
of Pittsburgh, PA, USA
- Department of Critical Care Medicine,
University
of Pittsburgh, PA, USA
- Department of Pediatrics,
University
of Pittsburgh, PA, USA
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22
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Demené C, Maresca D, Kohlhauer M, Lidouren F, Micheau P, Ghaleh B, Pernot M, Tissier R, Tanter M. Multi-parametric functional ultrasound imaging of cerebral hemodynamics in a cardiopulmonary resuscitation model. Sci Rep 2018; 8:16436. [PMID: 30401816 PMCID: PMC6219610 DOI: 10.1038/s41598-018-34307-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 10/11/2018] [Indexed: 01/11/2023] Open
Abstract
Patient mortality at one year reaches 90% after out-of-hospital cardiac arrest and resuscitation. Temperature management is one of the main strategies proposed to improve patient outcome after resuscitation and preclinical studies have shown neuroprotective effects when hypothermia is achieved rapidly, although the underlying mechanisms have not yet been elucidated. State-of-the-art brain imaging technologies can bring new insights into the early cerebral events taking place post cardiac arrest and resuscitation. In this paper, we characterized cerebral hemodynamics in a post-cardiac arrest rabbit model using functional ultrasound imaging. Ultrasound datasets were processed to map the dynamic changes in cerebral blood flow and cerebral vascular resistivity with a 10 second repetition rate while animals underwent cardiac arrest and a cardiopulmonary resuscitation. We report that a severe transient hyperemia takes place in the brain within the first twenty minutes post resuscitation, emphasizing the need for fast post-cardiac arrest care. Furthermore, we observed that this early hyperemic event is not spatially homogeneous and that maximal cerebral hyperemia happens in the hippocampus. Finally, we show that rapid cooling induced by total liquid ventilation reduces early cerebral hyperemia, which could explain the improved neurological outcome reported in preclinical studies.
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Affiliation(s)
- Charlie Demené
- Institut Langevin, ESPCI ParisTech, Paris Sciences & Lettres Research University, CNRS UMR7587, INSERM U979, Paris, France.
| | - David Maresca
- Institut Langevin, ESPCI ParisTech, Paris Sciences & Lettres Research University, CNRS UMR7587, INSERM U979, Paris, France
| | - Matthias Kohlhauer
- Inserm, U955, Equipe 03, Créteil, France
- UMR_S955, UPEC, Ecole Nationale Vétérinaire d'Alfort, 94700, Maisons-Alfort, France
| | - Fanny Lidouren
- Inserm, U955, Equipe 03, Créteil, France
- UMR_S955, UPEC, Ecole Nationale Vétérinaire d'Alfort, 94700, Maisons-Alfort, France
| | - Philippe Micheau
- Mechanical Engineering Dpt, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Bijan Ghaleh
- Inserm, U955, Equipe 03, Créteil, France
- UMR_S955, UPEC, Ecole Nationale Vétérinaire d'Alfort, 94700, Maisons-Alfort, France
| | - Mathieu Pernot
- Institut Langevin, ESPCI ParisTech, Paris Sciences & Lettres Research University, CNRS UMR7587, INSERM U979, Paris, France
| | - Renaud Tissier
- Inserm, U955, Equipe 03, Créteil, France
- UMR_S955, UPEC, Ecole Nationale Vétérinaire d'Alfort, 94700, Maisons-Alfort, France
| | - Mickaël Tanter
- Institut Langevin, ESPCI ParisTech, Paris Sciences & Lettres Research University, CNRS UMR7587, INSERM U979, Paris, France
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Cerebral Perfusion and Cerebral Autoregulation after Cardiac Arrest. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4143636. [PMID: 29854752 PMCID: PMC5964572 DOI: 10.1155/2018/4143636] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/28/2018] [Accepted: 04/03/2018] [Indexed: 12/31/2022]
Abstract
Out of hospital cardiac arrest is the leading cause of death in industrialized countries. Recovery of hemodynamics does not necessarily lead to recovery of cerebral perfusion. The neurological injury induced by a circulatory arrest mainly determines the prognosis of patients after cardiac arrest and rates of survival with a favourable neurological outcome are low. This review focuses on the temporal course of cerebral perfusion and changes in cerebral autoregulation after out of hospital cardiac arrest. In the early phase after cardiac arrest, patients have a low cerebral blood flow that gradually restores towards normal values during the first 72 hours after cardiac arrest. Whether modification of the cerebral blood flow after return of spontaneous circulation impacts patient outcome remains to be determined.
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24
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Keilhoff G, Esser T, Titze M, Ebmeyer U, Schild L. High-potential defense mechanisms of neocortex in a rat model of transient asphyxia induced cardiac arrest. Brain Res 2017; 1674:42-54. [DOI: 10.1016/j.brainres.2017.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/24/2017] [Accepted: 08/14/2017] [Indexed: 01/14/2023]
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25
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Modification to the Rice-Vannucci perinatal hypoxic-ischaemic encephalopathy model in the P7 rat improves the reliability of cerebral infarct development after 48hours. J Neurosci Methods 2017. [PMID: 28648719 DOI: 10.1016/j.jneumeth.2017.06.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Rice-Vannucci model of hypoxic-ischaemic encephalopathy (HIE) has been associated with a high degree of variability with respect to the development of cerebral infarction and infarct lesion volume. For this reason, we examined the occurrence of communicational blood flow within the common carotid (CCA), internal (ICA), and external (ECA) carotid arteries following CCA occlusion as a source of variability in the model. NEW METHOD We propose a novel modification to the Rice-Vannucci model, whereby both the CCA and ECA are permanently ligated; mitigating communicational blood flow. RESULTS Using magnetic resonance angiography, phase-contrast velocity encoding, and pulsed arterial spin labelling, the modified Rice-Vannucci model (CCA/ECA occlusion) was demonstrated to mitigate communicational blood flow, whilst significantly reducing ipsilateral hemispherical cerebral blood flow (CBF). Comparatively, the original Rice-Vannucci model (CCA occlusion) demonstrated anterograde and retrograde blood flow within the ICA and CCA, respectively, with a non-significant reduction in ipsilateral CBF. Furthermore, CCA/ECA occlusion plus hypoxia (8% O2/92% N2; 2.5h) resulted in 100% of animals presenting with an infarct (vs 87%), significantly larger infarct volume at 48h (18.5% versus 10.0%; p<0.01), reduced standard deviation (±10% versus ±15%), and significantly worsened functional outcomes when compared to CCA occlusion plus hypoxia. COMPARISON WITH EXISTING METHOD We compared a modified Rice-Vannucci model (CCA/ECA occlusion±hypoxia) to the commonly used Rice-Vannucci model (CCA occlusion±hypoxia). CONCLUSION This study demonstrates that CCA/ECA occlusion in the Rice-Vannucci model of HIE reduces infarct volume variability by limiting communicational blood flow.
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26
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Thermoregulate, autoregulate and ventilate: brain-directed critical care for pediatric cardiac arrest. Curr Opin Pediatr 2017; 29:259-265. [PMID: 28306631 DOI: 10.1097/mop.0000000000000482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Cardiac arrest in childhood is associated with a high risk for mortality and poor long-term functional outcome. This review discusses the current evidence for neuroprotective therapies and goals for postarrest care in the context of the pathophysiology of hypoxic-ischemic injury, modalities for neurologic prognostication in these children and potential future monitoring paradigms for maximizing cerebral perfusion in the postarrest period. RECENT FINDINGS The recent publication of the in-hospital and out-of-hospital Therapeutic Hypothermia After Cardiac Arrest trials demonstrated a lack of statistically significant benefit for the use of postarrest therapeutic hypothermia. As a result, targeted normothermic temperature management has become standard of care. Continuous electroencephalographic monitoring during the acute postarrest period provides useful additional data for neurologic prognostication, in addition to its value for detection of seizures. Ongoing research into noninvasive monitoring of cerebrovascular autoregulation has the potential to individualize blood pressure goals in the postarrest period, maximizing cerebral perfusion in these patients. SUMMARY Therapeutic strategies after cardiac arrest seek to maximize cerebral perfusion while mitigating the effects of secondary brain injury and loss of autoregulation. Future research into new monitoring strategies and better long-term outcome measures may allow more precise targeting of therapies to these goals.
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Ansari MZ, Kang EJ, Manole MD, Dreier JP, Humeau-Heurtier A. Monitoring microvascular perfusion variations with laser speckle contrast imaging using a view-based temporal template method. Microvasc Res 2017; 111:49-59. [PMID: 28065672 DOI: 10.1016/j.mvr.2016.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 12/06/2016] [Accepted: 12/09/2016] [Indexed: 01/22/2023]
Abstract
PURPOSE Laser speckle contrast imaging (LSCI) continues to gain an increased interest in clinical and research studies to monitor microvascular perfusion. Due to its high spatial and temporal resolutions, LSCI may lead to a large amount of data. The analysis of such data, as well as the determination of the regions where the perfusion varies, can become a lengthy and tedious task. We propose here to analyze if a view-based temporal template method, the motion history image (MHI) algorithm, may be of use in detecting the perfusion variations locations. METHODS LSCI data recorded during three different kinds of perfusion variations are considered: (i) cerebral blood flow during spreading depolarization (SD) in a mouse; (ii) cerebral blood flow during SD in a rat; (iii) cerebral blood flow during cardiac arrest in a rat. Each of these recordings was processed with MHI. RESULTS We show that, for the three pathophysiological situations, MHI identifies the area in which perfusion evolves with time. The results are more easily obtained compared with a visual inspection of all of the frames constituting the recordings. MHI also has the advantage of relying on a rather simple algorithm. CONCLUSIONS MHI can be tested in clinical and research studies to aid the user in perfusion analyses.
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Affiliation(s)
- Mohammad Zaheer Ansari
- Department of Physics, Cambridge Institute of Polytechnic, Baheya, Angara, Ranchi 835103, Jharkhand, India.
| | - Eun-Jeung Kang
- Department of Experimental Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany; Center for Stroke Research, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Mioara D Manole
- University of Pittsburgh, Safar Center for Resuscitation Research, USA
| | - Jens P Dreier
- Department of Experimental Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany; Center for Stroke Research, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Anne Humeau-Heurtier
- Univ Angers, LARIS - Laboratoire Angevin de Recherche en Ingénierie des Systèmes, Angers, France
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28
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Foley LM, Clark RS, Vazquez AL, Hitchens TK, Alexander H, Ho C, Kochanek PM, Manole MD. Enduring disturbances in regional cerebral blood flow and brain oxygenation at 24 h after asphyxial cardiac arrest in developing rats. Pediatr Res 2017; 81:94-98. [PMID: 27636898 PMCID: PMC5287715 DOI: 10.1038/pr.2016.175] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 07/25/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Disturbances in cerebral blood flow (CBF) and brain oxygenation (PbO2) are present early after pediatric cardiac arrest (CA). CBF-targeted therapies improved neurological outcome in our CA model. To assess the therapeutic window for CBF- and PbO2-targeted therapies, we propose to determine if CBF and PbO2 disturbances persist at 24 h after experimental pediatric CA. METHODS Regional CBF and PbO2 were measured at 24 h after asphyxial CA in immature rats (n = 26, 6-8/group) using arterial spin label MRI and tissue electrodes, respectively. RESULTS In all regions but the thalamus, CBF recovered to sham values by 24 h; thalamic CBF was >32% higher after CA vs. sham. PbO2 values at 24 h after CA in the cortex and thalamus were similar to shams in rats who received supplemental oxygen, however, on room air, cortical PbO2 was lower after CA vs. shams. CONCLUSION CBF remains increased in the thalamus at 24 h after CA and PbO2 is decreased to hypoxic levels in cortex at 24 h after CA in rats who do not receive supplemental oxygen. Given the enduring disturbances in this model and the lack of routine CBF or PbO2 monitoring in patients, our data suggest the need for clinical correlation.
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Affiliation(s)
- Lesley M. Foley
- Animal Imaging Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert S.B. Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
| | - Alberto L. Vazquez
- Animal Imaging Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - T. Kevin Hitchens
- Animal Imaging Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Henry Alexander
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
| | - Chien Ho
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mioara D. Manole
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
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29
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Iordanova B, Li L, Clark RSB, Manole MD. Alterations in Cerebral Blood Flow after Resuscitation from Cardiac Arrest. Front Pediatr 2017; 5:174. [PMID: 28861407 PMCID: PMC5561008 DOI: 10.3389/fped.2017.00174] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/28/2017] [Indexed: 01/07/2023] Open
Abstract
Greater than 50% of patients successfully resuscitated from cardiac arrest have evidence of neurological disability. Numerous studies in children and adults, as well as in animal models have demonstrated that cerebral blood flow (CBF) is impaired after cardiac arrest. Stages of cerebral perfusion post-resuscitation include early hyperemia, followed by hypoperfusion, and finally either resolution of normal blood flow or protracted hyperemia. At the level of the microcirculation the blood flow is heterogeneous, with areas of no flow, low flow, and increased flow. CBF directed therapies in animal models of cardiac arrest improved neurological outcome, and therefore, the alterations in CBF after cardiac arrest likely contribute to the development of hypoxic ischemic encephalopathy. Current intensive care after cardiac arrest is centered upon maintaining systemic oxygenation, normal blood pressure values for age, maintaining general homeostasis, and avoiding hyperthermia. Assessment of CBF and oxygenation is not routinely performed after cardiac arrest. Currently available and underutilized techniques to assess cerebral perfusion include transcranial doppler, near-infrared spectroscopy, and arterial spin labeling magnetic resonance imaging. Limited clinical studies established the role of CBF and oxygenation monitoring in prognostication after cardiac arrest and few studies suggest that guiding critical care post-resuscitation to mean arterial pressures above the minimal autoregulatory range might improve outcome. Important knowledge gaps thus remain in cerebral monitoring and CBF and oxygen goal-directed therapies post-resuscitation from cardiac arrest.
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Affiliation(s)
- Bistra Iordanova
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Lingjue Li
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Robert S B Clark
- Safar Center for Resuscitation Research, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States.,Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mioara D Manole
- Safar Center for Resuscitation Research, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States
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30
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Crouzet C, Wilson RH, Bazrafkan A, Farahabadi MH, Lee D, Alcocer J, Tromberg BJ, Choi B, Akbari Y. Cerebral blood flow is decoupled from blood pressure and linked to EEG bursting after resuscitation from cardiac arrest. BIOMEDICAL OPTICS EXPRESS 2016; 7:4660-4673. [PMID: 27896005 PMCID: PMC5119605 DOI: 10.1364/boe.7.004660] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/05/2016] [Accepted: 10/10/2016] [Indexed: 05/03/2023]
Abstract
In the present study, we have developed a multi-modal instrument that combines laser speckle imaging, arterial blood pressure, and electroencephalography (EEG) to quantitatively assess cerebral blood flow (CBF), mean arterial pressure (MAP), and brain electrophysiology before, during, and after asphyxial cardiac arrest (CA) and resuscitation. Using the acquired data, we quantified the time and magnitude of the CBF hyperemic peak and stabilized hypoperfusion after resuscitation. Furthermore, we assessed the correlation between CBF and MAP before and after stabilized hypoperfusion. Finally, we examined when brain electrical activity resumes after resuscitation from CA with relation to CBF and MAP, and developed an empirical predictive model to predict when brain electrical activity resumes after resuscitation from CA. Our results show that: 1) more severe CA results in longer time to stabilized cerebral hypoperfusion; 2) CBF and MAP are coupled before stabilized hypoperfusion and uncoupled after stabilized hypoperfusion; 3) EEG activity (bursting) resumes after the CBF hyperemic phase and before stabilized hypoperfusion; 4) CBF predicts when EEG activity resumes for 5-min asphyxial CA, but is a poor predictor for 7-min asphyxial CA. Together, these novel findings highlight the importance of using multi-modal approaches to investigate CA recovery to better understand physiological processes and ultimately improve neurological outcome.
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Affiliation(s)
- Christian Crouzet
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, CA 92617, USA
- Department of Biomedical Engineering, University of California, Irvine, CA 92697, USA
| | - Robert H. Wilson
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, CA 92617, USA
| | - Afsheen Bazrafkan
- Department of Neurology, University of California, Irvine, CA 92697, USA
| | - Maryam H. Farahabadi
- Department of Neurology, University of California, Irvine, CA 92697, USA
- School of Medicine, University of California, Irvine, CA 92697, USA
| | - Donald Lee
- Department of Neurology, University of California, Irvine, CA 92697, USA
| | - Juan Alcocer
- Department of Neurology, University of California, Irvine, CA 92697, USA
| | - Bruce J. Tromberg
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, CA 92617, USA
- Department of Biomedical Engineering, University of California, Irvine, CA 92697, USA
- Department of Surgery, University of California, Irvine, CA 92868, USA
| | - Bernard Choi
- Beckman Laser Institute and Medical Clinic, University of California, Irvine, CA 92617, USA
- Department of Biomedical Engineering, University of California, Irvine, CA 92697, USA
- Department of Surgery, University of California, Irvine, CA 92868, USA
- Edwards Lifesciences Center for Advanced Cardiovascular Technology, University of California, Irvine, CA 92697, USA
| | - Yama Akbari
- Department of Neurology, University of California, Irvine, CA 92697, USA
- School of Medicine, University of California, Irvine, CA 92697, USA
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31
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Young L. Real-time monitoring of cerebral blood flow by laser speckle contrast imaging after cardiac arrest in rat. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:6971-4. [PMID: 26737896 DOI: 10.1109/embc.2015.7319996] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cardiac arrest (CA) results in global brain ischemia. To explore the role of cerebral blood flow (CBF) during ischemia, laser speckle contrast imaging (LSCI), a full-field high-resolution optical imaging technique, was used for real-time monitoring of the fluctuations of CBF in a rat model of asphyxial-CA. The temporal changes of CBF were characterized and the relationship between CBF and mean arterial pressure (MAP) was evaluated. Asphyxial-CA led to transient CBF dysregulation, manifested by changes in CBF velocity were significantly impacted by MAP. Hyperemia is aligned with a bolus injection of vecuronium, the first two minutes of asphyxia, the time of epinephrine injection and cardiopulmonary resuscitation, and then lasted for 13 min after the return of spontaneous respiratory (ROSC), followed by hypoperfusion about 55-70% of baseline level no later than 40 min after ROSC. Interestingly, we found that the velocity of venule blood flow increased more than that of the arteriole blood flow during the hyperemia (176% vs 120%). Our study, for the first time, shows real-time CBF changes during and immediately after asphyxial-CA, with high spatial and temporal resolution images. The quantified cerebro-vascular response during the different phases of recovery after CA may underlie the mechanism of injury and recovery after brain ischemia. The study provides a new technique to study the neurovascular coupling and metabolic regulation of CBF after CA.
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Manchester LC, Lee V, Schmithorst V, Kochanek PM, Panigrahy A, Fink EL. Global and Regional Derangements of Cerebral Blood Flow and Diffusion Magnetic Resonance Imaging after Pediatric Cardiac Arrest. J Pediatr 2016; 169:28-35.e1. [PMID: 26561380 PMCID: PMC4729616 DOI: 10.1016/j.jpeds.2015.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 08/19/2015] [Accepted: 10/01/2015] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To quantify and examine the relationship between global and regional cerebral blood flow (CBF) and water diffusion on brain magnetic resonance imaging (MRI) in children after cardiac arrest. STUDY DESIGN Children admitted to a tertiary care children's hospital from July 2011 to April 2013 who received a brain MRI within 2 weeks after cardiac arrest that included arterial spin labeling and apparent diffusion coefficient (ADC) sequences were studied. CBF and ADC values were calculated globally and in 19 regions of interest. Outcome variables included survival and favorable neurologic outcome, which was defined as Pediatric Cerebral Performance Category ≤3 at 6 months. We examined global and regional relationships between CBF and ADC and their association with outcome. RESULTS This sample included 14 pediatric patients (mean time to MRI 6 ± 4 days), 9 of whom survived and 6 who survived with favorable outcome. Global ADC was significantly decreased in patients with unfavorable outcome (P = .02). Increased CBF and decreased ADC often were colocalized in the same region, especially in children who had unfavorable outcomes. CONCLUSIONS In this exploratory study, global restricted water diffusion on ADC after pediatric cardiac arrest was associated with unfavorable outcome. MRI assessments of perfusion and diffusion may have prognostic value after pediatric cardiac arrest.
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Affiliation(s)
| | - Vince Lee
- Department of Radiology, Children’s Hospital of Pittsburgh
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Shaik JSB, Poloyac SM, Kochanek PM, Alexander H, Tudorascu DL, Clark RS, Manole MD. 20-Hydroxyeicosatetraenoic Acid Inhibition by HET0016 Offers Neuroprotection, Decreases Edema, and Increases Cortical Cerebral Blood Flow in a Pediatric Asphyxial Cardiac Arrest Model in Rats. J Cereb Blood Flow Metab 2015; 35:1757-63. [PMID: 26058691 PMCID: PMC4635230 DOI: 10.1038/jcbfm.2015.117] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 03/24/2015] [Accepted: 04/17/2015] [Indexed: 12/28/2022]
Abstract
Vasoconstrictive and vasodilatory eicosanoids generated after cardiac arrest (CA) may contribute to cerebral vasomotor disturbances and neurodegeneration. We evaluated the balance of vasodilator/vasoconstrictor eicosanoids produced by cytochrome P450 (CYP) metabolism, and determined their role on cortical perfusion, functional outcome, and neurodegeneration after pediatric asphyxial CA. Cardiac arrest of 9 and 12 minutes was induced in 16- to 18-day-old rats. At 5 and 120 minutes after CA, we quantified the concentration of CYP eicosanoids in the cortex and subcortical areas. In separate rats, we inhibited 20-hydroxyeicosatetraenoic acid (20-HETE) synthesis after CA and assessed cortical cerebral blood flow (CBF), neurologic deficit score, neurodegeneration, and edema. After 9 minutes of CA, vasodilator eicosanoids markedly increased versus sham. Conversely, after 12 minutes of CA, vasoconstrictor eicosanoid 20-HETE increased versus sham, without compensatory increases in vasodilator eicosanoids. Inhibition of 20-HETE synthesis after 12 minutes of CA decreased cortical 20-HETE levels, increased CBF, reduced neurologic deficits at 3 hours, and reduced neurodegeneration and edema at 48 hours versus vehicle-treated rats. In conclusion, cerebral vasoconstrictor eicosanoids increased after a pediatric CA of 12 minutes. Inhibition of 20-HETE synthesis improved cortical perfusion and short-term neurologic outcome. These results suggest that alterations in CYP eicosanoids have a role in cerebral hypoperfusion and neurodegeneration after CA and may represent important therapeutic targets.
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Affiliation(s)
- Jafar Sadik B Shaik
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samuel M Poloyac
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Henry Alexander
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dana L Tudorascu
- Department of Internal Medicine, Department of Psychiatry, and Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert Sb Clark
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mioara D Manole
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Au AK, Chen Y, Du L, Smith CM, Manole MD, Baltagi SA, Chu CT, Aneja RK, Bayır H, Kochanek PM, Clark RSB. Ischemia-induced autophagy contributes to neurodegeneration in cerebellar Purkinje cells in the developing rat brain and in primary cortical neurons in vitro. Biochim Biophys Acta Mol Basis Dis 2015; 1852:1902-11. [PMID: 26071643 DOI: 10.1016/j.bbadis.2015.06.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/12/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
Abstract
Increased autophagy/mitophagy is thought to contribute to cerebellar dysfunction in Purkinje cell degeneration mice. Intriguingly, cerebellar Purkinje cells are highly vulnerable to hypoxia-ischemia (HI), related at least in part to their high metabolic activity. Whether or not excessive or supraphysiologic autophagy plays a role in Purkinje cell susceptibility to HI is unknown. Accordingly, we evaluated the role of autophagy in the cerebellum after global ischemia produced by asphyxial cardiac arrest in postnatal day (PND) 16-18 rats, using siRNA-targeted inhibition of Atg7, necessary for microtubule-associated protein light chain 3-II (LC3-II) and Atg12-Atg5 complex formation. Two days before a 9min asphyxial cardiac arrest or sham surgery, Atg7 or control siRNA was injected intracisternally to target the cerebellum. Treatment with Atg7 siRNA: 1) reduced Atg7 protein expression in the cerebellum by 56%; 2) prevented the typical ischemia-induced formation of LC3-II in the cerebellum 24h after asphyxial cardiac arrest; 3) improved performance on the beam-balance apparatus on days 1-5; and 4) increased calbindin-labeled Purkinje cell survival assessed on day 14. Improved Purkinje cell survival was more consistent in female vs. male rats, and improved beam-balance performance was only seen in female rats. Similar responses to Atg7 siRNA i.e. reduced autophagy and neurodegeneration vs. control siRNA were seen when exposing sex-segregated green fluorescent protein-LC3 tagged mouse primary cortical neurons to oxygen glucose deprivation in vitro. Thus, inhibition of autophagy after global ischemia in PND 16-18 rats leads to increased survival of Purkinje cells and improved motor performance in a sex-dependent manner.
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Affiliation(s)
- Alicia K Au
- Department of Critical Care Medicine, The Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yaming Chen
- Department of Critical Care Medicine, The Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lina Du
- Department of Critical Care Medicine, The Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Craig M Smith
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mioara D Manole
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Sirine A Baltagi
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Charleen T Chu
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Rajesh K Aneja
- Department of Critical Care Medicine, The Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Hülya Bayır
- Department of Critical Care Medicine, The Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA; Department of Environmental and Occupational Health, Center for Free Radical and Antioxidant Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, The Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA; Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, The Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA; Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA.
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Leger PL, Bonnin P, Renolleau S, Baud O, Charriaut-Marlangue C. Ischemic postconditioning in cerebral ischemia: Differences between the immature and mature brain? Int J Dev Neurosci 2015; 45:39-43. [PMID: 25777940 DOI: 10.1016/j.ijdevneu.2015.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 03/12/2015] [Accepted: 03/12/2015] [Indexed: 10/23/2022] Open
Abstract
Ischemic postconditioning (postC), defined as serial mechanical interruptions of blood flow at reperfusion, effectively reduces myocardial infarct size in all species tested so far, including humans. In the brain, ischemic postC leads to controversial results regardless of variations in factors such as onset time of beginning, the duration of ischemia and/or reperfusion, and the number of cycles of occlusion/reperfusion. Thus, many major issues remain to be resolved regarding its protective effects. Future studies should aim to identify the parameters that yield the strongest protection, as well as to understand why the efficacy of ischemic postC differs between models. This review will focus on initial hemodynamic changes and their consequences, and on specific features such as NO-dependent vascular tone and/or prolonged acidosis in cerebral ischemia-reperfusion in order to better understand the dynamics of ischemic postC in the developing brain.
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Affiliation(s)
- Pierre-Louis Leger
- Univ. Paris Diderot, Sorbonne Paris Cité, INSERM UMR 1141, 75019 Paris, France; PremUp Foundation, 75006 Paris, France; UPMC-Paris6, AP-HP, Hôpital Armand Trousseau, Service de Réanimation Néonatale et Pédiatrique, 75012 Paris, France
| | - Philippe Bonnin
- Univ. Paris Diderot, Sorbonne Paris Cité, AP-HP, Hôpital Lariboisière, Physiologie Clinique, Explorations-Fonctionnelles, 75010 Paris, France; Univ. Paris Diderot, Sorbonne Paris Cité, INSERM, U965, 75010 Paris, France
| | - Sylvain Renolleau
- Univ. Paris Diderot, Sorbonne Paris Cité, INSERM UMR 1141, 75019 Paris, France; Univ. Paris Descartes, AP-HP, CHU Necker-Enfants Malades, Réanimation et USC médico-chirurgicales pédiatriques, 75015 Paris, France
| | - Olivier Baud
- Univ. Paris Diderot, Sorbonne Paris Cité, INSERM UMR 1141, 75019 Paris, France; PremUp Foundation, 75006 Paris, France
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Lin X, Kraut JA, Wu D. Coadministration of a Na+-H+ exchange inhibitor and sodium bicarbonate for the treatment of asphyxia-induced cardiac arrest in piglets. Pediatr Res 2014; 76:118-26. [PMID: 24796369 DOI: 10.1038/pr.2014.65] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 01/27/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND The present study tested the hypothesis that addition of an inhibitor of Na(+)/H(+) exchanger (NHE1) to sodium bicarbonate might improve the response to base therapy from prolonged asphyxial cardiac arrest in piglets. METHODS Asphyxial cardiac arrest was induced by endotracheal tube clamping. Animals were randomly assigned to four study groups: (i) vehicle control, (ii) administration of sabiporide (NHE1 inhibitor), (iii) administration of sodium bicarbonate, and (iv) administration of sabiporide and sodium bicarbonate. RESULTS Administration of sodium bicarbonate alone did not affect survival, hemodynamic measures, and regional blood flow to critical tissues such as brain, heart, kidney, liver, and spleen. In contrast, sabiporide given alone or combined with sodium bicarbonate improved these. Furthermore, treatment with sabiporide reduced accumulation of neutrophils, reduced cytokine production in the lung, and reduced plasma levels of cardiac troponin-I, alanine aminotransferase, aspartate aminotransferase, and urea. In addition, the combined use of sabiporide and sodium bicarbonate had more profound reduction in interleukin (IL)-6 and IL-10, compared to sabiporide alone. CONCLUSION These results suggest that addition of sabiporide to the administration of sodium bicarbonate might improve hemodynamic response and dampen the inflammatory cascade noted with cardiac arrest, and therefore being an attractive option in the treatment of cardiac arrest.
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Affiliation(s)
- Xinchun Lin
- Department of Research, Mount Sinai Medical Center, Miami Beach, Florida
| | - Jeffrey A Kraut
- 1] Medical and Research Services and Division of Nephrology, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California [2] David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Dongmei Wu
- 1] Department of Research, Mount Sinai Medical Center, Miami Beach, Florida [2] Department of Biotechnology, Information Science, and Nanotechnology (BIN) Fusion Technology, Chonbuk National University, Jeonju, Korea
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Tress EE, Clark RSB, Foley LM, Alexander H, Hickey RW, Drabek T, Kochanek PM, Manole MD. Blood brain barrier is impermeable to solutes and permeable to water after experimental pediatric cardiac arrest. Neurosci Lett 2014; 578:17-21. [PMID: 24937271 DOI: 10.1016/j.neulet.2014.06.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/20/2014] [Accepted: 06/07/2014] [Indexed: 01/04/2023]
Abstract
Pediatric asphyxial cardiac arrest (CA) results in unfavorable neurological outcome in most survivors. Development of neuroprotective therapies is contingent upon understanding the permeability of intravenously delivered medications through the blood brain barrier (BBB). In a model of pediatric CA we sought to characterize BBB permeability to small and large molecular weight substances. Additionally, we measured the percent brain water after CA. Asphyxia of 9 min was induced in 16-18 day-old rats. The rats were resuscitated and the BBB permeability to small (sodium fluorescein and gadoteridol) and large (immunoglobulin G, IgG) molecules was assessed at 1, 4, and 24 h after asphyxial CA or sham surgery. Percent brain water was measured post-CA and in shams using wet-to-dry brain weight. Fluorescence, gadoteridol uptake, or IgG staining at 1, 4h and over the entire 24 h post-CA did not differ from shams, suggesting absence of BBB permeability to these solutes. Cerebral water content was increased at 3h post-CA vs. sham. In conclusion, after 9 min of asphyxial CA there is no BBB permeability over 24h to conventional small or large molecule tracers despite the fact that cerebral water content is increased early post-CA indicating the development of brain edema. Evaluation of novel therapies targeting neuronal death after pediatric CA should include their capacity to cross the BBB.
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Affiliation(s)
- Erika E Tress
- University of Pittsburgh, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Robert S B Clark
- University of Pittsburgh, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA; University of Pittsburgh, Critical Care Medicine, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA; University of Pittsburgh, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
| | - Lesley M Foley
- Carnegie Mellon University, NMR Center for Biomedical Research, 4400 Fifth Avenue, Pittsburgh, PA 15213, USA.
| | - Henry Alexander
- University of Pittsburgh, Critical Care Medicine, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA; University of Pittsburgh, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
| | - Robert W Hickey
- University of Pittsburgh, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Tomas Drabek
- University of Pittsburgh, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA; University of Pittsburgh Department of Anesthesiology, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
| | - Patrick M Kochanek
- University of Pittsburgh, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA; University of Pittsburgh, Critical Care Medicine, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA; University of Pittsburgh, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
| | - Mioara D Manole
- University of Pittsburgh, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA; University of Pittsburgh, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
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Global and regional differences in cerebral blood flow after asphyxial versus ventricular fibrillation cardiac arrest in rats using ASL-MRI. Resuscitation 2014; 85:964-71. [PMID: 24727136 DOI: 10.1016/j.resuscitation.2014.03.314] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 02/11/2014] [Accepted: 03/31/2014] [Indexed: 12/20/2022]
Abstract
Both ventricular fibrillation cardiac arrest (VFCA) and asphyxial cardiac arrest (ACA) are frequent causes of CA. However, only isolated reports compared cerebral blood flow (CBF) reperfusion patterns after different types of CA, and even fewer reports used methods that allow serial and regional assessment of CBF. We hypothesized that the reperfusion patterns of CBF will differ between individual types of experimental CA. In a prospective block-randomized study, fentanyl-anesthetized adult rats were subjected to 8min VFCA or ACA. Rats were then resuscitated with epinephrine, bicarbonate, manual chest compressions and mechanical ventilation. After the return of spontaneous circulation, CBF was then serially assessed via arterial spin-labeling magnetic resonance imaging (ASL-MRI) in cortex, thalamus, hippocampus and amygdala/piriform complex over 1h resuscitation time (RT). Both ACA and VFCA produced significant temporal and regional differences in CBF. All regions in both models showed significant changes over time (p<0.01), with early hyperperfusion and delayed hypoperfusion. ACA resulted in early hyperperfusion in cortex and thalamus (both p<0.05 vs. amygdala/piriform complex). In contrast, VFCA induced early hyperperfusion only in cortex (p<0.05 vs. other regions). Hyperperfusion was prolonged after ACA, peaking at 7min RT (RT7; 199% vs. BL, Baseline, in cortex and 201% in thalamus, p<0.05), then returning close to BL at ∼RT15. In contrast, VFCA model induced mild hyperemia, peaking at RT7 (141% vs. BL in cortex). Both ACA and VFCA showed delayed hypoperfusion (ACA, ∼30% below BL in hippocampus and amygdala/piriform complex, p<0.05; VFCA, 34-41% below BL in hippocampus and amygdala/piriform complex, p<0.05). In conclusion, both ACA and VFCA in adult rats produced significant regional and temporal differences in CBF. In ACA, hyperperfusion was most pronounced in cortex and thalamus. In VFCA, the changes were more modest, with hyperperfusion seen only in cortex. Both insults resulted in delayed hypoperfusion in all regions. Both early hyperperfusion and delayed hypoperfusion may be important therapeutic targets. This study was approved by the University of Pittsburgh IACUC 1008816-1.
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Djabir Y, Letson HL, Dobson GP. Adenosine, lidocaine, and Mg2+ (ALM™) increases survival and corrects coagulopathy after eight-minute asphyxial cardiac arrest in the rat. Shock 2014; 40:222-32. [PMID: 23846412 DOI: 10.1097/shk.0b013e3182a03566] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION No drug therapy has demonstrated improved survival following cardiac arrest (CA) of cardiac or noncardiac origin. In an effort to translate the cardiorescue properties of Adenocaine (adenosine and lidocaine) and magnesium sulfate (ALM) from cardiac surgery and hemorrhagic shock to resuscitation, we examined the effect of ALM on hemodynamic rescue and coagulopathy following asphyxial-induced CA in the rat. METHODS Nonheparinized animals (400-500 g, n = 39) were randomly assigned to 0.9% saline (n = 12) and 0.9% saline ALM (n = 10) groups. After baseline data were acquired, the animal was surface cooled (33°C-34°C) and the ventilator line clamped for 8 min inducing CA; 0.5 mL of solution was injected intravenously followed by 60-s chest compressions (300/min), and rats were rewarmed. Return of spontaneous circulation (ROSC), mean arterial pressure, heart rate, and rectal temperature were recorded for 2 h. Additional rats were randomized for rotation thromboelastometry measurements (n = 17). RESULTS Rats treated with ALM had a significant survival benefit (100% ALM vs. 67% controls achieved ROSC) and generated a higher mean arterial pressure than did controls after 75 min (81 vs. 72 mmHg at 120 min, P < 0.05). In all rats, rotation thromboelastometry lysis index decreased during CA, implying hyperfibrinolysis. Control ROSC survivors displayed hypocoagulopathy (prolonged EXTEM/INTEM clotting time, clot formation time, prothrombin time, activated partial thromboplastin time), decreased maximal clot firmness, lowered elasticity, and lowered clot amplitudes but no change in lysis index. These coagulation abnormalities were corrected by ALM at 120 min after ROSC. CONCLUSIONS Small bolus of 0.9% NaCl ALM improved survival and hemodynamics following nonhemorrhagic, asphyxial CA and corrected prolonged clot times and clot retraction compared with controls.
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Affiliation(s)
- Yulia Djabir
- Heart and Trauma Research Laboratory, Physiology and Pharmacology, James Cook University, Queensland, Australia
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Protein kinase C delta modulates endothelial nitric oxide synthase after cardiac arrest. J Cereb Blood Flow Metab 2014; 34:613-20. [PMID: 24447953 PMCID: PMC3982078 DOI: 10.1038/jcbfm.2013.232] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 11/25/2013] [Accepted: 11/28/2013] [Indexed: 12/21/2022]
Abstract
We previously showed that inhibition of protein kinase C delta (PKCδ) improves brain perfusion 24 hours after asphyxial cardiac arrest (ACA) and confers neuroprotection in the cortex and CA1 region of the hippocampus 7 days after arrest. Therefore, in this study, we investigate the mechanism of action of PKCδ-mediated hypoperfusion after ACA in the rat by using the two-photon laser scanning microscopy (TPLSM) to observe cortical cerebral blood flow (CBF) and laser Doppler flowmetry (LDF) detecting regional CBF in the presence/absence of δV1-1 (specific PKCδ inhibitor), nitric oxide synthase (NOS) substrate (L-arginine, L-arg) and inhibitor (N(ω)-Nitro-L-arginine, NLA), and nitric oxide (NO) donor (sodium nitroprusside, SNP). There was an increase in regional LDF and local (TPLSM) CBF in the presence of δV1-1+L-arg, but only an increase in regional CBF under δV1-1+SNP treatments. Systemic blood nitrite levels were measured 15 minutes and 24 hours after ACA. Nitrite levels were enhanced by pretreatment with δV1-1 30 minutes before ACA possibly attributable to enhanced endothelial NOS protein levels. Our results suggest that PKCδ can modulate NO machinery in cerebral vasculature. Protein kinase C delta can depress endothelial NOS blunting CBF resulting in hypoperfusion, but can be reversed with δV1-1 improving brain perfusion, thus providing subsequent neuroprotection after ACA.
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Manole MD, Kochanek PM, Bayır H, Alexander H, Dezfulian C, Fink EL, Bell MJ, Clark RS. Brain tissue oxygen monitoring identifies cortical hypoxia and thalamic hyperoxia after experimental cardiac arrest in rats. Pediatr Res 2014; 75:295-301. [PMID: 24226633 PMCID: PMC3970819 DOI: 10.1038/pr.2013.220] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 07/04/2013] [Indexed: 11/13/2022]
Abstract
BACKGROUND Optimization of cerebral oxygenation after pediatric cardiac arrest (CA) may reduce neurological damage associated with the post-CA syndrome. We hypothesized that important alterations in regional partial pressure of brain tissue oxygen (PbO2) occur after resuscitation from CA and that clinically relevant interventions such as hyperoxia and blood pressure augmentation would influence PbO2. METHODS Cortical and thalamic PbO2 were monitored in immature rats subjected to asphyxial CA (9 or 12 min asphyxia) and sham-operated rats using oxygen sensors. RESULTS Thalamus and cortex showed similar baseline PbO2. Postresuscitation, there was early and sustained cortical hypoxia in an insult-duration dependent fashion. In contrast, thalamic PbO2 initially increased fourfold and afterwards returned to baseline values. PbO2 level was dependent on the fraction of inspired O2, and the response to oxygen was more pronounced after a 9 vs. 12 min CA. After a 12 min CA, PbO2 was modestly affected by blood pressure augmentation using epinephrine in the thalamus but not in the cortex. CONCLUSION After asphyxial pediatric CA, there is marked regional variability of cerebral oxygenation. Cortical hypoxia is pronounced and appears early, whereas thalamic hyperoxia is followed by normoxia. Compromised PbO2 in the cortex may represent a relevant and clinically measurable therapeutic target aimed at improving neurological outcome after pediatric CA.
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Affiliation(s)
- Mioara D. Manole
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Patrick M. Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Hulya Bayır
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Henry Alexander
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Cameron Dezfulian
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Ericka L. Fink
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Michael J. Bell
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Robert S.B. Clark
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Enhanced external counterpulsation improves cerebral blood flow following cardiopulmonary resuscitation. Am J Emerg Med 2013; 31:1638-45. [DOI: 10.1016/j.ajem.2013.08.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/15/2013] [Accepted: 08/15/2013] [Indexed: 11/20/2022] Open
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Topjian AA, Berg RA, Bierens JJLM, Branche CM, Clark RS, Friberg H, Hoedemaekers CWE, Holzer M, Katz LM, Knape JTA, Kochanek PM, Nadkarni V, van der Hoeven JG, Warner DS. Brain resuscitation in the drowning victim. Neurocrit Care 2013; 17:441-67. [PMID: 22956050 DOI: 10.1007/s12028-012-9747-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Drowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating non-convulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific post-resuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.
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Affiliation(s)
- Alexis A Topjian
- The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Suite 7C23, Philadelphia, PA 19104, USA.
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MRI assessment of cerebral blood flow after experimental traumatic brain injury combined with hemorrhagic shock in mice. J Cereb Blood Flow Metab 2013; 33:129-36. [PMID: 23072750 PMCID: PMC3597358 DOI: 10.1038/jcbfm.2012.145] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Secondary insults such as hypotension or hemorrhagic shock (HS) can greatly worsen outcome after traumatic brain injury (TBI). We recently developed a mouse combined injury model of TBI and HS using a controlled cortical impact (CCI) model and showed that 90 minutes of HS can exacerbate neuronal death in hippocampus beneath the contusion. This combined injury model has three clinically relevant phases, a shock, pre hospital, and definitive care phases. Mice were randomly assigned to four groups, shams as well as a CCI only, an HS only, and a CCI+HS groups. The CCI and HS reduced cerebral blood flow (CBF) in multiple regions of interest (ROIs) in the hemisphere ipsilateral and contralateral to injury. Hemorrhagic shock to a level of ∼30 mm Hg exacerbated the CCI-induced CBF reductions in multiple ROIs ipsilateral to injury (hemisphere and thalamus) and in the hemisphere contralateral to injury (hemisphere, thalamus, hippocampus, and cortex, all P<0.05 versus CCI only, HS only or both). An important effect of HS duration was also seen after CCI with maximal CBF reduction seen at 90 minutes (P<0.0001 group-time effect in ipsilateral hippocampus). Given that neuronal death in hippocampus is exacerbated by 90 minutes of HS in this model, our data suggest an important role for exacerbation of posttraumatic ischemia in mediating the secondary injury in CCI plus HS. In conclusion, the serial, non invasive assessment of CBF using ASL-MRI (magnetic resonance imaging with arterial spin labeling) is feasible in mice even in the complex setting of combined CCI+HS. The impact of resuscitation therapies and various mutant mouse strains on CBF and other outcomes merits investigation in this model.
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Leger PL, Bonnin P, Lacombe P, Couture-Lepetit E, Fau S, Renolleau S, Gharib A, Baud O, Charriaut-Marlangue C. Dynamic spatio-temporal imaging of early reflow in a neonatal rat stroke model. J Cereb Blood Flow Metab 2013; 33:137-45. [PMID: 23047273 PMCID: PMC3597373 DOI: 10.1038/jcbfm.2012.147] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The aim of the study was to better understand blood-flow changes in large arteries and microvessels during the first 15 minutes of reflow in a P7 rat model of arterial occlusion. Blood-flow changes were monitored by using ultrasound imaging with sequential Doppler recordings in internal carotid arteries (ICAs) and basilar trunk. Relative cerebral blood flow (rCBF) changes were obtained by using laser speckle Doppler monitoring. Tissue perfusion was measured with [(14)C]-iodoantipyrine autoradiography. Cerebral energy metabolism was evaluated by mitochondrial oxygen consumption. Gradual increase in mean blood-flow velocities illustrated a gradual perfusion during early reflow in both ICAs. On ischemia, the middle cerebral artery (MCA) territory presented a residual perfusion, whereas the caudal territory remained normally perfused. On reflow, speckle images showed a caudorostral propagation of reperfusion through anastomotic connections, and a reduced perfusion in the MCA territory. Autoradiography highlighted the caudorostral gradient, and persistent perfusion in ventral and medial regions. These blood-flow changes were accompanied by mitochondrial respiration impairment in the ipsilateral cortex. Collectively, these data indicate the presence of a primary collateral pathway through the circle of Willis, providing an immediate diversion of blood flow toward ischemic regions, and secondary efficient cortical anastomoses in the immature rat brain.
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Optimizing oxygenation and ventilation after cardiac arrest in “little adults”. Resuscitation 2012; 83:1425-6. [DOI: 10.1016/j.resuscitation.2012.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 09/07/2012] [Indexed: 11/20/2022]
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Lin X, Lee D, Wu D. Protective effects of NHE1 inhibition with sabiporide in an experimental model of asphyxia-induced cardiac arrest in piglets. Resuscitation 2012; 84:520-5. [PMID: 22989728 DOI: 10.1016/j.resuscitation.2012.08.334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 07/30/2012] [Accepted: 08/29/2012] [Indexed: 11/27/2022]
Abstract
The present study investigated the protective effects of a novel NHE1 selective inhibitor, sabiporide, in a porcine model of asphyxia-induced cardiac arrest. Asphyxial cardiac arrest was induced by endotracheal tube clamping (ETC). The animals remained untreated for 3 min after loss of aortic pulsations (LOAP), and followed by chest compression and defibrillation. Sixteen of eighteen pigs had return of spontaneous circulation (ROSC), and were randomly assigned to two study groups. Group 1: vehicle control. Group 2: 3mg/kg sabiporide was given at 15 min after ROSC. Post-arrest myocardial dysfunction was present in both groups, and progressed over hours. Animals treated with sabiporide had less wall motion abnormality and higher left ventricular ejection fraction than control animals (33% in control group vs. 47% in sabiporide group). Sabopiride treatment also significantly improved post-arrest arterial blood pressure by 25% and cardiac stroke volume by 44%, and improved mixed-venous blood oxygen saturation by 38% and oxygen delivery by 118%. Furthermore, compared to the control group, the sabiporide group also had higher blood flows in the brain, heart, kidney, liver and spleen at 30 min after ROSC. There was no significant blood flow difference in distal ileum mucosa between control and sabiporide groups. In addition, sabiporide treatment significantly reduced cardiac myeloperoxidase (MPO) activity by 53% and cardiac troponin I by 51%, and reduced the plasma level of TNF-α by 52% and IL-6 by 41%. This study shows that post-arrest pharmacological conditioning with sabiporide affords protection from whole body ischemia-reperfusion injury in this model of asphyxia-induced cardiac arrest and resuscitation.
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Affiliation(s)
- Xinchun Lin
- Department of Research, Mount Sinai Medical Center, Miami Beach, FL, USA
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Thalamocortical dysfunction and thalamic injury after asphyxial cardiac arrest in developing rats. J Neurosci 2012; 32:4972-81. [PMID: 22492052 DOI: 10.1523/jneurosci.5597-11.2012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Global hypoxia-ischemia interrupts oxygen delivery and blood flow to the entire brain. Previous studies of global brain hypoxia-ischemia have primarily focused on injury to the cerebral cortex and to the hippocampus. Susceptible neuronal populations also include inhibitory neurons in the thalamic reticular nucleus. We therefore investigated the impact of global brain hypoxia-ischemia on the thalamic circuit function in the somatosensory system of young rats. We used single neuron recordings and controlled whisker deflections to examine responses of thalamocortical neurons to sensory stimulation in rat survivors of 9 min of asphyxial cardiac arrest incurred on postnatal day 17. We found that 48-72 h after cardiac arrest, thalamocortical neurons demonstrate significantly elevated firing rates both during spontaneous activity and in response to whisker deflections. The elevated evoked firing rates persist for at least 6-8 weeks after injury. Despite the overall increase in firing, by 6 weeks, thalamocortical neurons display degraded receptive fields, with decreased responses to adjacent whiskers. Nine minutes of asphyxial cardiac arrest was associated with extensive degeneration of neurites in the somatosensory nucleus as well as activation of microglia in the reticular nucleus. Global brain hypoxia-ischemia during cardiac arrest has a long-term impact on processing and transfer of sensory information by thalamic circuitry. Thalamic circuitry and normalization of its function may represent a distinct therapeutic target after cardiac arrest.
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Manole MD, Kochanek PM, Foley LM, Hitchens TK, Bayır H, Alexander H, Garman R, Ma L, Hsia CJC, Ho C, Clark RSB. Polynitroxyl albumin and albumin therapy after pediatric asphyxial cardiac arrest: effects on cerebral blood flow and neurologic outcome. J Cereb Blood Flow Metab 2012; 32:560-9. [PMID: 22126915 PMCID: PMC3293121 DOI: 10.1038/jcbfm.2011.165] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Postresuscitation cerebral blood flow (CBF) disturbances and generation of reactive oxygen species likely contribute to impaired neurologic outcome after pediatric cardiac arrest (CA). Hence, we determined the effects of the antioxidant colloid polynitroxyl albumin (PNA) versus albumin or normal saline (NS) on CBF and neurologic outcome after asphyxial CA in immature rats. We induced asphyxia for 9 minutes in male and female postnatal day 16 to 18 rats randomized to receive PNA, albumin, or NS at resuscitation from CA or sham surgery. Regional CBF was measured serially from 5 to 150 minutes after resuscitation by arterial spin-labeled magnetic resonance imaging. We assessed motor function (beam balance and inclined plane), spatial memory retention (water maze), and hippocampal neuronal survival. Polynitroxyl albumin reduced early hyperemia seen 5 minutes after CA. In contrast, albumin markedly increased and prolonged hyperemia. In the delayed period after resuscitation (90 to 150 minutes), CBF was comparable among groups. Both PNA- and albumin-treated rats performed better in the water maze versus NS after CA. This benefit was observed only in males. Hippocampal neuron survival was similar between injury groups. Treatment of immature rats with PNA or albumin resulted in divergent acute changes in CBF, but both improved spatial memory retention in males after asphyxial CA.
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Affiliation(s)
- Mioara D Manole
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Lee JK, Yang ZJ, Wang B, Larson AC, Jamrogowicz JL, Kulikowicz E, Kibler KK, Mytar JO, Carter EL, Burman HT, Brady KM, Smielewski P, Czosnyka M, Koehler RC, Shaffner DH. Noninvasive autoregulation monitoring in a swine model of pediatric cardiac arrest. Anesth Analg 2012; 114:825-36. [PMID: 22314692 DOI: 10.1213/ane.0b013e31824762d5] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cerebrovascular autoregulation after resuscitation has not been well studied in an experimental model of pediatric cardiac arrest. Furthermore, developing noninvasive methods of monitoring autoregulation using near-infrared spectroscopy (NIRS) would be clinically useful in guiding neuroprotective hemodynamic management after pediatric cardiac arrest. We tested the hypotheses that the lower limit of autoregulation (LLA) would shift to a higher arterial blood pressure between 1 and 2 days of recovery after cardiac arrest and that the LLA would be detected by NIRS-derived indices of autoregulation in a swine model of pediatric cardiac arrest. We also tested the hypothesis that autoregulation with hypertension would be impaired after cardiac arrest. METHODS Data on LLA were obtained from neonatal piglets that had undergone hypoxic-asphyxic cardiac arrest and recovery for 1 day (n = 8) or 2 days (n = 8), or that had undergone sham surgery with 2 days of recovery (n = 8). Autoregulation with hypertension was examined in a separate cohort of piglets that underwent hypoxic-asphyxic cardiac arrest (n = 5) or sham surgery (n = 5) with 2 days of recovery. After the recovery period, piglets were reanesthetized, and autoregulation was monitored by standard laser-Doppler flowmetry and autoregulation indices derived from NIRS (the cerebral oximetry [COx] and hemoglobin volume [HVx] indices). The LLA was determined by decreasing blood pressure through inflation of a balloon catheter in the inferior vena cava. Autoregulation during hypertension was evaluated by inflation of an aortic balloon catheter. RESULTS The LLAs were similar between sham-operated piglets and piglets that recovered for 1 or 2 days after arrest. The NIRS-derived indices accurately detected the LLA determined by laser-Doppler flowmetry. The area under the curve of the receiver operator characteristic curve for cerebral oximetry index was 0.91 at 1 day and 0.92 at 2 days after arrest. The area under the curve for hemoglobin volume index was 0.92 and 0.89 at the respective time points. During induced hypertension, the static rate of autoregulation, defined as the percentage change in cerebrovascular resistance divided by the percentage change in cerebral perfusion pressure, was not different between postarrest and sham-operated piglets. At 2 days recovery from arrest, piglets exhibited neurobehavioral deficits and histologic neuronal injury. CONCLUSIONS In a swine model of pediatric hypoxic-asphyxic cardiac arrest with confirmed brain damage, the LLA did not differ 1 and 2 days after resuscitation. The NIRS-derived indices accurately detected the LLA in comparison with laser-Doppler flow measurements at those time points. Autoregulation remained functional during hypertension.
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Affiliation(s)
- Jennifer K Lee
- Department of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University, Blalock 904, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
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