1
|
Luzzi S, Bektaşoğlu PK, Doğruel Y, Güngor A. Beyond nimodipine: advanced neuroprotection strategies for aneurysmal subarachnoid hemorrhage vasospasm and delayed cerebral ischemia. Neurosurg Rev 2024; 47:305. [PMID: 38967704 PMCID: PMC11226492 DOI: 10.1007/s10143-024-02543-5] [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: 12/11/2023] [Revised: 05/15/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024]
Abstract
The clinical management of aneurysmal subarachnoid hemorrhage (SAH)-associated vasospasm remains a challenge in neurosurgical practice, with its prevention and treatment having a major impact on neurological outcome. While considered a mainstay, nimodipine is burdened by some non-negligible limitations that make it still a suboptimal candidate of pharmacotherapy for SAH. This narrative review aims to provide an update on the pharmacodynamics, pharmacokinetics, overall evidence, and strength of recommendation of nimodipine alternative drugs for aneurysmal SAH-associated vasospasm and delayed cerebral ischemia. A PRISMA literature search was performed in the PubMed/Medline, Web of Science, ClinicalTrials.gov, and PubChem databases using a combination of the MeSH terms "medical therapy," "management," "cerebral vasospasm," "subarachnoid hemorrhage," and "delayed cerebral ischemia." Collected articles were reviewed for typology and relevance prior to final inclusion. A total of 346 articles were initially collected. The identification, screening, eligibility, and inclusion process resulted in the selection of 59 studies. Nicardipine and cilostazol, which have longer half-lives than nimodipine, had robust evidence of efficacy and safety. Eicosapentaenoic acid, dapsone and clazosentan showed a good balance between effectiveness and favorable pharmacokinetics. Combinations between different drug classes have been studied to a very limited extent. Nicardipine, cilostazol, Rho-kinase inhibitors, and clazosentan proved their better pharmacokinetic profiles compared with nimodipine without prejudice with effective and safe neuroprotective role. However, the number of trials conducted is significantly lower than for nimodipine. Aneurysmal SAH-associated vasospasm remains an area of ongoing preclinical and clinical research where the search for new drugs or associations is critical.
Collapse
Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Pınar Kuru Bektaşoğlu
- Department of Neurosurgery, University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, İstanbul, Türkiye
| | - Yücel Doğruel
- Department of Neurosurgery, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Türkiye
| | - Abuzer Güngor
- Faculty of Medicine, Department of Neurosurgery, Istinye University, İstanbul, Türkiye
| |
Collapse
|
2
|
Becker K. Animal Welfare Aspects in Planning and Conducting Experiments on Rodent Models of Subarachnoid Hemorrhage. Cell Mol Neurobiol 2023; 43:3965-3981. [PMID: 37861870 DOI: 10.1007/s10571-023-01418-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/18/2023] [Indexed: 10/21/2023]
Abstract
Subarachnoid hemorrhage is an acute life-threatening cerebrovascular disease with high socio-economic impact. The most frequent cause, the rupture of an intracerebral aneurysm, is accompanied by abrupt changes in intracerebral pressure, cerebral perfusion pressure and, consequently, cerebral blood flow. As aneurysms rupture spontaneously, monitoring of these parameters in patients is only possible with a time delay, upon hospitalization. To study alterations in cerebral perfusion immediately upon ictus, animal models are mandatory. This article addresses the points necessarily to be included in an animal project proposal according to EU directive 2010/63/EU for the protection of animals used for scientific purposes and herewith offers an insight into animal welfare aspects of using rodent models for the investigation of cerebral perfusion after subarachnoid hemorrhage. It compares surgeries, model characteristics, advantages, and drawbacks of the most-frequently used rodent models-the endovascular perforation model and the prechiasmatic and single or double cisterna magna injection model. The topics of discussing anesthesia, advice on peri- and postanesthetic handling of animals, assessing the severity of suffering the animals undergo during the procedure according to EU directive 2010/63/EU and weighing the use of these in vivo models for experimental research ethically are also presented. In conclusion, rodent models of subarachnoid hemorrhage display pathophysiological characteristics, including changes of cerebral perfusion similar to the clinical situation, rendering the models suited to study the sequelae of the bleeding. A current problem is low standardization of the models, wherefore reporting according to the ARRIVE guidelines is highly recommended. Animal welfare aspects of rodent models of subarachnoid hemorrhage. Rodent models for investigation of cerebral perfusion after subarachnoid hemorrhage are compared regarding surgeries and model characteristics, and 3R measures are suggested. Anesthesia is discussed, and advice given on peri- and postanesthetic handling. Severity of suffering according to 2010/63/EU is assessed and use of these in vivo models weighed ethically.
Collapse
Affiliation(s)
- Katrin Becker
- Institute for Translational Neurosurgery, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.
- Institute for Cardiovascular Sciences, University Hospital Bonn, 53127, Bonn, Germany.
| |
Collapse
|
3
|
Datta A, Saha C, Godse P, Sharma M, Sarmah D, Bhattacharya P. Neuroendocrine regulation in stroke. Trends Endocrinol Metab 2023; 34:260-277. [PMID: 36922255 DOI: 10.1016/j.tem.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 03/14/2023]
Abstract
The neuroendocrine system, a crosstalk between the central nervous system and endocrine glands, balances and controls hormone secretion and their functions. Neuroendocrine pathways and mechanisms often get dysregulated following stroke, leading to altered hormone secretion and aberrant receptor expression. Dysregulation of the hypothalamus-pituitary-thyroid (HPT) axis and hypothalamus-pituitary-adrenal (HPA) axis often led to severe stroke outcomes. Post-stroke complications such as cognitive impairment, depression, infection etc. are directly or indirectly influenced by the altered neuroendocrine activity that plays a crucial role in stroke vulnerability and susceptibility. Therefore, it is imperative to explore various neurohormonal inter-relationships in regulating stroke, its outcome, and prognosis. Here, we review the biology of different hormones associated with stroke and explore their regulation with a view towards prospective therapeutics.
Collapse
Affiliation(s)
- Aishika Datta
- Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat-382355, India
| | - Chandrima Saha
- Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat-382355, India
| | - Pratiksha Godse
- Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat-382355, India
| | - Muskaan Sharma
- Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat-382355, India
| | - Deepaneeta Sarmah
- Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat-382355, India
| | - Pallab Bhattacharya
- Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat-382355, India.
| |
Collapse
|
4
|
Li Y, Zhang J, Wang H, Zhu L, Zhang H, Ma Q, Liu X, Dong L, Lu G. Does erythropoietin affect the outcome and complication rates of patient with traumatic brain injury? A pooled-analysis. Neurol Sci 2022; 43:3783-3793. [PMID: 35044560 DOI: 10.1007/s10072-022-05877-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 01/08/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this meta-analysis was to review the scientific literature published until April 18, 2021, to summarize existing knowledge on the efficacy and safety of erythropoietin (EPO) for traumatic brain injury (TBI). METHODS This systematic review followed PRISMA guidelines. Randomized controlled trials (RCTs) reporting on the efficacy and safety of EPO in the treatment of TBI were systematically searched in relevant electronic databases according to a pre-designed search strategy. The primary outcomes are the mortality; and secondary outcomes are the good functional outcome (GFO) and adverse events (AEs). RESULTS A total of 10 RCTs involving 2,402 participants fulfilled the inclusion criteria. The results showed that there is a significant difference in terms of the mortality (RR = 0.67, 95% CI = 0.54-0.84, P = 0.0003) and seizure rate (RR = 0.52, 95% CI = 0.29-0.96, P = 0.04) between the EPO groups compared to those in the control groups. However, compared with the control groups, the GFO in the EPO groups was not statistically significant (RR = 1.18, 95% CI = 0.93-1.48, P = 0.17). CONCLUSIONS Findings of the present meta-analysis suggest that the use of EPO could reduce mortality rate in patients with TBI, without increasing the incidence of AEs. EPO has potential research and application value in the treatment of TBI.
Collapse
Affiliation(s)
- Yuping Li
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College, Yangzhou University, Yangzhou, China.,Department of Neurosurgery, Yangzhou Clinical Medical College of Xuzhou Medical University, Xuzhou, China
| | - Jun Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Haili Wang
- Department of Clinical Medicine, Dalian Medical University, Dalian Liaoning, China
| | - Lei Zhu
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Hengzhu Zhang
- Department of Neurosurgery, Yangzhou Clinical Medical College of Xuzhou Medical University, Xuzhou, China
| | - Qiang Ma
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Xiaoguang Liu
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Lun Dong
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College, Yangzhou University, Yangzhou, China.,Department of Neurosurgery, Yangzhou Clinical Medical College of Xuzhou Medical University, Xuzhou, China
| | - Guangyu Lu
- Institute of Public Health, Medical College, Yangzhou University, Yangzhou, China.
| |
Collapse
|
5
|
Ayerdem G, Bosma MJ, Vinke JSJ, Ziengs AL, Potgieser ARE, Gansevoort RT, Bakker SJL, De Borst MH, Eisenga MF. Association of Endogenous Erythropoietin Levels and Iron Status With Cognitive Functioning in the General Population. Front Aging Neurosci 2022; 14:862856. [PMID: 35462689 PMCID: PMC9024369 DOI: 10.3389/fnagi.2022.862856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundEmerging data suggest that erythropoietin (EPO) promotes neural plasticity and that iron homeostasis is needed to maintain normal physiological brain function. Cognitive functioning could therefore be influenced by endogenous EPO levels and disturbances in iron status.ObjectiveTo determine whether endogenous EPO levels and disturbances in iron status are associated with alterations in cognitive functioning in the general population.Materials and MethodsCommunity-dwelling individuals from the Prevention of Renal and Vascular End-Stage Disease (PREVEND) study, a general population-based cohort in Groningen, Netherlands, were surveyed between 2003 and 2006. Additionally, endogenous EPO levels and iron status, consisting of serum iron, transferrin, ferritin, and transferrin saturation were analyzed. Cognitive function was assessed by scores on the Ruff Figural Fluency Test (RFFT), as a reflection of executive function, and the Visual Association Test (VAT), as a reflection of associative memory.ResultsAmong 851 participants (57% males; mean age 60 ± 13 years), higher endogenous EPO levels were independently associated with an improved cognitive function, reflected by RFFT scores (ß = 0.09, P = 0.008). In multivariable backward linear regression analysis, EPO levels were among the most important modifiable determinants of RFFT scores (ß = 0.09, P = 0.002), but not of VAT scores. Of the iron status parameters, only serum ferritin levels were inversely associated with cognitive function, reflected by VAT scores, in multivariable logistic regression analysis (odds ratio, 0.77; 95% confidence interval 0.63–0.95; P = 0.02 for high performance on VAT, i.e., ≥11 points). No association between iron status parameters and RFFT scores was identified.ConclusionThe findings suggest that endogenous EPO levels and serum ferritin levels are associated with specific cognitive functioning tests in the general population. Higher EPO levels are associated with better RFFT scores, implying better executive function. Serum ferritin levels, but not other iron status parameters, were inversely associated with high performance on the VAT score, implying a reduced ability to create new memories and recall recent past. Further research is warranted to unravel underlying mechanisms and possible benefits of therapeutic interventions.
Collapse
Affiliation(s)
- Gizem Ayerdem
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Matthijs J. Bosma
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Joanna Sophia J. Vinke
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Aaltje L. Ziengs
- Department of Neuropsychology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Adriaan R. E. Potgieser
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ron T. Gansevoort
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephan J. L. Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Martin H. De Borst
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Michele F. Eisenga
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- *Correspondence: Michele F. Eisenga,
| |
Collapse
|
6
|
Lyubashina OA, Mamontov OV, Volynsky MA, Zaytsev VV, Kamshilin AA. Contactless Assessment of Cerebral Autoregulation by Photoplethysmographic Imaging at Green Illumination. Front Neurosci 2019; 13:1235. [PMID: 31798408 PMCID: PMC6863769 DOI: 10.3389/fnins.2019.01235] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/31/2019] [Indexed: 12/15/2022] Open
Abstract
Accurate and practical assessment of the brain circulation is needed to adequately estimate the viability of cerebral blood flow regulatory mechanisms in various physiological conditions. The objective of our study was to examine feasibility of the contactless green-light imaging photoplethysmography (PPG) for assessing cerebral autoregulation by revealing the dynamic relationships between cortical microcirculation assessed by PPG and changes in systemic blood pressure caused by visceral and somatic peripheral stimuli. In anesthetized male Wistar rats, the PPG video images of the open parietal cortex (either with unimpaired or dissected dura mater), electrocardiogram, and systemic arterial blood pressure (ABP) in the femoral artery were continuously recorded before, during and after visceral (colorectal distension) or somatic (tail squeezing) stimulation. In the vast majority of experiments with intact and removed dura mater, both spontaneous and peripheral stimulation-evoked changes in ABP negatively correlated with the accompanying alterations in the amplitude of pulsatile PPG component (APC), i.e., an increase of ABP resulted in a decrease of APC and vice versa. The most pronounced ABP and APC alterations were induced by noxious stimuli. Visceral painful stimulation in all cases caused short-term hypotension with simultaneous increase in cortical APC, whereas somatic noxious stimuli in 8 of 21 trials produced hypertensive effect with decreased APC. Animals with pressure 50-70 mmHg possessed higher negative cerebrovascular response rate of ABP-APC gradients than rats with either lower or higher pressure. Severe hypotension reversed the negative ratio to positive one, which was especially evident under visceral pain stimulation. Amplitude of the pulsatile PPG component probably reflects the regulation of vascular tone of cerebral cortex in response to systemic blood pressure fluctuations. When combined with different kinds of peripheral stimuli, the technique is capable for evaluation of normal and elucidation of impaired cerebrovascular system reactivity to particular physiological events, for example pain. The reported contactless PPG monitoring of cortical circulatory dynamics during neurosurgical interventions in combination with recordings of changes in other physiological parameters, such as systemic blood pressure and ECG, has the appealing potential to monitor viability of the cortex vessels and determine the state of patient’s cerebrovascular autoregulation.
Collapse
Affiliation(s)
- Olga A Lyubashina
- Laboratory of Cortico-Visceral Physiology, Pavlov Institute of Physiology, Russian Academy of Sciences, Saint Petersburg, Russia.,Valdman Institute of Pharmacology, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - Oleg V Mamontov
- Department of Circulation Physiology, Almazov National Medical Research Centre, Saint Petersburg, Russia.,Faculty of Applied Optics, ITMO University, Saint Petersburg, Russia
| | - Maxim A Volynsky
- Faculty of Applied Optics, ITMO University, Saint Petersburg, Russia
| | - Valeriy V Zaytsev
- Faculty of Applied Optics, ITMO University, Saint Petersburg, Russia
| | | |
Collapse
|
7
|
Neuroprotective Role of the Nrf2 Pathway in Subarachnoid Haemorrhage and Its Therapeutic Potential. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:6218239. [PMID: 31191800 PMCID: PMC6525854 DOI: 10.1155/2019/6218239] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/17/2019] [Accepted: 03/20/2019] [Indexed: 12/11/2022]
Abstract
The mechanisms underlying poor outcome following subarachnoid haemorrhage (SAH) are complex and multifactorial. They include early brain injury, spreading depolarisation, inflammation, oxidative stress, macroscopic cerebral vasospasm, and microcirculatory disturbances. Nrf2 is a global promoter of the antioxidant and anti-inflammatory response and has potential protective effects against all of these mechanisms. It has been shown to be upregulated after SAH, and Nrf2 knockout animals have poorer functional and behavioural outcomes after SAH. There are many agents known to activate the Nrf2 pathway. Of these, the actions of sulforaphane, curcumin, astaxanthin, lycopene, tert-butylhydroquinone, dimethyl fumarate, melatonin, and erythropoietin have been studied in SAH models. This review details the different mechanisms of injury after SAH including the contribution of haemoglobin (Hb) and its breakdown products. It then summarises the evidence that the Nrf2 pathway is active and protective after SAH and finally examines the evidence supporting Nrf2 upregulation as a therapy after SAH.
Collapse
|
8
|
The Acute Phase of Experimental Subarachnoid Hemorrhage: Intracranial Pressure Dynamics and Their Effect on Cerebral Blood Flow and Autoregulation. Transl Stroke Res 2018; 10:566-582. [PMID: 30443885 DOI: 10.1007/s12975-018-0674-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/11/2018] [Accepted: 11/07/2018] [Indexed: 02/07/2023]
Abstract
Clinical presentation and neurological outcome in subarachnoid hemorrhage (SAH) is highly variable. Aneurysmal SAH (aSAH) is hallmarked by sudden increase of intracranial pressure (ICP) and acute hypoperfusion contributing to early brain injury (EBI) and worse outcome, while milder or non-aneurysmal SAH with comparable amount of blood are associated with better neurological outcome, possibly due to less dramatic changes in ICP. Acute pressure dynamics may therefore be an important pathophysiological aspect determining neurological complications and outcome. We investigated the influence of ICP variability on acute changes after SAH by modulating injection velocity and composition in an experimental model of SAH. Five hundred microliters of arterial blood (AB) or normal saline (NS) were injected intracisternally over 1 (AB1, NS1), 10 (AB10, NS10), or 30 min (AB30) with monitoring for 6 h (n = 68). Rapid blood injection resulted in highest ICP peaks (AB1 median 142.7 mmHg [1.Q 116.7-3.Q 230.6], AB30 33.42 mmHg [18.8-38.3], p < 0.001) and most severe hypoperfusion (AB1 16.6% [11.3-30.6], AB30 44.2% [34.8-59.8]; p < 0.05). However, after 30 min, all blood groups showed comparable ICP elevation and prolonged hypoperfusion. Cerebral autoregulation was disrupted initially due to the immediate ICP increase in all groups except NS10; only AB1, however, resulted in sustained impairment of autoregulation, as well as early neuronal cell loss. Rapidity and composition of hemorrhage resulted in characteristic hyperacute hemodynamic changes, with comparable hypoperfusion despite different ICP ranges. Only rapid ICP increase was associated with pronounced and early, but sustained disruption of cerebral autoregulation, possibly contributing to EBI.
Collapse
|
9
|
Hayman EG, Wessell A, Gerzanich V, Sheth KN, Simard JM. Mechanisms of Global Cerebral Edema Formation in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2017; 26:301-310. [PMID: 27995510 DOI: 10.1007/s12028-016-0354-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A growing body of clinical literature emphasizes the impact of cerebral edema in early brain injury following aneurysmal subarachnoid hemorrhage (aSAH). Aneurysm rupture itself initiates global cerebral edema in up to two thirds of cases. Although cerebral edema is not a universal feature of aSAH, it portends a poor clinical course, with quantitative analysis revealing a direct correlation between cerebral edema and poor outcome, including mortality and cognitive deficits. Mechanistically, global cerebral edema has been linked to global ischemia at the time of aneurysm rupture, dysfunction of autoregulation, blood breakdown products, neuroinflammation, and hyponatremia/endocrine abnormalities. At a molecular level, several culprits have been identified, including aquaporin-4, matrix metalloproteinase-9, SUR1-TRPM4 cation channels, vascular endothelial growth factor, bradykinin, and others. Here, we review these cellular and molecular mechanisms of global cerebral edema formation in aSAH. Given the importance of edema to the outcome of patients with aSAH and its status as a highly modifiable pathological process, a better understanding of cerebral edema in aSAH promises to hasten the development of medical therapies to improve outcomes in this frequently devastating disease.
Collapse
Affiliation(s)
- Erik G Hayman
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Aaron Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Kevin N Sheth
- Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA.,Department of Neurosurgery, Yale New Haven Hospital, New Haven, CT, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA. .,Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA. .,Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
10
|
Abstract
Recombinant erythropoietin (EPO) is used to correct for anaemia caused by chronic renal failure or cancer therapy. Improvement of the quality of life of anaemic patients treated with EPO was recently demonstrated and preliminary clinical results suggest an improvement of cognitive functions in patients receiving EPO. High expression of EPO and its receptor in the brain during embryonic development has led to the investigation of not only the neurotrophic role of EPO but also its neuroprotective properties. The neuroprotective effects of EPO have various complementary actions including antagonism of the effects of glutamate, increased expression of antioxidant enzymes, changes in production of neurotransmitters and induction of neuroglobin. Convincing experimental results suggest a blood-brain transport of EPO whereas clinical pharmacokinetic data do not as yet support this. The neuroprotective effects of EPO and its therapeutic promise need to be underlined.
Collapse
Affiliation(s)
- M Milano
- Centre de convalescence du CHU de Nice, Tende, France.
| | | |
Collapse
|
11
|
Grasso G, Tomasello G, Noto M, Alafaci C, Cappello F. Erythropoietin for the Treatment of Subarachnoid Hemorrhage: A Feasible Ingredient for a Successful Medical Recipe. Mol Med 2015; 21:979-987. [PMID: 26581085 DOI: 10.2119/molmed.2015.00177] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/16/2015] [Indexed: 11/06/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) following aneurysm bleeding accounts for 6% to 8% of all cerebrovascular accidents. Although an aneurysm can be effectively managed by surgery or endovascular therapy, delayed cerebral ischemia is diagnosed in a high percentage of patients resulting in significant morbidity and mortality. Cerebral vasospasm occurs in more than half of all patients after aneurysm rupture and is recognized as the leading cause of delayed cerebral ischemia after SAH. Hemodynamic strategies and endovascular procedures may be considered for the treatment of cerebral vasospasm. In recent years, the mechanisms contributing to the development of vasospasm, abnormal reactivity of cerebral arteries and cerebral ischemia following SAH, have been investigated intensively. A number of pathological processes have been identified in the pathogenesis of vasospasm, including endothelial injury, smooth muscle cell contraction from spasmogenic substances produced by the subarachnoid blood clots, changes in vascular responsiveness and inflammatory response of the vascular endothelium. To date, the current therapeutic interventions remain ineffective as they are limited to the manipulation of systemic blood pressure, variation of blood volume and viscosity and control of arterial carbon dioxide tension. In this scenario, the hormone erythropoietin (EPO) has been found to exert neuroprotective action during experimental SAH when its recombinant form (rHuEPO) is administered systemically. However, recent translation of experimental data into clinical trials has suggested an unclear role of recombinant human EPO in the setting of SAH. In this context, the aim of the current review is to present current evidence on the potential role of EPO in cerebrovascular dysfunction following aneurysmal subarachnoid hemorrhage.
Collapse
Affiliation(s)
- Giovanni Grasso
- Neurosurgical Clinic, Department of Experimental Biomedicine and Clinical Neurosciences, Euro-Mediterranean Institute of Science and Technology (IEMEST), Palermo, Italy
| | - Giovanni Tomasello
- Section of Anatomy, Department of Experimental Biomedicine and Clinical Neurosciences, and Euro-Mediterranean Institute of Science and Technology (IEMEST), Palermo, Italy
| | | | - Concetta Alafaci
- Department of Neurosurgery, University of Messina, Messina, Italy
| | - Francesco Cappello
- Section of Anatomy, Department of Experimental Biomedicine and Clinical Neurosciences, and Euro-Mediterranean Institute of Science and Technology (IEMEST), Palermo, Italy
| |
Collapse
|
12
|
Kertmen H, Gürer B, Yilmaz ER, Kanat MA, Arikok AT, Ergüder BI, Hasturk AE, Ergil J, Sekerci Z. Antioxidant and antiapoptotic effects of darbepoetin-α against traumatic brain injury in rats. Arch Med Sci 2015; 11:1119-28. [PMID: 26528358 PMCID: PMC4624756 DOI: 10.5114/aoms.2015.54869] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/14/2013] [Accepted: 10/04/2013] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION In this study, we tried to determine whether darbepoetin-α would protect the brain from oxidative stress and apoptosis in a rat traumatic brain injury model. MATERIAL AND METHODS The animals were randomized into four groups; group 1 (sham), group 2 (trauma), group 3 (darbepoetin α), group 4 (methylprednisolone). In the sham group only the skin incision was performed. In all the other groups, a moderate traumatic brain injury modelwas applied. RESULTS Following trauma both glutathione peroxidase, superoxide dismutase levels decreased (p < 0.001 for both); darbepoetin-α increased the activity of both antioxidant enzymes (p = 0.001 and p < 0.001 respectively). Trauma caused significant elevation in the nitric oxide synthetase and xanthine oxidase levels (p < 0.001 for both). Administration of darbepoetin-α significantly decreased the levels of nitric oxide synthetase and xanthine oxidase (p < 0.001 for both). Also, trauma caused significant elevation in the nitric oxide levels (p < 0.001); darbepoetin-α administration caused statistically significant reduction in the nitric oxide levels (p < 0.001). On the other hand, malondialdehyde levels were increased following trauma (p < 0.001), and darbepoetin α significantly reduced the malondialdehyde levels (p < 0.001). Due to the elevated apoptotic activity following the injury, caspase-3 activity increased significantly. Darbepoetin-α treatment significantly inhibited apoptosis by lowering the caspase-3 activity (p < 0.001). In the darbepoetin group, histopathological score was lower than the trauma group (p = 0.016). CONCLUSIONS In this study, darbepoetin-α was shown to be at least as effective as methylprednisolone in protecting brain from oxidative stress, lipid peroxidation and apoptosis.
Collapse
Affiliation(s)
- Hayri Kertmen
- Ministry of Health, Diskapi Yildirim Beyazit Education and Research Hospital, Neurosurgery Clinic, Ankara, Turkey
| | - Bora Gürer
- Ministry of Health, Diskapi Yildirim Beyazit Education and Research Hospital, Neurosurgery Clinic, Ankara, Turkey
| | - Erdal Resit Yilmaz
- Ministry of Health, Diskapi Yildirim Beyazit Education and Research Hospital, Neurosurgery Clinic, Ankara, Turkey
| | - Mehmet Ali Kanat
- Ministry of Health, Refik Saydam National Public Health Agency, Ankara, Turkey
| | - Ata Türker Arikok
- Department of Pathology, Ministry of Health, Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey
| | | | - Askin Esen Hasturk
- Department of Neurosurgery, Ministry of Health, Oncology Training and Research Hospital, Ankara, Turkey
| | - Julide Ergil
- Department of Anesthesiology, Ministry of Health, Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey
| | - Zeki Sekerci
- Ministry of Health, Diskapi Yildirim Beyazit Education and Research Hospital, Neurosurgery Clinic, Ankara, Turkey
| |
Collapse
|
13
|
Donnelly J, Aries MJ, Czosnyka M. Further understanding of cerebral autoregulation at the bedside: possible implications for future therapy. Expert Rev Neurother 2015; 15:169-85. [PMID: 25614952 DOI: 10.1586/14737175.2015.996552] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cerebral autoregulation reflects the ability of the brain to keep the cerebral blood flow (CBF) relatively constant despite changes in cerebral perfusion pressure. It is an intrinsic neuroprotective physiological phenomenon often suggested as part of pathophysiological pathways in brain research. However, despite increasing knowledge of this phenomenon for over 50 years, harnessing cerebral autoregulation as a basis for therapy remains an elegant concept rather than a practical reality. This raises the question is it useful to measure at the bedside or is it merely a scientific curiosity that is too complex and has little pragmatic relevance. In this article, we attempt to answer this question by demonstrating how cerebral autoregulation assessment can have prognostic value, indicate pathological states, and potentially even influence therapy with the use of the 'optimal cerebral perfusion pressure' paradigm. Evidence from the literature is combined with bedside clinical examples to address the following fundamental questions about cerebral autoregulation: What is it? How do we measure it? Why is it important? Can we use it as a basis for therapy?
Collapse
Affiliation(s)
- Joseph Donnelly
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK
| | | | | |
Collapse
|
14
|
The Role of Erythropoietin in Aneurysmal Subarachnoid Haemorrhage: From Bench to Bedside. ACTA NEUROCHIRURGICA SUPPLEMENT 2015; 120:75-80. [DOI: 10.1007/978-3-319-04981-6_13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
|
15
|
Lund A, Lundby C, Olsen NV. High-dose erythropoietin for tissue protection. Eur J Clin Invest 2014; 44:1230-8. [PMID: 25345962 DOI: 10.1111/eci.12357] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 10/20/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND The discovery of potential anti-apoptotic and cytoprotective effects of recombinant human erythropoietin (rHuEPO) has led to clinical trials investigating the use of high-dose, short-term rHuEPO therapy for tissue protection in conditions such as stroke and myocardial infarction. Experimental studies have been favourable, but the clinical efficacy has yet to be validated. MATERIALS AND METHODS We have reviewed clinical studies regarding the use of high-dose, short-term rHuEPO therapy for tissue protection in humans with the purpose to detail the safety and efficacy of rHuEPO for this indication. A systematic literature search was performed using the PubMed/MEDLINE database for randomized, placebo-controlled clinical trials. RESULTS Twenty-six randomized controlled trials that enrolled 3176 patients were included. The majority of trials (20 trials including 2724 patients) reported no effect of rHuEPO therapy on measures of tissue protection. Five trials including 1025 patients reported safety concerns in the form of increased mortality or adverse event rates. No studies reported reduced mortality. CONCLUSIONS Evidence is sparse to support a tissue-protective benefit of rHuEPO in humans. Moreover, a number of studies indicate that short-term administration of high-dose rHuEPO is associated with an increased risk of mortality and serious adverse events. Further work is needed to elucidate the mechanisms of toxicity of rHuEPO in humans.
Collapse
Affiliation(s)
- Anton Lund
- Department of Neuroscience and Pharmacology, The Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | | |
Collapse
|
16
|
Budohoski KP, Guilfoyle M, Helmy A, Huuskonen T, Czosnyka M, Kirollos R, Menon DK, Pickard JD, Kirkpatrick PJ. The pathophysiology and treatment of delayed cerebral ischaemia following subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2014; 85:1343-53. [PMID: 24847164 DOI: 10.1136/jnnp-2014-307711] [Citation(s) in RCA: 183] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Cerebral vasospasm has traditionally been regarded as an important cause of delayed cerebral ischaemia (DCI) which occurs after aneurysmal subarachnoid haemorrhage, and often leads to cerebral infarction and poor neurological outcome. However, data from recent studies argue against a pure focus on vasospasm as the cause of delayed ischaemic complications. Findings that marked reduction in the incidence of vasospasm does not translate to a reduction in DCI, or better outcomes has intensified research into other possible mechanisms which may promote ischaemic complications. Early brain injury and cell death, blood-brain barrier disruption and initiation of an inflammatory cascade, microvascular spasm, microthrombosis, cortical spreading depolarisations and failure of cerebral autoregulation, have all been implicated in the pathophysiology of DCI. This review summarises the current knowledge about the mechanisms underlying the development of DCI. Furthermore, it aims to describe and categorise the known pharmacological treatment options with respect to the presumed mechanism of action and its role in DCI.
Collapse
Affiliation(s)
- Karol P Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Mathew Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Terhi Huuskonen
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK Department of Neurosurgery, Kuopio Neurocenter, Kuopio University Hospital, Kuopio, Finland
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Ramez Kirollos
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - David K Menon
- Department of Anaesthesiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - John D Pickard
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter J Kirkpatrick
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| |
Collapse
|
17
|
Kertmen H, Gürer B, Yilmaz ER, Arikok AT, Kanat MA, Ergüder BI, Sekerci Z. The comparative effects of recombinant human erythropoietin and darbepoetin-alpha on cerebral vasospasm following experimental subarachnoid hemorrhage in the rabbit. Acta Neurochir (Wien) 2014; 156:951-62. [PMID: 24497025 DOI: 10.1007/s00701-014-2008-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/18/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND Darbepoetin alpha is a hypersialylated analogue of erythropoietin effective for activating erythropoietin-receptors. This study investigated the vasodilator and neuroprotective effects of darbepoetin alpha on an experimental subarachnoid hemorrhage model and compared it with erythropoietin. METHODS Forty adult male New Zealand white rabbits were randomly divided into four groups of ten rabbits each: group 1 (control), group 2 (subarachnoid hemorrhage), group 3 (erythropoietin), and group 4 (darbepoetin alpha). Recombinant human erythropoietin was administered at a dose of 1,000 U/kg intraperitoneally after the induction of subarachnoid hemorrhage and continued every 8 h up to 72 h. Darbepoetin alpha was administered at a single intraperitoneal dose of 30 μg/kg. Animals were killed 72 h after subarachnoid hemorrhage. Basilar artery cross-sectional areas, arterial wall thicknesses, hippocampal degeneration scores and biochemical analyses were measured in all groups. RESULTS Both erythropoietin and darbepoetin alpha treatments were found to attenuate cerebral vasospasm and provide neuroprotection after subarachnoid hemorrhage in rabbits. Darbepoetin alpha revealed better morphometric and histopathological results than erythropoietin among experimental subarachnoid hemorrhage-induced vasospasm. CONCLUSIONS Our findings, for the first time, showed that darbepoetin alpha can prevent vasospasm and provides neuroprotection following experimental subarachnoid hemorrhage. Moreover, darbepoetin alpha showed better results when compared with erythropoietin.
Collapse
Affiliation(s)
- Hayri Kertmen
- Neurosurgery Clinic, Ministry of Health, Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey
| | | | | | | | | | | | | |
Collapse
|
18
|
Erythropoietin improves motor and cognitive deficit, axonal pathology, and neuroinflammation in a combined model of diffuse traumatic brain injury and hypoxia, in association with upregulation of the erythropoietin receptor. J Neuroinflammation 2013; 10:156. [PMID: 24344874 PMCID: PMC3896698 DOI: 10.1186/1742-2094-10-156] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 12/05/2013] [Indexed: 01/12/2023] Open
Abstract
Background Diffuse axonal injury is a common consequence of traumatic brain injury (TBI) and often co-occurs with hypoxia, resulting in poor neurological outcome for which there is no current therapy. Here, we investigate the ability of the multifunctional compound erythropoietin (EPO) to provide neuroprotection when administered to rats after diffuse TBI alone or with post-traumatic hypoxia. Methods Sprague–Dawley rats were subjected to diffuse traumatic axonal injury (TAI) followed by 30 minutes of hypoxic (Hx, 12% O2) or normoxic ventilation, and were administered recombinant human EPO-α (5000 IU/kg) or saline at 1 and 24 hours post-injury. The parameters examined included: 1) behavioural and cognitive deficit using the Rotarod, open field and novel object recognition tests; 2) axonal pathology (NF-200); 3) callosal degradation (hematoxylin and eosin stain); 3) dendritic loss (MAP2); 4) expression and localisation of the EPO receptor (EpoR); 5) activation/infiltration of microglia/macrophages (CD68) and production of IL-1β. Results EPO significantly improved sensorimotor and cognitive recovery when administered to TAI rats with hypoxia (TAI + Hx). A single dose of EPO at 1 hour reduced axonal damage in the white matter of TAI + Hx rats at 1 day by 60% compared to vehicle. MAP2 was decreased in the lateral septal nucleus of TAI + Hx rats; however, EPO prevented this loss, and maintained MAP2 density over time. EPO administration elicited an early enhanced expression of EpoR 1 day after TAI + Hx compared with a 7-day peak in vehicle controls. Furthermore, EPO reduced IL-1β to sham levels 2 hours after TAI + Hx, concomitant to a decrease in CD68 positive cells at 7 and 14 days. Conclusions When administered EPO, TAI + Hx rats had improved behavioural and cognitive performance, attenuated white matter damage, resolution of neuronal damage spanning from the axon to the dendrite, and suppressed neuroinflammation, alongside enhanced expression of EpoR. These data provide compelling evidence of EPO’s neuroprotective capability. Few benefits were observed when EPO was administered to TAI rats without hypoxia, indicating that EPO’s neuroprotective capacity is bolstered under hypoxic conditions, which may be an important consideration when EPO is employed for neuroprotection in the clinic.
Collapse
|
19
|
Brathwaite S, Macdonald RL. Current management of delayed cerebral ischemia: update from results of recent clinical trials. Transl Stroke Res 2013; 5:207-26. [PMID: 24338266 DOI: 10.1007/s12975-013-0316-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 11/23/2013] [Accepted: 11/29/2013] [Indexed: 01/19/2023]
Abstract
Subarachnoid hemorrhage (SAH) accounts for 5-7% of all strokes worldwide and is associated with high mortality and morbidity. Even after surgical intervention, approximately 30% of patients develop long-term cognitive and neurological deficits that significantly affect their capacity to return to work or daily life unassisted. Much of this stems from a secondary ischemic phenomenon referred to as delayed cerebral ischemia (DCI). While DCI has been historically attributed to the narrowing of the large basal cerebral arteries, it is now recognized that numerous pathways contribute to its pathogenesis, including microcirculatory dysfunction, microthrombosis, cortical spreading depression, and early brain injury. This paper seeks to summarize some of the key pathophysiological events that are associated with poor outcome after SAH, provide a general overview of current methods of treating SAH patients, and review the results of recent clinical trials directed at improving outcome after SAH. The scientific basis of these studies will be discussed, in addition to the available results and recommendations for effective patient management. Therapeutic methods under current clinical investigation will also be addressed. In particular, the mechanisms by which they are expected to elicit improved outcome will be investigated, as well as the specific study designs and anticipated time lines for completion.
Collapse
Affiliation(s)
- Shakira Brathwaite
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, Canada, M5B 1W8
| | | |
Collapse
|
20
|
Abstract
Subarachnoid haemorrhage (SAH) causes early brain injury (EBI) that is mediated by effects of transient cerebral ischaemia during bleeding plus effects of the subarachnoid blood. Secondary effects of SAH include increased intracranial pressure, destruction of brain tissue by intracerebral haemorrhage, brain shift, and herniation, all of which contribute to pathology. Many patients survive these phenomena, but deteriorate days later from delayed cerebral ischaemia (DCI), which causes poor outcome or death in up to 30% of patients with SAH. DCI is thought to be caused by the combined effects of angiographic vasospasm, arteriolar constriction and thrombosis, cortical spreading ischaemia, and processes triggered by EBI. Treatment for DCI includes prophylactic administration of nimodipine, and current neurointensive care. Prompt recognition of DCI and immediate treatment by means of induced hypertension and balloon or pharmacological angioplasty are considered important by many physicians, although the evidence to support such approaches is limited. This Review summarizes the pathophysiology of DCI after SAH and discusses established treatments for this condition. Novel strategies--including drugs such as statins, sodium nitrite, albumin, dantrolene, cilostazol, and intracranial delivery of nimodipine or magnesium--are also discussed.
Collapse
|
21
|
Güresir E, Vasiliadis N, Konczalla J, Raab P, Hattingen E, Seifert V, Vatter H. Erythropoietin prevents delayed hemodynamic dysfunction after subarachnoid hemorrhage in a randomized controlled experimental setting. J Neurol Sci 2013; 332:128-35. [DOI: 10.1016/j.jns.2013.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 06/30/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022]
|
22
|
Abstract
OPINION STATEMENT Erythropoietin (EPO) is an approved drug that is used in the treatment of chronic anemia associated with chronic renal failure. In the Neuro ICU, there are 2 potential uses for treatment with EPO. Anemia is common in patients with acute neurological disorders and may be a cause of secondary insults. Studies of EPO to treat anemia associated with critical illness have not conclusively shown a beneficial risk/benefit ratio. The relatively small reduction in transfusion requirement with EPO in critically ill patients is likely due to the 7-10 days required to see an effect of EPO on hematocrit. For these reasons, EPO is not recommended to treat anemia of critical illness. Neuroprotection is the other potential use for EPO in the Neuro ICU. Many experimental studies demonstrate neuroprotective effects with EPO in a variety of acute neurological disorders. To date, no clinical studies have confirmed beneficial effects of EPO on neurological outcome although some studies have suggested a reduction in mortality rate in trauma patients treated with EPO. Additional clinical studies are needed before EPO administration can be recommended for cytoprotection in neurological disorders.
Collapse
Affiliation(s)
- Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA,
| | | |
Collapse
|
23
|
Yu Z, Sun Q, Han S, Lu J, Ohlsson A, Guo X. Erythropoietin for preterm infants with hypoxic ischaemic encephalopathy. Hippokratia 2012. [DOI: 10.1002/14651858.cd010272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Zhangbin Yu
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Qing Sun
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Shuping Han
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Junjie Lu
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Arne Ohlsson
- University of Toronto; Departments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation; 600 University Avenue Toronto Ontario Canada M5G 1X5
| | - Xirong Guo
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| |
Collapse
|
24
|
Helbok R, Shaker E, Beer R, Chemelli A, Sojer M, Sohm F, Broessner G, Lackner P, Beck M, Zangerle A, Pfausler B, Thome C, Schmutzhard E. High dose erythropoietin increases brain tissue oxygen tension in severe vasospasm after subarachnoid hemorrhage. BMC Neurol 2012; 12:32. [PMID: 22672319 PMCID: PMC3502085 DOI: 10.1186/1471-2377-12-32] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 05/17/2012] [Indexed: 01/09/2023] Open
Abstract
Background Vasospasm-related delayed cerebral ischemia (DCI) significantly impacts on outcome after aneurysmal subarachnoid hemorrhage (SAH). Erythropoietin (EPO) may reduce the severity of cerebral vasospasm and improve outcome, however, underlying mechanisms are incompletely understood. In this study, the authors aimed to investigate the effect of EPO on cerebral metabolism and brain tissue oxygen tension (PbtO2). Methods Seven consecutive poor grade SAH patients with multimodal neuromonitoring (MM) received systemic EPO therapy (30.000 IU per day for 3 consecutive days) for severe cerebral vasospasm. Cerebral perfusion pressure (CPP), mean arterial blood pressure (MAP), intracranial pressure (ICP), PbtO2 and brain metabolic changes were analyzed during the next 24 hours after each dose given. Statistical analysis was performed with a mixed effects model. Results A total of 22 interventions were analyzed. Median age was 47 years (32–68) and 86 % were female. Three patients (38 %) developed DCI. MAP decreased 2 hours after intervention (P < 0.04) without significantly affecting CPP and ICP. PbtO2 significantly increased over time (P < 0.05) to a maximum of 7 ± 4 mmHg increase 16 hours after infusion. Brain metabolic parameters did not change over time. Conclusions EPO increases PbtO2 in poor grade SAH patients with severe cerebral vasospasm. The effect on outcome needs further investigation.
Collapse
Affiliation(s)
- Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
How Large Is the Typical Subarachnoid Hemorrhage? A Review of Current Neurosurgical Knowledge. World Neurosurg 2012; 77:686-97. [DOI: 10.1016/j.wneu.2011.02.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 02/07/2011] [Accepted: 02/12/2011] [Indexed: 11/22/2022]
|
26
|
Barry C, Turner RJ, Corrigan F, Vink R. New therapeutic approaches to subarachnoid hemorrhage. Expert Opin Investig Drugs 2012; 21:845-59. [DOI: 10.1517/13543784.2012.683113] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
27
|
Chalkias A, Xanthos T. Post-cardiac arrest brain injury: pathophysiology and treatment. J Neurol Sci 2012; 315:1-8. [PMID: 22251931 DOI: 10.1016/j.jns.2011.12.007] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 12/15/2011] [Accepted: 12/19/2011] [Indexed: 12/31/2022]
Abstract
Cardiac arrest is a leading cause of death that affects more than a million individuals worldwide every year. Despite the recent advancement in the field of cardiac arrest and resuscitation, the management and prognosis of post-cardiac arrest brain injury remain suboptimal. The pathophysiology of post-cardiac arrest brain injury involves a complex cascade of molecular events, most of which remain unknown. Considering that a potentially broad therapeutic window for neuroprotective drug therapy is offered in most successfully resuscitated patient after cardiac arrest, the need for further research is imperative. The aim of this article is to present the major pathophysiological disturbances leading to post-cardiac arrest brain injury, as well as to review the available pharmacological therapies.
Collapse
Affiliation(s)
- Athanasios Chalkias
- National and Kapodistrian University of Athens, Medical School, Department of Anatomy, Greece.
| | | |
Collapse
|
28
|
Grasso G, Tomasello F. Erythropoietin for subarachnoid hemorrhage: is there a reason for hope? World Neurosurg 2011; 77:46-8. [PMID: 22079816 DOI: 10.1016/j.wneu.2011.01.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 01/13/2011] [Accepted: 01/19/2011] [Indexed: 11/27/2022]
|
29
|
Robertson CS, Cherian L, Shah M, Garcia R, Navarro JC, Grill RJ, Hand CC, Tian TS, Hannay HJ. Neuroprotection with an erythropoietin mimetic peptide (pHBSP) in a model of mild traumatic brain injury complicated by hemorrhagic shock. J Neurotrauma 2011; 29:1156-66. [PMID: 21545288 DOI: 10.1089/neu.2011.1827] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pyroglutamate helix B surface peptide (pHBSP) is an 11 amino acid peptide, designed to interact with a novel cell surface receptor, composed of the classical erythropoietin (EPO) receptor disulfide linked to the beta common receptor. pHBSP has the cytoprotective effects of EPO without stimulating erythropoiesis. Effects on early cerebral hemodynamics and neurological outcome at 2 weeks post-injury were compared in a rat model of mild cortical impact injury (3m/sec, 2.5 mm deformation) followed by 50 min of hemorrhagic hypotension (MAP 40 mm Hg for 50 min). Rats were randomly assigned to receive 5000 U/kg of EPO, 30 μg/kg of pHBSP, or an inactive substance every 12 h for 3 days, starting at the end of resuscitation from the hemorrhagic hypotension, which was 110 min post-injury. Both treatments reduced contusion volume at 2 weeks post-injury, from 20.8±2.8 mm(3) in the control groups to 7.7±2.0 mm(3) in the EPO-treated group and 5.9±1.5 mm(3) in the pHBSP-treated group (p=0.001). Both agents improved recovery of cerebral blood flow in the injured brain following resuscitation, and resulted in more rapid recovery of performance on beam balancing and beam walking tests. These studies suggest that pHBSP has neuroprotective effects similar to EPO in this model of combined brain injury and hypotension. pHBSP may be more useful in the clinical situation because there is less risk of thrombotic adverse effects.
Collapse
Affiliation(s)
- Claudia S Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas 77030, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Sargin D, Friedrichs H, El-Kordi A, Ehrenreich H. Erythropoietin as neuroprotective and neuroregenerative treatment strategy: comprehensive overview of 12 years of preclinical and clinical research. Best Pract Res Clin Anaesthesiol 2010; 24:573-94. [PMID: 21619868 DOI: 10.1016/j.bpa.2010.10.005] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 10/11/2010] [Indexed: 12/13/2022]
Abstract
Erythropoietin (EPO), originally discovered as hematopoietic growth factor, has direct effects on cells of the nervous system that make it a highly attractive candidate drug for neuroprotection/neuroregeneration. Hardly any other compound has led to so much preclinical work in the field of translational neuroscience than EPO. Almost all of the >180 preclinical studies performed by many independent research groups from all over the world in the last 12 years have yielded positive results on EPO as a neuroprotective drug. The fact that EPO was approved for the treatment of anemia >20 years ago and found to be well tolerated and safe, facilitated the first steps of translation from preclinical findings to the clinic. On the other hand, the same fact, naturally associated with loss of patent protection, hindered to develop EPO as a highly promising therapeutic strategy for application in human brain disease. Therefore, only few clinical neuroprotection studies have been concluded, all with essentially positive and stimulating results, but no further development towards the clinic has occurred thus far. This article reviews the preclinical and clinical work on EPO for the indications neuroprotection/neuroregeneration and cognition, and hopefully will stimulate new endeavours promoting development of EPO for the treatment of human brain diseases.
Collapse
Affiliation(s)
- Derya Sargin
- Division of Clinical Neuroscience, Max Planck Institute of Experimental Medicine, Hermann-Rein Str. 3, 37075 Göttingen, Germany
| | | | | | | |
Collapse
|
31
|
Velly L, Pellegrini L, Guillet B, Bruder N, Pisano P. Erythropoietin 2nd cerebral protection after acute injuries: a double-edged sword? Pharmacol Ther 2010; 128:445-59. [PMID: 20732352 DOI: 10.1016/j.pharmthera.2010.08.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 08/02/2010] [Indexed: 12/20/2022]
Abstract
Over the past 15 years, a large body of evidence has revealed that the cytokine erythropoietin exhibits non-erythropoietic functions, especially tissue-protective effects. The discovery of EPO and its receptors in the central nervous system and the evidence that EPO is made locally in response to injury as a protective factor in the brain have raised the possibility that recombinant human EPO (rhEPO) could be administered as a cytoprotective agent after acute brain injuries. This review highlights the potential applications of rhEPO as a neuroprotectant in experimental and clinical settings such as ischemia, traumatic brain injury, and subarachnoid and intracerebral hemorrhage. In preclinical studies, EPO prevented apoptosis, inflammation, and oxidative stress induced by injury and exhibited strong neuroprotective and neurorestorative properties. EPO stimulates vascular repair by facilitating endothelial progenitor cell migration into the brain and neovascularisation, and it promotes neurogenesis. In humans, small clinical trials have shown promising results but large prospective randomized studies failed to demonstrate a benefit of EPO for brain protection and showed unwanted side effects, especially thrombotic complications. Recently, regions have been identified within the EPO molecule that mediate tissue protection, allowing the development of non-erythropoietic EPO variants for neuroprotection conceptually devoid of side effects. The efficacy and the safety profile of these new compounds are still to be demonstrated to obtain, in patients, the benefits observed in experimental studies.
Collapse
Affiliation(s)
- L Velly
- Laboratoire de Pharmacologie, INSERM UMR 608, Université de la Méditerranée, Faculté de Pharmacie, Marseille, France
| | | | | | | | | |
Collapse
|
32
|
Turner JD, Mammis A, Prestigiacomo CJ. Erythropoietin for the Treatment of Subarachnoid Hemorrhage: A Review. World Neurosurg 2010; 73:500-7. [DOI: 10.1016/j.wneu.2010.02.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 02/10/2010] [Indexed: 12/20/2022]
|
33
|
|
34
|
Grasso G, Graziano F, Sfacteria A, Carletti F, Meli F, Maugeri R, Passalacqua M, Certo F, Fazio M, Buemi M, Iacopino DG. Neuroprotective effect of erythropoietin and darbepoetin alfa after experimental intracerebral hemorrhage. Neurosurgery 2010; 65:763-9; discussion 769-70. [PMID: 19834382 DOI: 10.1227/01.neu.0000347475.73347.5f] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Intracerebral hemorrhage (ICH) is a devastating clinical syndrome for which no truly efficacious therapy has yet been identified. In preclinical studies, erythropoietin (EPO) and its long-lasting analog, darbepoetin alfa, have been demonstrated to be neuroprotective in several models of neuronal insult. The objectives of this study were to analyze whether the systemic administration of recombinant human EPO (rHuEPO) and its long-lasting derivative darbepoetin alfa expedited functional recovery and brain damage in a rat model of ICH. METHODS Experimental ICH was induced in rats by injecting autologous blood into the right striatum under stereotactic guidance. Subsequently, animals underwent placebo treatment, daily injections of rHuEPO, or weekly injections of darbepoetin alfa. Animals were killed 14 days after injury. RESULTS Both rHuEPO and darbepoetin alfa were effective in reducing neurological impairment after injury, as assessed by the neurological tasks performed. rHuEPO- and darbepoetin alfa-treated animals exhibited a restricted brain injury with nearly normal parenchymal architecture. In contrast, the saline-treated group exhibited extensive cerebral cytoarchitectural disruption and edema. The number of surviving NeuN-positive neurons was significantly higher in the rats treated with rHuEPO and darbepoetin alfa compared with those that received saline (P < 0.05). CONCLUSION These results demonstrate that weekly administered darbepoetin alfa confers behavioral and histological neuroprotection after ICH in rats similar to that of daily EPO administration. Administration of EPO and its long-lasting recombinant forms affords significant neuroprotection in an ICH model and may hold promise for future clinical applications.
Collapse
Affiliation(s)
- Giovanni Grasso
- Neurosurgical Clinic, Department of Clinical Neurosciences, University of Palermo, Palermo, Italy.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Yu Z, Guo X, Han S, Lu J, Sun Q. Erythropoietin for term and late preterm infants with hypoxic ischemic encephalopathy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008316] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Zhangbin Yu
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Xirong Guo
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Shuping Han
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Junjie Lu
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| | - Qing Sun
- Nanjing Maternal and Child Health Hospital of Nanjing Medical University; Department of Pediatrics, Section of Neonatology; No. 123 Tian Fei Xiang Mo Chou Road Nanjing China 210004
| |
Collapse
|
36
|
Byts N, Sirén AL. Erythropoietin: a multimodal neuroprotective agent. EXPERIMENTAL & TRANSLATIONAL STROKE MEDICINE 2009; 1:4. [PMID: 20142991 PMCID: PMC2816866 DOI: 10.1186/2040-7378-1-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Accepted: 10/21/2009] [Indexed: 05/28/2023]
Abstract
The tissue protective functions of the hematopoietic growth factor erythropoietin (EPO) are independent of its action on erythropoiesis. EPO and its receptors (EPOR) are expressed in multiple brain cells during brain development and upregulated in the adult brain after injury. Peripherally administered EPO crosses the blood-brain barrier and activates in the brain anti-apoptotic, anti-oxidant and anti-inflammatory signaling in neurons, glial and cerebrovascular endothelial cells and stimulates angiogenesis and neurogenesis. These mechanisms underlie its potent tissue protective effects in experimental models of stroke, cerebral hemorrhage, traumatic brain injury, neuroinflammatory and neurodegenerative disease. The preclinical data in support of the use of EPO in brain disease have already been translated to first clinical pilot studies with encouraging results with the use of EPO as a neuroprotective agent.
Collapse
Affiliation(s)
- Nadiya Byts
- University of Würzburg, Department of Neurosurgery, Würzburg, Germany
| | - Anna-Leena Sirén
- University of Würzburg, Department of Neurosurgery, Würzburg, Germany
| |
Collapse
|
37
|
Tseng MY, Hutchinson PJ, Richards HK, Czosnyka M, Pickard JD, Erber WN, Brown S, Kirkpatrick PJ. Acute systemic erythropoietin therapy to reduce delayed ischemic deficits following aneurysmal subarachnoid hemorrhage: a Phase II randomized, double-blind, placebo-controlled trial. J Neurosurg 2009; 111:171-80. [DOI: 10.3171/2009.3.jns081332] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Delayed ischemic deficits (DIDs), a major source of disability following aneurysmal subarachnoid hemorrhage (aSAH), are usually associated with severe cerebral vasospasm and impaired autoregulation. Systemic erythropoietin (EPO) therapy has been demonstrated to have neuroprotective properties acting via EPO receptors on cerebrovascular endothelia and ischemic neurons. In this trial, the authors explored the potential neuroprotective effects of acute EPO therapy following aSAH.
Methods
Within 72 hours of aSAH, 80 patients (age range 24–82 years) were randomized to receive intravenous EPO (30,000 U) or placebo every 48 hours for a total of 90,000 U. Primary end points were the incidence, duration, and severity of vasospasm and impaired autoregulation on transcranial Doppler ultrasonography. Secondary end points were incidence of DIDs and outcome at discharge and at 6 months.
Results
Randomization characteristics were balanced except for age, with the EPO group being older (mean age 59.6 vs 53.3 years, p = 0.034). No differences were demonstrated in the incidence of vasospasm and adverse events; however, patients receiving EPO had a decreased incidence of severe vasospasm from 27.5 to 7.5% (p = 0.037), reduced DIDs with new cerebral infarcts from 40.0 to 7.5% (p = 0.001), a shortened duration of impaired autoregulation (ipsilateral side, p < 0.001), and more favorable outcome at discharge (favorable Glasgow Outcome Scale score, p = 0.039). Among the 71 survivors, the EPO group had fewer deficits measured with National Institutes of Health Stroke Scale (median Score 2 vs 6, p = 0.008).
Conclusions
This preliminary study showed that EPO seemed to reduce delayed cerebral ischemia following aSAH via decreasing severity of vasospasm and shortening impaired autoregulation.
Collapse
Affiliation(s)
| | | | | | | | | | - Wendy N. Erber
- 2Hematology, Addenbrooke's Hospital, University of Cambridge, United Kingdom
| | - Stephen Brown
- 2Hematology, Addenbrooke's Hospital, University of Cambridge, United Kingdom
| | | |
Collapse
|
38
|
Margulies S, Hicks R. Combination therapies for traumatic brain injury: prospective considerations. J Neurotrauma 2009; 26:925-39. [PMID: 19331514 PMCID: PMC2857809 DOI: 10.1089/neu.2008.0794] [Citation(s) in RCA: 193] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Traumatic brain injury (TBI) initiates a cascade of numerous pathophysiological events that evolve over time.Despite the complexity of TBI, research aimed at therapy development has almost exclusively focused on single therapies, all of which have failed in multicenter clinical trials. Therefore, in February 2008 the National Institute of Neurological Disorders and Stroke, with support from the National Institute of Child Health and Development, the National Heart, Lung, and Blood Institute, and the Department of Veterans Affairs, convened a workshop to discuss the opportunities and challenges of testing combination therapies for TBI. Workshop participants included clinicians and scientists from a variety of disciplines, institutions, and agencies. The objectives of the workshop were to: (1) identify the most promising combinations of therapies for TBI; (2) identify challenges of testing combination therapies in clinical and pre-clinical studies; and (3) propose research methodologies and study designs to overcome these challenges. Several promising combination therapies were discussed, but no one combination was identified as being the most promising. Rather, the general recommendation was to combine agents with complementary targets and effects (e.g., mechanisms and time-points), rather than focusing on a single target with multiple agents. In addition, it was recommended that clinical management guidelines be carefully considered when designing pre-clinical studies for therapeutic development.To overcome the challenges of testing combination therapies it was recommended that statisticians and the U.S. Food and Drug Administration be included in early discussions of experimental design. Furthermore, it was agreed that an efficient and validated screening platform for candidate therapeutics, sensitive and clinically relevant biomarkers and outcome measures, and standardization and data sharing across centers would greatly facilitate the development of successful combination therapies for TBI. Overall there was great enthusiasm for working collaboratively to act on these recommendations.
Collapse
Affiliation(s)
- Susan Margulies
- School of Engineering and Applied Science, Department of Bioengineering, University of Pennsylvania, 210 S. 33rd Street, Philadelphia, PA 19104-6321, USA.
| | | |
Collapse
|
39
|
Chen G, Zhang S, Shi J, Ai J, Hang C. Effects of recombinant human erythropoietin (rhEPO) on JAK2/STAT3 pathway and endothelial apoptosis in the rabbit basilar artery after subarachnoid hemorrhage. Cytokine 2009; 45:162-8. [PMID: 19144539 DOI: 10.1016/j.cyto.2008.11.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Revised: 11/15/2008] [Accepted: 11/29/2008] [Indexed: 01/19/2023]
Abstract
Previous studies have shown that recombinant human erythropoietin (rhEPO) can attenuate the degree of cerebral vasospasm following experimental subarachnoid hemorrhage (SAH). However, the mechanisms for this beneficial effect are still poorly understood. SAH-induced endothelial apoptosis may trigger, aggravate, and maintain cerebral vasospasm. We, therefore, tried to analyze whether rhEPO administration influenced the endothelial cell apoptosis in the basilar artery after SAH. Another aim of the current study was to investigate the modulation of rhEPO on the activity of Janus kinase 2 (JAK2) and signal transducer and activator of transcription 3 (STAT3), which played an important role in the signaling of apoptosis. A total of 48 rabbits were randomly divided into four groups; control group, SAH group, SAH+vehicle group, and SAH+rhEPO group. All SAH animals were subjected to injection of autologous blood into cisterna magna twice on day 0 and day 2. The rhEPO was administered i.p. starting 5 min after the induction of SAH on day 0 and repeated every 8 h for 120 h. The basilar arteries were extracted on day 5 after SAH. As a result, we found that administration of rhEPO could activate JAK2 and STAT3 in the basilar artery and decrease the apoptosis index of endothelial cells following SAH. Moreover, the anti-apoptotic genes such as bcl-2 and bcl-xL were up-regulated after the injections of rhEPO. In conclusion, the therapeutic effect of rhEPO on the subsequent vasospasm after SAH may relate to its inhibition on the endothelial apoptosis in the cerebral arteries, which may be mediated in part by JAK2/STAT3 signaling pathway.
Collapse
Affiliation(s)
- Gang Chen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, China.
| | | | | | | | | |
Collapse
|
40
|
Murphy AM, Xenocostas A, Pakkiri P, Lee TY. Hemodynamic effects of recombinant human erythropoietin on the central nervous system after subarachnoid hemorrhage: reduction of microcirculatory impairment and functional deficits in a rabbit model. J Neurosurg 2009; 109:1155-64. [PMID: 19035736 DOI: 10.3171/jns.2008.109.12.1155] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors investigated the hemodynamic effects of recombinant human erythropoietin (rhEPO) after subarachnoid hemorrhage (SAH) in rabbits. METHODS The authors used male New Zealand White rabbits in this study divided into the following groups: SAH plus saline (16 rabbits), SAH plus low-dose rhEPO (16 rabbits; 1500 IU/kg on Day 0 and 500 IU/kg on Days 2 and 4), SAH plus high-dose rhEPO (10 rabbits; 1500 IU/kg on Days 0, 2, 4, and 6), and sham (6 rabbits). Computed tomography perfusion studies and CT angiography were performed for 1 hour after SAH on Day 0, and once each on Days 2, 4, 7, 9, and 16 after SAH. Assessments of neurological function and tissue histology were also performed. RESULTS The mortality rate was significantly lower after rhEPO treatment (12%) than after saline treatment (44%) (p < 0.05). Neurological outcomes in the low-dose and high-dose rhEPO groups were better than in the saline group after SAH (p < 0.05), and the cerebral blood flow in the high-dose rhEPO group was greater than that in the saline group (p < 0.05). The mean transit time was significantly lower on Days 2 and 4 in the low-dose and high-dose rhEPO groups than in the saline group, but increased significantly on Day 7 in both groups (p < 0.05). The hematocrit increased significantly from baseline values in the high-dose and low-dose rhEPO groups on Days 4 and 7, respectively (p < 0.05). CONCLUSIONS Treatment with rhEPO after experimental SAH is associated with improved cerebral blood flow and microcirculatory flow as reflected by lower mean transit times. Improved tissue perfusion correlated with reduced mortality and improved neurological outcomes. Further investigation of the impact of increasing hematocrit on hemodynamic changes is needed.
Collapse
Affiliation(s)
- Amanda M Murphy
- Imaging Program, Lawson Health Research Institute, London, Ontario, Canada
| | | | | | | |
Collapse
|
41
|
Hartley CE, Varma M, Fischer JP, Riccardi R, Strauss JA, Shah S, Zhang S, Yang ZJ. Neuroprotective effects of erythropoietin on acute metabolic and pathological changes in experimentally induced neurotrauma. J Neurosurg 2008; 109:708-14. [PMID: 18826359 DOI: 10.3171/jns/2008/109/10/0708] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Head trauma is a dynamic process characterized by a cascade of metabolic and molecular events. Erythropoietin (EPO) has been shown to have neuroprotective effects in animal models of traumatic brain injury (TBI). Acute in vivo mechanisms and pathological changes associated with EPO following TBI are unknown. In this study the authors compare acute metabolic and pathological changes following TBI with and without systemically administered EPO. METHODS Right frontal lobe microdialysis cannulae and right parietal lobe percussion hubs were inserted into 16 Sprague-Dawley rats. After a 4- to 5-day recovery, TBI was induced via a DragonFly fluid-percussion device at 2.5-2.8 atm. Rats were randomized into 2 groups, which received 5000 U/kg EPO or normal saline intraperitoneally 30 minutes after TBI. Microdialysis samples for glucose, lactate, pyruvate, and glutamate were obtained every 25 minutes for 10 hours. Rats were killed, their brains processed for light microscopy, and sections stained with H & E. RESULTS Erythropoietin administered 30 minutes after TBI directly affects acute brain metabolism. Brains treated with EPO maintain higher levels of glucose 4-10 hours after TBI (p<0.01), lower levels of lactate 6-10 hours after TBI (p<0.01), and lower levels of pyruvate 7.5-10 hours after TBI (p<0.01) compared with saline-treated controls. Erythropoietin maintains aerobic metabolism after TBI. Systemic EPO administration reduces acute TBI-induced lesion volume (p<0.05). CONCLUSIONS Following TBI, neuron use initially increases, with subsequent depletion of extracellular glucose, resulting in increased levels of extracellular lactate and pyruvate. This energy requirement can result in cell death due to increased metabolic demands. These data suggest that the neuroprotective effect of EPO may be partially due to improved energy metabolism in the acute phase in this rat model of TBI.
Collapse
Affiliation(s)
- Chad E Hartley
- Department of Neurosurgery, Upstate Medical University, State University of New York, Syracuse, New York 13210, USA.
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Brines M, Cerami A. Erythropoietin-mediated tissue protection: reducing collateral damage from the primary injury response. J Intern Med 2008; 264:405-32. [PMID: 19017170 DOI: 10.1111/j.1365-2796.2008.02024.x] [Citation(s) in RCA: 244] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In its classic hormonal role, erythropoietin (EPO) is produced by the kidney and regulates the number of erythrocytes within the circulation to provide adequate tissue oxygenation. EPO also mediates other effects directed towards optimizing oxygen delivery to tissues, e.g. modulating regional blood flow and reducing blood loss by promoting thrombosis within damaged vessels. Over the past 15 years, many unexpected nonhaematopoietic functions of EPO have been identified. In these more recently appreciated nonhormonal roles, locally-produced EPO signals through a different receptor isoform and is a major molecular component of the injury response, in which it counteracts the effects of pro-inflammatory cytokines. Acutely, EPO prevents programmed cell death and reduces the development of secondary, pro-inflammatory cytokine-induced injury. Within a longer time frame, EPO provides trophic support to enable regeneration and healing. As the region immediately surrounding damage is typically relatively deficient in endogenous EPO, administration of recombinant EPO can provide increased tissue protection. However, effective use of EPO as therapy for tissue injury requires higher doses than for haematopoiesis, potentially triggering serious adverse effects. The identification of a tissue-protective receptor isoform has facilitated the engineering of nonhaematopoietic, tissue-protective EPO derivatives, e.g. carbamyl EPO, that avoid these complications. Recently, regions within the EPO molecule mediating tissue protection have been identified and this has enabled the development of potent tissue-protective peptides, including some mimicking EPO's tertiary structure but unrelated in primary sequence.
Collapse
Affiliation(s)
- M Brines
- Warren Pharmaceuticals, Ossining, NY 10562, USA.
| | | |
Collapse
|
43
|
Bartels C, Späte K, Krampe H, Ehrenreich H. Recombinant Human Erythropoietin: Novel Strategies for Neuroprotective/Neuro-regenerative Treatment of Multiple Sclerosis. Ther Adv Neurol Disord 2008; 1:193-206. [PMID: 21180577 PMCID: PMC3002551 DOI: 10.1177/1756285608098422] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Treatment of multiple sclerosis (MS) is still unsatisfactory and essentially non-existing for the progressive course of the disease. Recombinant human erythropoietin (EPO) may be a promising neuroprotective/neuroregenerative treatment of MS. In the nervous system, EPO acts anti-apoptotic, antioxidative, anti-inflammatory, neurotrophic and plasticity-modulating. Beneficial effects have been shown in animal models of various neurological and psychiatric diseases, including different models of experimental autoimmune encephalomyelitis. EPO is also effective in human brain disease, as shown in double-blind placebo-controlled clinical studies on ischemic stroke and chronic schizophrenia. An exploratory study on chronic progressive MS yielded lasting improvement in motor and cognitive performance upon high-dose long-term EPO treatment.
Collapse
Affiliation(s)
- Claudia Bartels
- Division of Clinical Neuroscience, Max-Planck-Institute of Experimental
Medicine, Göttingen, Germany
| | - Kira Späte
- Division of Clinical Neuroscience, Max-Planck-Institute of Experimental
Medicine, Göttingen, Germany
| | - Henning Krampe
- Division of Clinical Neuroscience, Max-Planck-Institute of Experimental
Medicine, Göttingen, Germany
| | - Hannelore Ehrenreich
- Ehrenreich Division of Clinical Neuroscience, Max-Planck-Institute of
Experimental Medicine, Göttingen, Germany,
| |
Collapse
|
44
|
Shafi NI, Andresen J, Marrelli SP, Bryan RM. Erythropoietin potentiates EDHF-mediated dilations in rat middle cerebral arteries. J Neurotrauma 2008; 25:257-65. [PMID: 18352839 DOI: 10.1089/neu.2007.0347] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The neuroprotective effects of exogenous erythropoietin (EPO) in animals and humans after brain injury may be afforded, in part, by the influence of EPO on cerebral arteries. We tested (1) if EPO itself is vasoactive and (2) if EPO enhances endothelium-mediated dilations, specifically those mediated by endothelium-derived hyperpolarizing factor (EDHF). Immunoblotting and reverse transcriptase-polymerase chain reaction (RT-PCR) were used to detect EPO receptor. Rat middle cerebral arteries (MCAs) were isolated, pressurized, and perfused in vitro. EPO was directly applied to MCAs to test its vasoactivity. Endothelium-mediated dilations were elicited by UTP, whereas EDHF-mediated dilations were elicited by UTP after inhibition of endothelial nitric oxide synthase and cyclooxygenase. mRNA and protein for EPO receptor was found in rat MCA. Abluminal application of 0.001-10 U/mL EPO, which is selective for vascular smooth muscle, did not alter vessel diameter. In contrast, luminal application of EPO, which is selective for endothelium, resulted in concentration-dependent dilations of up to 39 +/- 16% at 10 U/mL (p = 0.0018), though responses were variable. A single dose of EPO (1,000 U/kg) administered to rats 24 h prior to examining vascular function potentiated dilations to UTP 2.6-fold (p < 0.0001). EDHF-mediated dilations were potentiated 2.1-fold following in vivo EPO treatment (p = 0.0034). This study demonstrates that EPO can directly dilate rat MCAs via the endothelium, though not all vessels are responsive. Additionally, pre-treatment with EPO for 24 h in vivo potentiates endothelium-mediated dilations, specifically those mediated by EDHF. Thus, enhanced endothelium-mediated dilations may partially underlie the neuroprotective effects of EPO after brain injury.
Collapse
Affiliation(s)
- Nadeem I Shafi
- Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | | | | |
Collapse
|
45
|
Mogensen J, Boyd MH, Nielsen MD, Kristensen RS, Malá H. Erythropoietin improves spatial delayed alternation in a T-maze in rats subjected to ablation of the prefrontal cortex. Brain Res Bull 2008; 77:1-7. [PMID: 18639740 DOI: 10.1016/j.brainresbull.2008.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2007] [Revised: 05/16/2008] [Accepted: 05/21/2008] [Indexed: 10/21/2022]
Abstract
Systemically administered human recombinant erythropoietin (EPO) may have the potential to reduce the cognitive and behavioural symptoms of mechanical brain injury. In a series of studies we address this possibility. Previously, we studied the effects of EPO given to fimbria-fornix transected rats at the moment of injury. We have found that such treatment improves substantially the posttraumatic acquisition of allocentric place learning tasks administered in a water maze and in an 8-arm radial maze as well as a spatial delayed alternation task administered in a T-maze. It is, however, essential also to evaluate this clinically important ability of EPO after other types of mechanical brain injury. Consequently, we presently studied the effects of similarly administered EPO in rats subjected to bilateral subpial aspiration of the anteromedial prefrontal cortex as well as control operated rats, respectively. We evaluated the posttraumatic behavioural/cognitive abilities of these animals in a spatial delayed alternation task performed in a T-maze. Administration of EPO to the prefrontally ablated rats was associated with a reduction of the lesion-associated behavioural impairment--while such an impairment was clearly seen in the saline injected prefrontally ablated group. In sham operated rats administration of EPO did not influence the task acquisition significantly. The results of the present study confirm our previous demonstrations that EPO is able to reduce the behavioural/cognitive consequences of mechanical brain injury. This ability is emphasized by its relative independence on the type of lesion as well as the neural structure affected.
Collapse
Affiliation(s)
- Jesper Mogensen
- The Unit for Cognitive Neuroscience, Department of Psychology, University of Copenhagen, Denmark.
| | | | | | | | | |
Collapse
|
46
|
Gluhovschi G, Gluhovschi C, Bob F, Velciov S, Trandafirescu V, Petrica L, Bozdog G. Multiorgan-protective actions of blockers of the renin-angiotensin system, statins and erythropoietin: common pleiotropic effects in reno-, cardio- and neuroprotection. Acta Clin Belg 2008; 63:152-69. [PMID: 18714846 DOI: 10.1179/acb.2008.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Renal diseases induce nephroprotective measures that may affect the heart, brain and other organs. In addition, many cardiovascular and neurological diseases are accompanied by renal lesions. For these reasons, multiorgan-protective measures, including cardio-, reno- and neuro-protective measures, are necessary to treat these diseases. The drugs used in nephrology are often pleiotropic. Although they usually address a single organ or tissue, many of them have complex actions that may provide multiorgan-protection. The present paper aims to review 3 classes of drugs that are commonly prescribed in nephrological practice: statins, RAS blockers (such as ACEIs and ARBs) and erythropoietin (EPO). This paper highlights the renoprotective actions, as well as those that are protective of the heart, brain and other organs, of these drugs at the cellular and molecular level. Their protective actions are attributable to their main effects and pleiotropic effects. The protective pleiotropic actions of these drugs may be exerted on multiple organs, making them multiorgan-protective. Another objective is to analyse the shared multiorgan-protective pleiotropic effects of RAS blockers (ACEIs and ARBs), statins and erythropoietin. This will allow for the practical association of the main renoprotective drugs with multiorgan protection.
Collapse
Affiliation(s)
- G Gluhovschi
- Nephrology Department, University of Medicine and Pharmacy Victor Babes, Timisoara, Romania.
| | | | | | | | | | | | | |
Collapse
|
47
|
Ehrenreich H, Bartels C, Sargin D, Stawicki S, Krampe H. Recombinant human erythropoietin in the treatment of human brain disease: focus on cognition. J Ren Nutr 2008; 18:146-53. [PMID: 18089462 DOI: 10.1053/j.jrn.2007.10.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Treatment of human brain disease with erythropoietin (EPO) in order to achieve neuroprotection and/or neuroregeneration represents a totally new frontier in translational neuroscience. Rather than specifically targeting the cause of a particular disease entity, EPO nonspecifically influences components of the "final common pathway" that determine disease severity and progression in a number of entirely different brain diseases. EPO acts in an antiapoptotic, anti-inflammatory, antioxidant, neurotrophic, angiogenetic, stem cell-modulatory fashion. Importantly, it appears to influence neural plasticity. Most likely due to these properties, EPO has been found by many investigators to be protective or regenerative and to improve cognitive performance in various rodent models of neurological and psychiatric disease. The "Göttingen-EPO-stroke trial" has provided first promising data on humans for a neuroprotective therapy of an acute brain disease. Experimental EPO treatment to improve cognitive function in patients with schizophrenia represents a novel neuroregenerative strategy for a chronic brain disease. An exploratory trial in chronic progressive multiple sclerosis as an example of an inflammatory disease of the nervous system yielded first positive results of EPO treatment on both motor function and cognition. These promising results are just the beginning and will hopefully stimulate further work along these lines.
Collapse
Affiliation(s)
- Hannelore Ehrenreich
- Division of Clinical Neuroscience, Max-Planck-Institute of Experimental Medicine, Göttingen, Germany.
| | | | | | | | | |
Collapse
|
48
|
Grasso G, Meli F, Fodale V, Calapai G, Buemi M, Iacopino DG. Neuroprotective potential of erythropoietin and darbepoetin alfa in an experimental model of sciatic nerve injury. Laboratory investigation. J Neurosurg Spine 2008; 7:645-51. [PMID: 18074690 DOI: 10.3171/spi-07/12/645] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The objectives of this study were to examine whether the systemic administration of recombinant human erythropoietin (rHuEPO) and its long-lasting derivative darbepoetin alfa expedited functional recovery in a rat model of sciatic nerve injury, and to compare the effects of these agents in the model. METHODS Thirty male Sprague-Dawley rats received a crush injury to the left sciatic nerve and subsequently underwent either placebo treatment, daily injections of rHuEPO, or weekly injections of darbepoetin alfa. RESULTS Both rHuEPO and darbepoetin alfa were effective in reducing neurological impairment and improving compound muscle action potentials following nerve injury. Darbepoetin alfa, however, shortened the duration of peripheral nerve recovery'and facilitated recovery from the neurological and electrophysiological impairment following crush injury significantly better than rHuEPO. Examination of the footprint length factor data revealed that darbepoetin alfa-treated animals recovered preinjury function by postoperative Day 10, 4 days earlier than animals treated with rHuEPO and 11 days earlier than animals treated with placebo. CONCLUSIONS These results suggest that recovery of neurological function in a model of peripheral nerve injury is more rapid with weekly administration of darbepoetin alfa than with daily rHuEPO treatment. Agents that facilitate nerve regeneration have the potential to limit the extent of motor endplate loss and muscle atrophy. The administration of EPO in its long-lasting recombinant forms affords significant neuroprotection in peripheral nerve injury models and may hold promise for future clinical applications.
Collapse
Affiliation(s)
- Giovanni Grasso
- Neurosurgical Clinic, Department of Clinical Neurosciences, University of Palermo, Italy.
| | | | | | | | | | | |
Collapse
|
49
|
Malá H, Rodriguez Castro M, Dall Jørgensen K, Mogensen J. Effects of erythropoietin on posttraumatic place learning in fimbria-fornix transected rats after a 30-day postoperative pause. J Neurotrauma 2007; 24:1647-57. [PMID: 17970627 DOI: 10.1089/neu.2007.0292] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Human recombinant erythropoietin (EPO) has been shown to exert neuroprotective effects following both vascular and mechanical brain injury. Previously, we showed that behavioral symptoms associated with mechanical lesions of the hippocampus are nearly abolished due to EPO treatment. In these studies, the EPO administration took place simultaneously with the infliction of brain injury and the rehabilitation training started 6-7 days postoperatively. In the present study, we tested whether the therapeutic effect of EPO on the acquisition of an allocentric eight-arm radial maze spatial task also manifests itself if the rehabilitative training is postponed. Postoperatively, the animals were left without any specific stimulation for 30 days. The current results show an improved behavioral performance of the EPO-treated lesioned group relative to the saline-treated lesioned group, and confirm EPO's therapeutic effect even in case of postponed rehabilitation. However, compared to the control group, the EPO-treated lesioned group demonstrated an impaired task acquisition. All subjects eventually recovered functionally. Subsequently, the animals were given behavioral challenges during which the cue constellation in the room was changed. The challenges revealed that, although the EPO-treated lesion group had achieved the same level of task proficiency as the control group, the cognitive mechanisms mediating the task performance in the EPO-treated lesion group (as well as in the saline-treated lesion group) were dissimilar from those mediating the task in the control group. Both the EPO-treated and the saline-treated lesion group demonstrated an increased dependency on the original cue configuration.
Collapse
Affiliation(s)
- Hana Malá
- Unit for Cognitive Neuroscience, Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | | | | | | |
Collapse
|
50
|
Springborg JB, Møller C, Gideon P, Jørgensen OS, Juhler M, Olsen NV. Erythropoietin in patients with aneurysmal subarachnoid haemorrhage: a double blind randomised clinical trial. Acta Neurochir (Wien) 2007; 149:1089-101; discussion 1101. [PMID: 17876497 DOI: 10.1007/s00701-007-1284-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Accepted: 04/24/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Erythropoietin (EPO) is neuroprotective in experimental models of stroke and subarachnoid haemorrhage (SAH) and possibly in patients with thromboembolic stroke. We studied the efficacy and safety of EPO in patients with SAH. METHODS A larger scale clinical trial was planned but preliminarily terminated because of a lower than expected inclusion rate. However, 73 patients were randomised to treatment with EPO (500 IU/kg/day for three days) or placebo. The primary endpoint was Glasgow Outcome Score at six months. We further studied surrogate measures of secondary ischaemia, i.e. transcranial Doppler (TCD) flow velocity, symptomatic vasospasm, cerebral metabolism (microdialysis) and jugular venous oximetry, biochemical markers of brain damage (S-100beta and neuron specific enolase) and blood-brain barrier integrity. FINDINGS The limited sample size precluded our primary hypotheses being verified and refuted. However, data from this study are important for any other study of SAH and as much raw data as possible are presented and can be included in future meta analyses. On admission the proportion of patients in a poor condition was higher in the EPO group compared with the placebo group but the difference was statistically insignificant. In the EPO-treated patients the CSF concentration of EPO increased 600-fold. Except for a higher extracelullar concentration of glycerol in the EPO group probably caused by the poorer clinical condition of these patients, there were no statistically significant group differences in the primary or secondary outcome measures. EPO was well tolerated. CONCLUSIONS Beneficial effects of EPO in patients with SAH cannot be excluded or concluded on the basis of this study and larger scale trials are warranted.
Collapse
Affiliation(s)
- J B Springborg
- Department of Neuroanaesthesia, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark.
| | | | | | | | | | | |
Collapse
|