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Harris G, Rickard JJS, Butt G, Kelleher L, Blanch RJ, Cooper J, Oppenheimer PG. Review: Emerging Eye-Based Diagnostic Technologies for Traumatic Brain Injury. IEEE Rev Biomed Eng 2023; 16:530-559. [PMID: 35320105 PMCID: PMC9888755 DOI: 10.1109/rbme.2022.3161352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 02/11/2022] [Accepted: 03/15/2022] [Indexed: 11/06/2022]
Abstract
The study of ocular manifestations of neurodegenerative disorders, Oculomics, is a growing field of investigation for early diagnostics, enabling structural and chemical biomarkers to be monitored overtime to predict prognosis. Traumatic brain injury (TBI) triggers a cascade of events harmful to the brain, which can lead to neurodegeneration. TBI, termed the "silent epidemic" is becoming a leading cause of death and disability worldwide. There is currently no effective diagnostic tool for TBI, and yet, early-intervention is known to considerably shorten hospital stays, improve outcomes, fasten neurological recovery and lower mortality rates, highlighting the unmet need for techniques capable of rapid and accurate point-of-care diagnostics, implemented in the earliest stages. This review focuses on the latest advances in the main neuropathophysiological responses and the achievements and shortfalls of TBI diagnostic methods. Validated and emerging TBI-indicative biomarkers are outlined and linked to ocular neuro-disorders. Methods detecting structural and chemical ocular responses to TBI are categorised along with prospective chemical and physical sensing techniques. Particular attention is drawn to the potential of Raman spectroscopy as a non-invasive sensing of neurological molecular signatures in the ocular projections of the brain, laying the platform for the first tangible path towards alternative point-of-care diagnostic technologies for TBI.
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Affiliation(s)
- Georgia Harris
- School of Chemical Engineering, Advanced Nanomaterials Structures and Applications Laboratories, College of Engineering and Physical SciencesUniversity of BirminghamB15 2TTBirminghamU.K.
| | - Jonathan James Stanley Rickard
- School of Chemical Engineering, Advanced Nanomaterials Structures and Applications Laboratories, College of Engineering and Physical SciencesUniversity of BirminghamB15 2TTBirminghamU.K.
- Department of Physics, Cavendish LaboratoryUniversity of CambridgeCB3 0HECambridgeU.K.
| | - Gibran Butt
- Ophthalmology DepartmentUniversity Hospitals Birmingham NHS Foundation TrustB15 2THBirminghamU.K.
| | - Liam Kelleher
- School of Chemical Engineering, Advanced Nanomaterials Structures and Applications Laboratories, College of Engineering and Physical SciencesUniversity of BirminghamB15 2TTBirminghamU.K.
| | - Richard James Blanch
- Department of Military Surgery and TraumaRoyal Centre for Defence MedicineB15 2THBirminghamU.K.
- Neuroscience and Ophthalmology, Department of Ophthalmology, University Hospitals Birmingham NHS Foundation TrustcBirminghamU.K.
| | - Jonathan Cooper
- School of Biomedical EngineeringUniversity of GlasgowG12 8LTGlasgowU.K.
| | - Pola Goldberg Oppenheimer
- School of Chemical Engineering, Advanced Nanomaterials Structures and Applications Laboratories, College of Engineering and Physical SciencesUniversity of BirminghamB15 2TTBirminghamU.K.
- Healthcare Technologies Institute, Institute of Translational MedicineB15 2THBirminghamU.K.
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2
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Jacquens A, Needham EJ, Zanier ER, Degos V, Gressens P, Menon D. Neuro-Inflammation Modulation and Post-Traumatic Brain Injury Lesions: From Bench to Bed-Side. Int J Mol Sci 2022; 23:ijms231911193. [PMID: 36232495 PMCID: PMC9570205 DOI: 10.3390/ijms231911193] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Head trauma is the most common cause of disability in young adults. Known as a silent epidemic, it can cause a mosaic of symptoms, whether neurological (sensory-motor deficits), psychiatric (depressive and anxiety symptoms), or somatic (vertigo, tinnitus, phosphenes). Furthermore, cranial trauma (CT) in children presents several particularities in terms of epidemiology, mechanism, and physiopathology-notably linked to the attack of an immature organ. As in adults, head trauma in children can have lifelong repercussions and can cause social and family isolation, difficulties at school, and, later, socio-professional adversity. Improving management of the pre-hospital and rehabilitation course of these patients reduces secondary morbidity and mortality, but often not without long-term disability. One hypothesized contributor to this process is chronic neuroinflammation, which could accompany primary lesions and facilitate their development into tertiary lesions. Neuroinflammation is a complex process involving different actors such as glial cells (astrocytes, microglia, oligodendrocytes), the permeability of the blood-brain barrier, excitotoxicity, production of oxygen derivatives, cytokine release, tissue damage, and neuronal death. Several studies have investigated the effect of various treatments on the neuroinflammatory response in traumatic brain injury in vitro and in animal and human models. The aim of this review is to examine the various anti-inflammatory therapies that have been implemented.
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Affiliation(s)
- Alice Jacquens
- Unité de Neuroanesthésie-Réanimation, Hôpital de la Pitié Salpêtrière 43-87, Boulevard de l’Hôpital, F-75013 Paris, France
- Inserm, Maladies Neurodéveloppementales et Neurovasculaires, Université Paris Cité, F-75019 Paris, France
- Correspondence: ; Tel.: +33-1-42-16-00-00
| | - Edward J. Needham
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Box 93, Hills Road, Cambridge CB2 2QQ, UK
| | - Elisa R. Zanier
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Vincent Degos
- Unité de Neuroanesthésie-Réanimation, Hôpital de la Pitié Salpêtrière 43-87, Boulevard de l’Hôpital, F-75013 Paris, France
- Inserm, Maladies Neurodéveloppementales et Neurovasculaires, Université Paris Cité, F-75019 Paris, France
| | - Pierre Gressens
- Inserm, Maladies Neurodéveloppementales et Neurovasculaires, Université Paris Cité, F-75019 Paris, France
| | - David Menon
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Box 93, Hills Road, Cambridge CB2 2QQ, UK
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3
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Joyce JM, La PL, Walker R, Harris A. Magnetic resonance spectroscopy of traumatic brain injury and subconcussive hits: A systematic review and meta-analysis. J Neurotrauma 2022; 39:1455-1476. [PMID: 35838132 DOI: 10.1089/neu.2022.0125] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Magnetic resonance spectroscopy (MRS) is a non-invasive technique used to study metabolites in the brain. MRS findings in traumatic brain injury (TBI) and subconcussive hit literature have been mixed. The most common observation is a decrease in N-acetyl-aspartate (NAA), traditionally considered a marker of neuronal integrity. Other metabolites, however, such as creatine (Cr), choline (Cho), glutamate+glutamine (Glx) and myo-inositol (mI) have shown inconsistent changes in these populations. The objective of this systematic review and meta-analysis was to synthesize MRS literature in head injury and explore factors (brain region, injury severity, time since injury, demographic, technical imaging factors, etc.) that may contribute to differential findings. One hundred and thirty-eight studies met inclusion criteria for the systematic review and of those, 62 NAA, 24 Cr, 49 Cho, 18 Glx and 21 mI studies met inclusion criteria for meta-analysis. A random effects model was used for meta-analyses with brain region as a subgroup for each of the five metabolites studied. Meta-regression was used to examine the influence of potential moderators including injury severity, time since injury, age, sex, tissue composition and methodological factors. In this analysis of 1428 unique head-injured subjects and 1132 controls, the corpus callosum was identified as a brain region highly susceptible to metabolite alteration. NAA was consistently decreased in TBI of all severity, but not in subconcussive hits. Cho and mI were found to be increased in moderate-to-severe TBI but not mild TBI. Glx and Cr were largely unaffected, however did show alterations in certain conditions.
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Affiliation(s)
- Julie Michele Joyce
- University of Calgary, 2129, Radiology, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, 157742, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, 157744, Calgary, Alberta, Canada.,Integrated Concussion Research Program, Calgary, Alberta, Canada;
| | - Parker L La
- University of Calgary, 2129, Radiology, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, 157742, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, 157744, Calgary, Alberta, Canada.,Integrated Concussion Research Program, Calgary, Alberta, Canada;
| | - Robyn Walker
- University of Calgary, 2129, Radiology, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, 157742, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, 157744, Calgary, Alberta, Canada.,Integrated Concussion Research Program, Calgary, Alberta, Canada;
| | - Ashley Harris
- University of Calgary, Radiology, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, 157742, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, 157744, Calgary, Alberta, Canada.,Integrated Concussion Research Program, Calgary, Alberta, Canada;
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4
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Ruzinak R, Bittsansky M, Martinikova M, Nosal V, Kantorova E, Ballova J, Turcanova Koprusakova M, Hnilicova P, Grendar M, Dusenka R, Kolarovszki B, Zelenak K, Kurca E, Sivak S. Proton magnetic resonance spectroscopy changes in the brainstem in patients after mild traumatic brain injury with loss of consciousness. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021; 166:84-90. [PMID: 33976431 DOI: 10.5507/bp.2021.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 04/26/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Loss of consciousness (LOC) is used as a diagnostic feature of mild traumatic brain injury (MTBI). However, only 10% of concussions result in LOC. There are only a limited number of in-vivo studies dealing with unconsciousness and structural and functional integrity of the brainstem in patients with MTBI. The aim of our pilot study was to assess the sensitivity of proton magnetic resonance spectroscopy (1H-MRS) to detect metabolic changes in the brainstem in patients after MTBI with unconscioussness. METHODS Twenty-four patients (12 with LOC, and 12 without LOC) within 3 days of MTBI and 19 healthy controls were examined. All subjects underwent single-voxel 1H-MRS examination of the upper brainstem. Spectra were evaluated using LCModel software. Ratios of total N-acetylaspartate (tNAA), total choline-containing compounds (tCho) and glutamate plus glutamine (Glx) to total creatine (tCre) were used for calculations. RESULTS We found a significant decrease in tNAA/tCre and tCho/tCre ratios in the patient group with LOC when compared with the control group of healthy volunteers (P=0.002 and P=0.041, respectively), and a significant decrease in the tNAA/tCre ratio in the LOC group when compared with patients without LOC (P=0.04). Other metabolite ratios in the brainstem did not show any significant group differences. CONCLUSION Our findings indicate that decrease of tNAA/tCre ratio in the upper brainstem using single-voxel 1H-MRS may provide a potential biomarker for MTBI associated with LOC.
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Affiliation(s)
- Robert Ruzinak
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Michal Bittsansky
- Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratilava, Slovak Republic
| | - Martina Martinikova
- Department of Neurology, F.D. Roosevelt Hospital, Banska Bystrica, Slovak Republic
| | - Vladimir Nosal
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Ema Kantorova
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Jana Ballova
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Monika Turcanova Koprusakova
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Petra Hnilicova
- Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratilava, Slovak Republic
| | - Marian Grendar
- Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratilava, Slovak Republic
| | | | - Branislav Kolarovszki
- Clinic of Neurosurgery, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Kamil Zelenak
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
| | - Egon Kurca
- Clinic of Neurology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Slovak Republic
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5
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Stovell MG, Mada MO, Carpenter TA, Yan JL, Guilfoyle MR, Jalloh I, Welsh KE, Helmy A, Howe DJ, Grice P, Mason A, Giorgi-Coll S, Gallagher CN, Murphy MP, Menon DK, Hutchinson PJ, Carpenter KL. Phosphorus spectroscopy in acute TBI demonstrates metabolic changes that relate to outcome in the presence of normal structural MRI. J Cereb Blood Flow Metab 2020; 40:67-84. [PMID: 30226401 PMCID: PMC6927074 DOI: 10.1177/0271678x18799176] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Metabolic dysfunction is a key pathophysiological process in the acute phase of traumatic brain injury (TBI). Although changes in brain glucose metabolism and extracellular lactate/pyruvate ratio are well known, it was hitherto unknown whether these translate to downstream changes in ATP metabolism and intracellular pH. We have performed the first clinical voxel-based in vivo phosphorus magnetic resonance spectroscopy (31P MRS) in 13 acute-phase major TBI patients versus 10 healthy controls (HCs), at 3T, focusing on eight central 2.5 × 2.5 × 2.5 cm3 voxels per subject. PCr/γATP ratio (a measure of energy status) in TBI patients was significantly higher (median = 1.09) than that of HCs (median = 0.93) (p < 0.0001), due to changes in both PCr and ATP. There was no significant difference in PCr/γATP between TBI patients with favourable and unfavourable outcome. Cerebral intracellular pH of TBI patients was significantly higher (median = 7.04) than that of HCs (median = 7.00) (p = 0.04). Alkalosis was limited to patients with unfavourable outcome (median = 7.07) (p < 0.0001). These changes persisted after excluding voxels with > 5% radiologically visible injury. This is the first clinical demonstration of brain alkalosis and elevated PCr/γATP ratio acutely after major TBI. 31P MRS has potential for non-invasively assessing brain injury in the absence of structural injury, predicting outcome and monitoring therapy response.
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Affiliation(s)
- Matthew G Stovell
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marius O Mada
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - T Adrian Carpenter
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Jiun-Lin Yan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Department of Neurosurgery, Keelung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Ibrahim Jalloh
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Karen E Welsh
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Duncan J Howe
- Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Peter Grice
- Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Andrew Mason
- Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Susan Giorgi-Coll
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Clare N Gallagher
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Michael P Murphy
- MRC Mitochondrial Biology Unit, University of Cambridge, Cambridge, UK
| | - David K Menon
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Keri Lh Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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6
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Kondratyeva EA, Diment SV, Kondratyev SA, Ivanova NE, Bukkieva TA, Efimtsev AY, Trufanov GE, Kondratyev AN, Laurens S. [Magnetic resonance spectroscopy data in the prognosis of consciousness recovery in patients with vegetative state]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:7-14. [PMID: 31793537 DOI: 10.17116/jnevro20191191017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To study the prognostic value of magnetic resonance spectroscopy (MRS) in patients with vegetative state/unresponsive wakefulness syndrome (VS/UWS). MATERIAL AND METHODS Thirty-four patients with VS/UWS underwent multi-voxel MRS (thalamus, globus pallidus, putamen, internal capsules, fornix, brainstem, temporal and frontal cortex). Subjects were grouped according to etiology: 22 patients with traumatic brain injury (TBI) (group 1) and 12 patients with a hypoxia (group 2). The groups were matched by age and duration of UWS (mean 2, 3 months). The CRS-R was used to identify the first signs of consciousness during hospitalization and 6-12 months later. Outcomes of the patients with TBI were as follows: chronic VS/UWS (n=6), minimally conscious state (MCS) plus (n=9), emergence from MCS (EMCS) (n=7). Outcomes of the patients with hypoxia were: chronic vegetative state (n=10), minimally conscious state (MCS) (n=2). RESULTS The decrease in the NAA/Cr ratio in thalamus, capsula interna, temporal cortex are correlated with poor outcome in both groups. Higher rates of NAA/Cr in these structures are correlated with further recovery of consciousness. The decrease in the ratio of NAA Cr and NAA/NAA+Cho+Cr in the midbrain is correlated with poor outcome only in UWS with hypoxia. CONCLUSION The results suggest that the MRS allows to more accurately predicting the outcome in VS/UWS patients with hypoxic brain damage, as well as in UWS patients with TBI, who have recovered consciousness to the level of EMCS.
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Affiliation(s)
- E A Kondratyeva
- Polenov Neurosurgical Institute branch of Almazov National Medical Research Centre, St. Petersburg, Russia
| | | | - S A Kondratyev
- Polenov Neurosurgical Institute branch of Almazov National Medical Research Centre, St. Petersburg, Russia
| | - N E Ivanova
- Polenov Neurosurgical Institute branch of Almazov National Medical Research Centre, St. Petersburg, Russia
| | - T A Bukkieva
- Almazov National Medical Research Centre, St. Petersburg, Russia
| | - A Yu Efimtsev
- Almazov National Medical Research Centre, St. Petersburg, Russia
| | - G E Trufanov
- Almazov National Medical Research Centre, St. Petersburg, Russia
| | - A N Kondratyev
- Polenov Neurosurgical Institute branch of Almazov National Medical Research Centre, St. Petersburg, Russia
| | - S Laurens
- Coma Science Group, GIGA-Consciousness, University and University Hospital of Liège, Liège, Belgium
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7
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Andreasen SH, Andersen KW, Conde V, Dyrby TB, Puonti O, Kammersgaard LP, Madsen CG, Madsen KH, Poulsen I, Siebner HR. Limited Colocalization of Microbleeds and Microstructural Changes after Severe Traumatic Brain Injury. J Neurotrauma 2019; 37:581-592. [PMID: 31588844 DOI: 10.1089/neu.2019.6608] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Severe traumatic brain injury (TBI) produces shearing forces on long-range axons and brain vessels, causing axonal and vascular injury. To examine whether microbleeds and axonal injury colocalize after TBI, we performed whole-brain susceptibility-weighted imaging (SWI) and diffusion tensor imaging (DTI) in 14 patients during the subacute phase after severe TBI. SWI was used to determine the number and volumes of microbleeds in five brain regions: the frontotemporal lobe; parieto-occipital lobe; midsagittal region (cingular cortex, parasagittal white matter, and corpus callosum); deep nuclei (basal ganglia and thalamus); and brainstem. Averaged fractional anisotropy (FA) and mean diffusivity (MD) were measured to assess microstructural changes in the normal appearing white matter attributed to axonal injury in the same five regions. Regional expressions of microbleeds and microstructure were used in a partial least-squares model to predict the impairment of consciousness in the subacute stage after TBI as measured with the Coma Recovery Scale-Revised (CRS-R). Only in the midsagittal region, the expression of microbleeds was correlated with regional changes in microstructure as revealed by DTI. Microbleeds and microstructural DTI-based metrics of deep, but not superficial, brain regions were able to predict individual CRS-R. Our results suggest that microbleeds are not strictly related to axonal pathology in other than the midsagittal region. While each measure alone was predictive, the combination of both metrics scaled best with individual CRS-R. Structural alterations in deep brain structures are relevant in terms of determining the severity of impaired consciousness in the acute stage after TBI.
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Affiliation(s)
- Sara H Andreasen
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Research Unit on Brain Injury Rehabilitation Copenhagen (RUBRIC), Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kasper W Andersen
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Virginia Conde
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Clinical Neuroscience Laboratory, Institute of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tim B Dyrby
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Oula Puonti
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Lars Peter Kammersgaard
- Research Unit on Brain Injury Rehabilitation Copenhagen (RUBRIC), Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Neurology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Camilla G Madsen
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Radiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Kristoffer H Madsen
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Ingrid Poulsen
- Research Unit on Brain Injury Rehabilitation Copenhagen (RUBRIC), Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Nursing Science, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Hartwig R Siebner
- Danish Research Centre for Magnetic Resonance (DRCMR), Centre for Functional and Diagnostic Imaging Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department for Neurology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
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8
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Value of assessment of multivoxel proton chemical shift imaging to predict long term outcome in patients after out-of-hospital cardiac arrest: A preliminary prospective observational study. Resuscitation 2018; 134:136-144. [PMID: 30248375 DOI: 10.1016/j.resuscitation.2018.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 09/07/2018] [Accepted: 09/13/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Existing methods to predict recovery after out-of-hospital cardiac arrest (OHCA) lack of accuracy. The aim of this study was to determine whether quantitative proton chemical shift imaging (1H-CSI) during the subacute stage of OHCA can predict neurological outcome of such patients. METHODS This monocentric prospective observational study was conducted in a Intensive Care Unit of a teaching hospital. Forty consecutive patients with OHCA were enrolled between January 1st 2011-December 31st 2013. Multivoxel 1H-CSI values were compared to structural magnetic resonance imaging (MRI) sequences (fluid-attenuated inversion recovery and diffusion-weighted imaging). Ratios of N-acetyl-aspartate (NAA) to creatine (Cr) and choline compounds were analyzed using region of interest in bilateral lenticular cores and thalami. The outcome evaluated was the Cerebral Performance Category (CPC) at 6 months, dichotomized as favorable (CPC 1-2) and unfavorable outcome (CPC 3-5). The performance was compared by area under the receiver operating characteristic (ROCAUC) curves analysis. RESULTS Twenty nine OHCA had an interpretable MRI. Eight patients (28%) had favorable outcome at 6 months. The worst NAA/Cr in lenticular cores was the best 1H-CSI marker, with 80% sensitivity (95% confidence interval (CI), 57-94) and a 100% specificity (95% CI, 63-100) with a positive predictive value of 100%. Prognostic accuracy, as quantified by the ROCAUC, was higher with the worst NAA/Cr in lenticular cores (ROCAUC 0.88; 95% CI, 0.70-0.97) than with the structural MRI sequences. CONCLUSION In this preliminary study we found that multivoxel 1H-CSI in lenticular cores was highly predictive of unfavorable outcome at 6 months.
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9
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Karlsson M, Pukenas B, Chawla S, Ehinger JK, Plyler R, Stolow M, Gabello M, Hugerth M, Elmér E, Hansson MJ, Margulies S, Kilbaugh T. Neuroprotective Effects of Cyclosporine in a Porcine Pre-Clinical Trial of Focal Traumatic Brain Injury. J Neurotrauma 2018; 36:14-24. [PMID: 29929438 PMCID: PMC6306685 DOI: 10.1089/neu.2018.5706] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Mitochondrial dysfunction is thought to be a hallmark of traumatic brain injury (TBI) and plays a pivotal role in the resulting cellular injury. Cyclophilin D-mediated activation of the mitochondrial permeability transition pore has been suggested to contribute to this secondary injury cascade. Cyclosporine possesses neuroprotective properties that have been attributed to the desensitization of mitochondrial permeability transition pore activation. In vivo animal experiments have demonstrated neuroprotective effects of cyclosporine in more than 20 independent experimental studies in a multitude of different experimental models. However, the majority of these studies have been carried out in rodents. The aim of the present study was to evaluate the efficacy of a novel and cremophor/kolliphor EL-free lipid emulsion formulation of cyclosporine in a translational large animal model of TBI. A mild-to-moderate focal contusion injury was induced in piglets using a controlled cortical impact device. After initial step-wise analyses of pharmacokinetics and comparing with exposure of cyclosporine in clinical TBI trials, a 5-day dosing regimen with continuous intravenous cyclosporine infusion (20 mg/kg/day) was evaluated in a randomized and blinded placebo-controlled setting. Cyclosporine reduced the volume of parenchymal injury by 35%, as well as improved markers of neuronal injury, as measured with magnetic resonance spectroscopic imaging. Further, a consistent trend toward positive improvements in brain metabolism and mitochondrial function was observed in the pericontusional tissue. In this study, we have demonstrated efficacy using a novel cyclosporine formulation in clinically relevant and translatable outcome metrics in a large animal model of focal TBI.
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Affiliation(s)
- Michael Karlsson
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
- 2 Mitochondrial Medicine, Department of Clinical Sciences, Lund University , Lund, Sweden
- 3 Department of Neurosurgery, Rigshospitalet , Copenhagen, Denmark
- 4 NeuroVive Pharmaceutical AB , Lund, Sweden
| | - Bryan Pukenas
- 5 Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Sanjeev Chawla
- 5 Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Johannes K Ehinger
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
- 2 Mitochondrial Medicine, Department of Clinical Sciences, Lund University , Lund, Sweden
- 4 NeuroVive Pharmaceutical AB , Lund, Sweden
| | - Ross Plyler
- 6 Department of Bioengineering, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Madeline Stolow
- 6 Department of Bioengineering, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Melissa Gabello
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | | | - Eskil Elmér
- 2 Mitochondrial Medicine, Department of Clinical Sciences, Lund University , Lund, Sweden
- 4 NeuroVive Pharmaceutical AB , Lund, Sweden
| | - Magnus J Hansson
- 2 Mitochondrial Medicine, Department of Clinical Sciences, Lund University , Lund, Sweden
- 4 NeuroVive Pharmaceutical AB , Lund, Sweden
| | - Susan Margulies
- 6 Department of Bioengineering, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Todd Kilbaugh
- 1 Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
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Mathon B, Amelot A, Clemenceau S, Carpentier A, Boch AL. Commentary: La Pitié-Salpêtrière Hospital in Paris: the Historic Cradle of Neurosurgery. Neurosurgery 2018; 82:164-174. [DOI: 10.1093/neuros/nyy115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 03/08/2018] [Indexed: 01/09/2023] Open
Affiliation(s)
- Bertrand Mathon
- Assistance Publique - Hopitaux de Paris, Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Paris, France
- Sorbonne University, Pierre et Marie Curie School of Medicine, Paris, France
| | - Aymeric Amelot
- Assistance Publique - Hopitaux de Paris, Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Paris, France
- Sorbonne University, Pierre et Marie Curie School of Medicine, Paris, France
| | - Stéphane Clemenceau
- Assistance Publique - Hopitaux de Paris, Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Alexandre Carpentier
- Assistance Publique - Hopitaux de Paris, Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Paris, France
- Sorbonne University, Pierre et Marie Curie School of Medicine, Paris, France
| | - Anne-Laure Boch
- Assistance Publique - Hopitaux de Paris, Department of Neurosurgery, La Pitié-Salpêtrière University Hospital, Paris, France
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11
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Yang A, Xiao XH, Liu ZH, Wan ZL, Wang ZY. A Multimodal Magnetic Resonance Imaging Study of Recovery of Consciousness in Severe Traumatic Brain Injury: Preliminary Results. J Neurotrauma 2018; 35:308-313. [PMID: 29141511 DOI: 10.1089/neu.2017.5335] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ang Yang
- Department of MR, Affiliated Zhongshan City Hospital of Sun Yat-sen University, Sun Yat-sen University, Zhonshan, China
| | - Xue Hong Xiao
- Department of MR, Affiliated Zhongshan City Hospital of Sun Yat-sen University, Sun Yat-sen University, Zhonshan, China
| | - Zhong Hua Liu
- Department of Neurology and Neurological Rehabilitation, Affiliated Zhongshan City Hospital of Sun Yat-sen University, Sun Yat-sen University, Zhonshan, China
| | - Zhi Long Wan
- Department of MR, Affiliated Zhongshan City Hospital of Sun Yat-sen University, Sun Yat-sen University, Zhonshan, China
| | - Ze Yan Wang
- Department of MR, Affiliated Zhongshan City Hospital of Sun Yat-sen University, Sun Yat-sen University, Zhonshan, China
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12
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Ganau M, Holly LT, Mizuno J, Fehlings MG. Future Directions and New Technologies for the Management of Degenerative Cervical Myelopathy. Neurosurg Clin N Am 2018; 29:185-193. [DOI: 10.1016/j.nec.2017.09.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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13
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Sato M, Sugimoto M, Yamaguchi K, Kawaguchi T. Evaluation of nursing interventions using minimally invasive assessments methods for patients in a persistent vegetative state. Psychogeriatrics 2017; 17:406-413. [PMID: 28378507 DOI: 10.1111/psyg.12265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 02/11/2017] [Accepted: 02/15/2017] [Indexed: 11/30/2022]
Abstract
AIM This study aimed to evaluate the effects of nursing interventions using minimally invasive or non-invasive methods conducive to frequent use in order to assess patients in a persistent vegetative state (PVS). METHODS We provided three nursing interventions-sitting the patient in an upright position, footbath care, and oral care-to PVS patients (n = 11) and elderly bedridden subjects with consciousness (n = 6) for 3 weeks in addition to ordinary nursing treatments. The Kohnan Score, plasma cortisol and adrenaline levels, General Well-Being Schedule score, and facial expression assessments were used as evaluation methods. RESULTS The Kohnan Score of PVS patients declined significantly, indicating that the interventions increased patients' consciousness levels, but none of the other parameters showed significant change in either group. The change in Kohnan Score showed dependent trends for facial expression at baseline, cortisol change during the intervention, and the term of PVS. CONCLUSIONS The data suggest three indices for predicting intervention efficacy in individuals and for assessing an intervention's contribution to quality of life improvement. Among the multiple evaluation methods, Konan Scores was the most effective. Ultimately, the three nursing interventions used in this study and Konan Score led to the optimization of nursing home care and rehabilitation for PVS patients.
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Affiliation(s)
- Mitsue Sato
- Department of Human Arts and Sciences, Graduate School of the University of Human Arts and Sciences, Saitama, Japan.,Nursing Science, Human Care Department, Tohto College of Health Sciences, Fukaya, Japan.,Division of Salivary Gland and Health Medicine, Department of Oral Science, Graduate School of Dentistry, Kanagawa Dental University, Yokosuka, Japan
| | - Masahiro Sugimoto
- Division of Salivary Gland and Health Medicine, Department of Oral Science, Graduate School of Dentistry, Kanagawa Dental University, Yokosuka, Japan.,Institute for Advanced Biosciences, Keio University, Tsuruoka, Japan
| | | | - Takeshi Kawaguchi
- Department of Human Arts and Sciences, Graduate School of the University of Human Arts and Sciences, Saitama, Japan
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14
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Stovell MG, Yan JL, Sleigh A, Mada MO, Carpenter TA, Hutchinson PJA, Carpenter KLH. Assessing Metabolism and Injury in Acute Human Traumatic Brain Injury with Magnetic Resonance Spectroscopy: Current and Future Applications. Front Neurol 2017; 8:426. [PMID: 28955291 PMCID: PMC5600917 DOI: 10.3389/fneur.2017.00426] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/07/2017] [Indexed: 11/25/2022] Open
Abstract
Traumatic brain injury (TBI) triggers a series of complex pathophysiological processes. These include abnormalities in brain energy metabolism; consequent to reduced tissue pO2 arising from ischemia or abnormal tissue oxygen diffusion, or due to a failure of mitochondrial function. In vivo magnetic resonance spectroscopy (MRS) allows non-invasive interrogation of brain tissue metabolism in patients with acute brain injury. Nuclei with “spin,” e.g., 1H, 31P, and 13C, are detectable using MRS and are found in metabolites at various stages of energy metabolism, possessing unique signatures due to their chemical shift or spin–spin interactions (J-coupling). The most commonly used clinical MRS technique, 1H MRS, uses the great abundance of hydrogen atoms within molecules in brain tissue. Spectra acquired with longer echo-times include N-acetylaspartate (NAA), creatine, and choline. NAA, a marker of neuronal mitochondrial activity related to adenosine triphosphate (ATP), is reported to be lower in patients with TBI than healthy controls, and the ratio of NAA/creatine at early time points may correlate with clinical outcome. 1H MRS acquired with shorter echo times produces a more complex spectrum, allowing detection of a wider range of metabolites.31 P MRS detects high-energy phosphate species, which are the end products of cellular respiration: ATP and phosphocreatine (PCr). ATP is the principal form of chemical energy in living organisms, and PCr is regarded as a readily mobilized reserve for its replenishment during periods of high utilization. The ratios of high-energy phosphates are thought to represent a balance between energy generation, reserve and use in the brain. In addition, the chemical shift difference between inorganic phosphate and PCr enables calculation of intracellular pH.13 C MRS detects the 13C isotope of carbon in brain metabolites. As the natural abundance of 13C is low (1.1%), 13C MRS is typically performed following administration of 13C-enriched substrates, which permits tracking of the metabolic fate of the infused 13C in the brain over time, and calculation of metabolic rates in a range of biochemical pathways, including glycolysis, the tricarboxylic acid cycle, and glutamate–glutamine cycling. The advent of new hyperpolarization techniques to transiently boost signal in 13C-enriched MRS in vivo studies shows promise in this field, and further developments are expected.
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Affiliation(s)
- Matthew G Stovell
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jiun-Lin Yan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Department of Neurosurgery, Keelung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Alison Sleigh
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,National Institute for Health Research/Wellcome Trust Clinical Research Facility, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Marius O Mada
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - T Adrian Carpenter
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter J A Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Keri L H Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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15
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Metabolic Imaging Using Proton Magnetic Spectroscopy as a Predictor of Outcome After Surgery for Cervical Spondylotic Myelopathy. Clin Spine Surg 2017; 30:E615-E619. [PMID: 28525487 PMCID: PMC4510035 DOI: 10.1097/bsd.0000000000000248] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
STUDY DESIGN A single-center magnetic resonance spectroscopy (MRS) imaging and surgical outcome study involving 16 patients with cervical spondylotic myelopathy (CSM). OBJECTIVE In the present study, we assess the utility of MRS to quantify metabolic changes within the spinal cord and predict surgical outcome in CSM patients. SUMMARY OF BACKGROUND DATA MRS is an advanced spinal imaging modality that can provide pertinent metabolic and biochemical information regarding spinal cord function. Previous studies have demonstrated significant abnormalities in specific cellular metabolite concentrations in CSM patients. METHODS Sixteen patients with CSM were evaluated. Single voxel MRS was performed in the cervical cord. N-acetyl-aspartate (NAA) and choline metabolite concentration ratios with respect to creatine were quantified, as well as the presence or absence of a lactate peak. The modified Japanese Orthopaedic Association (mJOA) scale was used as the functional assessment measure. Correlation of MRS metabolites with change in mJOA score was performed. RESULTS The mean follow-up time was 19 months. There was a statistically significant improvement between mean preoperative and postoperative mJOA score after surgery (P<0.0001). The NAA/Cr ratio demonstrated a significant relationship to the change in mJOA score after surgery (P=0.0479; R=0.2513). The Cho/NAA ratio demonstrated an even stronger correlation with the change in mJOA score after surgery (P=0.0065; R=0.4219). Neither the Cho/Cr ratio, nor the presence of a lactate peak or T2-weighted signal change was significantly correlated with change in mJOA score after surgery. CONCLUSIONS MRS is a novel, noninvasive imaging modality that provides pertinent information regarding spinal cord cellular and metabolic function. In a cohort of operatively treated CSM patients, the NAA/Cr and Cho/NAA ratios were predictive of neurological outcome, as both were significantly associated with change in mJOA score after surgery.
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Abstract
There is a paucity of accurate and reliable biomarkers to detect traumatic brain injury, grade its severity, and model post-traumatic brain injury (TBI) recovery. This gap could be addressed via advances in brain mapping which define injury signatures and enable tracking of post-injury trajectories at the individual level. Mapping of molecular and anatomical changes and of modifications in functional activation supports the conceptual paradigm of TBI as a disorder of large-scale neural connectivity. Imaging approaches with particular relevance are magnetic resonance techniques (diffusion weighted imaging, diffusion tensor imaging, susceptibility weighted imaging, magnetic resonance spectroscopy, functional magnetic resonance imaging, and positron emission tomographic methods including molecular neuroimaging). Inferences from mapping represent unique endophenotypes which have the potential to transform classification and treatment of patients with TBI. Limitations of these methods, as well as future research directions, are highlighted.
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17
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Abstract
Magnetic resonance spectroscopy (MRS) provides a noninvasive tool to assess metabolic change in the brain following head injury. Observable metabolites reflect neuronal density and viability, glial density, membrane injury, and hypoxia or ischemia. MRS has been used in traumatic brain injury (TBI) research for nearly 20 years and this article reviews the MRS findings in the adult TBI population.Although MRS observations are heterogeneous, there are consistent patterns in TBI with the neuronal metabolite N-acetyl-aspartate (NAA) significantly reduced in the vast majority of studies, while the membrane related choline signal (Cho) is almost equally found to be elevated. The glial metabolites myo-inositol is often observed to be increased postinjury and this elevation persists into the chronic phase, which is interpreted as revealing gliosis. Observation of elevated lactate levels are sporadic and mainly in acute studies in severely injured subjects. In general, these spectral changes show a dependency on injury severity and acute changes relate to both neuropsychological deficits and to long-term outcome.
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18
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Moghieb A, Bramlett HM, Das JH, Yang Z, Selig T, Yost RA, Wang MS, Dietrich WD, Wang KKW. Differential Neuroproteomic and Systems Biology Analysis of Spinal Cord Injury. Mol Cell Proteomics 2016; 15:2379-95. [PMID: 27150525 PMCID: PMC4937511 DOI: 10.1074/mcp.m116.058115] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 04/08/2016] [Indexed: 12/13/2022] Open
Abstract
Acute spinal cord injury (SCI) is a devastating condition with many consequences and no known effective treatment. Although it is quite easy to diagnose traumatic SCI, the assessment of injury severity and projection of disease progression or recovery are often challenging, as no consensus biomarkers have been clearly identified. Here rats were subjected to experimental moderate or severe thoracic SCI. At 24h and 7d postinjury, spinal cord segment caudal to injury center versus sham samples was harvested and subjected to differential proteomic analysis. Cationic/anionic-exchange chromatography, followed by 1D polyacrylamide gel electrophoresis, was used to reduce protein complexity. A reverse phase liquid chromatography-tandem mass spectrometry proteomic platform was then utilized to identify proteome changes associated with SCI. Twenty-two and 22 proteins were up-regulated at 24 h and 7 day after SCI, respectively; whereas 19 and 16 proteins are down-regulated at 24 h and 7 day after SCI, respectively, when compared with sham control. A subset of 12 proteins were identified as candidate SCI biomarkers - TF (Transferrin), FASN (Fatty acid synthase), NME1 (Nucleoside diphosphate kinase 1), STMN1 (Stathmin 1), EEF2 (Eukaryotic translation elongation factor 2), CTSD (Cathepsin D), ANXA1 (Annexin A1), ANXA2 (Annexin A2), PGM1 (Phosphoglucomutase 1), PEA15 (Phosphoprotein enriched in astrocytes 15), GOT2 (Glutamic-oxaloacetic transaminase 2), and TPI-1 (Triosephosphate isomerase 1), data are available via ProteomeXchange with identifier PXD003473. In addition, Transferrin, Cathepsin D, and TPI-1 and PEA15 were further verified in rat spinal cord tissue and/or CSF samples after SCI and in human CSF samples from moderate/severe SCI patients. Lastly, a systems biology approach was utilized to determine the critical biochemical pathways and interactome in the pathogenesis of SCI. Thus, SCI candidate biomarkers identified can be used to correlate with disease progression or to identify potential SCI therapeutic targets.
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Affiliation(s)
- Ahmed Moghieb
- From the ‡Program for Neurotrauma, Neuroproteomics & Biomarkers Research, §The Departments of Psychiatry, and ‖Chemistry, University of Florida, Gainesville, Florida 32611
| | - Helen M Bramlett
- **Department of Neurological Surgery, ‡‡The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, 1095 NW 14th Terrace LPLC 3-18, Miami, Florida, 33136
| | - Jyotirmoy H Das
- From the ‡Program for Neurotrauma, Neuroproteomics & Biomarkers Research, §§Washington University School of Medicine, St. Louis, Missouri 63110
| | - Zhihui Yang
- From the ‡Program for Neurotrauma, Neuroproteomics & Biomarkers Research, §The Departments of Psychiatry, and
| | - Tyler Selig
- From the ‡Program for Neurotrauma, Neuroproteomics & Biomarkers Research
| | - Richard A Yost
- ‖Chemistry, University of Florida, Gainesville, Florida 32611
| | - Michael S Wang
- **Department of Neurological Surgery, ‡‡The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, 1095 NW 14th Terrace LPLC 3-18, Miami, Florida, 33136
| | - W Dalton Dietrich
- **Department of Neurological Surgery, ‡‡The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, 1095 NW 14th Terrace LPLC 3-18, Miami, Florida, 33136
| | - Kevin K W Wang
- From the ‡Program for Neurotrauma, Neuroproteomics & Biomarkers Research, §The Departments of Psychiatry, and ¶Neuroscience,
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Basic Principles and Clinical Applications of Magnetic Resonance Spectroscopy in Neuroradiology. J Comput Assist Tomogr 2016; 40:1-13. [PMID: 26484954 DOI: 10.1097/rct.0000000000000322] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Magnetic resonance spectroscopy is a powerful tool to assist daily clinical diagnostics. This review is intended to give an overview on basic principles of the technology, discuss some of its technical aspects, and present typical applications in daily clinical routine in neuroradiology.
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Abstract
CLINICAL/METHODICAL ISSUE Acceleration-deceleration rotational brain trauma is a common cause of disability or death in young adults and often leads to a focal destruction of axons. The resulting pathology, axonal shear injury is referred to as diffuse axonal injury (DAI). The DAI-associated lesions occur bilaterally, are widely dispersed and have been observed in the surface and deep white matter. They are found near to and far from the impact site. STANDARD RADIOLOGICAL METHODS When DAI is clinically suspected, magnetic resonance imaging (MRI) is the method of choice for further clarification, especially in patients where cranial computed tomography (CT) is inconspicuous. METHODICAL INNOVATIONS To investigate the presence of DAI after traumatic brain injury (TBI), a multimodal MRI approach is applied including the common structural and also functional imaging sequences. PERFORMANCE For structural MRI, fluid-attenuated inversion recovery (FLAIR) weighted and susceptibility contrast imaging (SWI) are the sequences mainly used. The SWI technique is extremely sensitive to blood breakdown products, which appear as small signal voids at three locations, at the gray-white interface, in the corpus callosum and in the brain stem. Functional MRI comprises a group of constantly developing techniques that have great potential in optimal evaluation of the white matter in patients after craniocerebral trauma. These imaging techniques allow the visualization of changes associated with shear injuries, such as functional impairment of axons and decreased blood flow and abnormal metabolic activity of the brain parts affected. ACHIEVEMENTS The multimodal MRI approach in patients with DAI results in a more detailed and differentiated representation of the underlying pathophysiological changes of the injured nerve tracts and helps to improve the diagnostic and prognostic accuracy of MRI. PRACTICAL RECOMMENDATIONS When DAI is suspected multimodal MRI should be performed as soon as possible after craniocerebral injury.
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Diffusion tensor imaging and magnetic resonance spectroscopy in traumatic brain injury: a review of recent literature. Brain Imaging Behav 2015; 8:487-96. [PMID: 24449140 DOI: 10.1007/s11682-013-9288-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Concussion is the most common form of traumatic brain injury (TBI), but diagnosis remains controversial because the brain appears quite normal in conventional computed tomography and magnetic resonance imaging (MRI). These conventional tools are not sensitive enough to detect diffuse traumatic axonal injury, and cannot depict aberrations in mild TBIs. Advanced MRI modalities including diffusion tensor imaging (DTI), and magnetic resonance spectroscopy (MRS), make it possible to detect brain injuries in TBI. The purpose of this review is to provide the latest information regarding the visualization and quantification of important abnormalities in TBI and new insights into their clinical significance. Advanced imaging modalities allow the discovery of biomarkers of injury and the detection of changes in brain injury over time. Such tools will likely be used to evaluate treatment efficacy in research. Combining multiple imaging modalities would not only provide greater insight into the underlying physiological changes in TBI, but also improve diagnostic accuracy in predicting outcomes. In this review we present evidence of brain abnormalities in TBI based on investigations using MRI, including DTI and MRS. Our review provides a summary of some of the important studies published from 2002 to 2012 on the topic of MRI findings in head trauma. With the growing realization that even mild head injury can lead to neurocognitive deficits, medical imaging has assumed preeminence for detecting abnormalities associated with TBI. Advanced MRI modalities such as DTI and MRS have an important role in the diagnosis of lesions for TBI patients.
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22
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Edlow BL, Rosenthal ES. Diagnostic, Prognostic, and Advanced Imaging in Severe Traumatic Brain Injury. CURRENT TRAUMA REPORTS 2015. [DOI: 10.1007/s40719-015-0018-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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23
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Carpenter KLH, Czosnyka M, Jalloh I, Newcombe VFJ, Helmy A, Shannon RJ, Budohoski KP, Kolias AG, Kirkpatrick PJ, Carpenter TA, Menon DK, Hutchinson PJ. Systemic, local, and imaging biomarkers of brain injury: more needed, and better use of those already established? Front Neurol 2015; 6:26. [PMID: 25741315 PMCID: PMC4332345 DOI: 10.3389/fneur.2015.00026] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 01/30/2015] [Indexed: 02/02/2023] Open
Abstract
Much progress has been made over the past two decades in the treatment of severe acute brain injury, including traumatic brain injury and subarachnoid hemorrhage, resulting in a higher proportion of patients surviving with better outcomes. This has arisen from a combination of factors. These include improvements in procedures at the scene (pre-hospital) and in the hospital emergency department, advances in neuromonitoring in the intensive care unit, both continuously at the bedside and intermittently in scans, evolution and refinement of protocol-driven therapy for better management of patients, and advances in surgical procedures and rehabilitation. Nevertheless, many patients still experience varying degrees of long-term disabilities post-injury with consequent demands on carers and resources, and there is room for improvement. Biomarkers are a key aspect of neuromonitoring. A broad definition of a biomarker is any observable feature that can be used to inform on the state of the patient, e.g., a molecular species, a feature on a scan, or a monitoring characteristic, e.g., cerebrovascular pressure reactivity index. Biomarkers are usually quantitative measures, which can be utilized in diagnosis and monitoring of response to treatment. They are thus crucial to the development of therapies and may be utilized as surrogate endpoints in Phase II clinical trials. To date, there is no specific drug treatment for acute brain injury, and many seemingly promising agents emerging from pre-clinical animal models have failed in clinical trials. Large Phase III studies of clinical outcomes are costly, consuming time and resources. It is therefore important that adequate Phase II clinical studies with informative surrogate endpoints are performed employing appropriate biomarkers. In this article, we review some of the available systemic, local, and imaging biomarkers and technologies relevant in acute brain injury patients, and highlight gaps in the current state of knowledge.
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Affiliation(s)
- Keri L. H. Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,*Correspondence: Keri L. H. Carpenter, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK e-mail:
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Ibrahim Jalloh
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Virginia F. J. Newcombe
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Richard J. Shannon
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Karol P. Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter J. Kirkpatrick
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Thomas Adrian Carpenter
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - David K. Menon
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Van Der Naalt J. Resting functional imaging tools (MRS, SPECT, PET and PCT). HANDBOOK OF CLINICAL NEUROLOGY 2015; 127:295-308. [PMID: 25702224 DOI: 10.1016/b978-0-444-52892-6.00019-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Functional imaging includes imaging techniques that provide information about the metabolic and hemodynamic status of the brain. Most commonly applied functional imaging techniques in patients with traumatic brain injury (TBI) include magnetic resonance spectroscopy (MRS), single photon emission computed tomography (SPECT), positron emission tomography (PET) and perfusion CT (PCT). These imaging modalities are used to determine the extent of injury, to provide information for the prediction of outcome, and to assess evidence of cerebral ischemia. In TBI, secondary brain damage mainly comprises ischemia and is present in more than 80% of fatal cases with traumatic brain injury (Graham et al., 1989; Bouma et al., 1991; Coles et al., 2004). In particular, while SPECT measures cerebral perfusion and MRS determines metabolism, PET is able to assess both perfusion and cerebral metabolism. This chapter will describe the application of these techniques in traumatic brain injury separately for the major groups of severity comprising the mild and moderate to severe group. The application in TBI and potential difficulties of each technique is described. The use of imaging techniques in children will be separately outlined.
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Affiliation(s)
- J Van Der Naalt
- Department of Neurology, University Medical Center Groningen, University of Groningen, The Netherlands.
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26
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Yang A, Xiao XH, Wang ZL. Evaluation of normal changes in pons metabolites due to aging using turbo spectroscopic imaging. AJNR Am J Neuroradiol 2014; 35:2099-105. [PMID: 24994832 DOI: 10.3174/ajnr.a4031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE To date, MRS study of both normal and pathologic brains have focused mainly on the supratentorial regions; few studies have investigated the infratentorial regions. However, the pons, an important structure of the brain, is associated with many neurodegenerative diseases and is often damaged by brain trauma. For MRS study of pontine disease, one must obtain MRS reference data on normal metabolite levels in the pons, including data on how these levels vary with age. The aim of this study was to analyze normal, age-related, metabolic changes in the pons by using turbo spectroscopic imaging. MATERIALS AND METHODS Seventy-eight healthy subjects with ages ranging from 5 days to 78 years were included in this study. NAA/Cr, Cho/Cr, and Cho/NAA ratios were measured by using turbo spectroscopic imaging. The 78 cases were divided into 4 groups by age: 0-5, 6-20, 21-50, and older than 50 years. The metabolite levels were compared with observed age-related changes among the groups. RESULTS The normal mean pontine metabolite ratios obtained for the combined age groups were NAA/Cr, 2.44 ± 0.45 (mean); Cho/Cr, 1.93 ± 0.25; and Cho/NAA, 0.83 ± 0.28. Statistically significant differences were found in the NAA/Cr between the 0- to 5- and 6- to 20-year-old groups, and among the 6- to 20-, 21- to 50-, and older than 50-year-old groups. A statistically significant difference was found in Cho/Cr between the 0- to 5- and 6- to 20-year-old subjects; however, no differences were found among the 6- to 20-, 21- to 50-, and older than 50-year-old groups. Statistically significant differences in Cho/NAA were also found among the 4 age groups. The NAA/Cr at birth was low, it rose rapidly at 0-5 years, reaching a peak at approximately 10-20 years, and then gradually decreased. The Cho/Cr decreased rapidly at 0-5 years, then continued to decline, and was stable after 20 years of age. CONCLUSIONS Turbo spectroscopic imaging is a good method for analyzing normal changes in the pons metabolites during growth, maturation, and aging.
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Affiliation(s)
- A Yang
- From the Medical Imaging Center, Affiliated Zhongshan City Hospital of Sun Yat-sen University, Zhongshan City, Guangdong Province, China.
| | - X h Xiao
- From the Medical Imaging Center, Affiliated Zhongshan City Hospital of Sun Yat-sen University, Zhongshan City, Guangdong Province, China
| | - Z l Wang
- From the Medical Imaging Center, Affiliated Zhongshan City Hospital of Sun Yat-sen University, Zhongshan City, Guangdong Province, China
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Liu S, Shen G, Deng S, Wang X, Wu Q, Guo A. Hyperbaric oxygen therapy improves cognitive functioning after brain injury. Neural Regen Res 2014; 8:3334-43. [PMID: 25206655 PMCID: PMC4145948 DOI: 10.3969/j.issn.1673-5374.2013.35.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 11/02/2013] [Indexed: 01/09/2023] Open
Abstract
Hyperbaric oxygen therapy has been widely applied and recognized in the treatment of brain injury; however, the correlation between the protective effect of hyperbaric oxygen therapy and changes of metabolites in the brain remains unclear. To investigate the effect and potential mechanism of hyperbaric oxygen therapy on cognitive functioning in rats, we established traumatic brain injury models using Feeney's free falling method. We treated rat models with hyperbaric oxygen therapy at 0.2 MPa for 60 minutes per day. The Morris water maze test for spatial navigation showed that the average escape latency was significantly prolonged and cognitive function decreased in rats with brain injury. After treatment with hyperbaric oxygen therapy for 1 and 2 weeks, the rats’ spatial learning and memory abilities were improved. Hydrogen proton magnetic resonance spectroscopy analysis showed that the N-acetylaspartate/creatine ratio in the hippocampal CA3 region was significantly increased at 1 week, and the N-acetylaspartate/choline ratio was significantly increased at 2 weeks after hyperbaric oxygen therapy. Nissl staining and immunohistochemical staining showed that the number of nerve cells and Nissl bodies in the hippocampal CA3 region was significantly increased, and glial fibrillary acidic protein positive cells were decreased after a 2-week hyperbaric oxygen therapy treatment. Our findings indicate that hyperbaric oxygen therapy significantly improves cognitive functioning in rats with traumatic brain injury, and the potential mechanism is mediated by metabolic changes and nerve cell restoration in the hippocampal CA3 region.
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Affiliation(s)
- Su Liu
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Guangyu Shen
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Shukun Deng
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Xiubin Wang
- Department of Imaging, Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Qinfeng Wu
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Aisong Guo
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
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Dhandapani S, Sharma A, Sharma K, Das L. Comparative evaluation of MRS and SPECT in prognostication of patients with mild to moderate head injury. J Clin Neurosci 2014; 21:745-50. [DOI: 10.1016/j.jocn.2013.07.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 06/22/2013] [Accepted: 07/04/2013] [Indexed: 02/08/2023]
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Mendes Arent A, de Souza LF, Walz R, Dafre AL. Perspectives on molecular biomarkers of oxidative stress and antioxidant strategies in traumatic brain injury. BIOMED RESEARCH INTERNATIONAL 2014; 2014:723060. [PMID: 24689052 PMCID: PMC3943200 DOI: 10.1155/2014/723060] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 12/04/2013] [Accepted: 12/09/2013] [Indexed: 11/23/2022]
Abstract
Traumatic brain injury (TBI) is frequently associated with abnormal blood-brain barrier function, resulting in the release of factors that can be used as molecular biomarkers of TBI, among them GFAP, UCH-L1, S100B, and NSE. Although many experimental studies have been conducted, clinical consolidation of these biomarkers is still needed to increase the predictive power and reduce the poor outcome of TBI. Interestingly, several of these TBI biomarkers are oxidatively modified to carbonyl groups, indicating that markers of oxidative stress could be of predictive value for the selection of therapeutic strategies. Some drugs such as corticosteroids and progesterone have already been investigated in TBI neuroprotection but failed to demonstrate clinical applicability in advanced phases of the studies. Dietary antioxidants, such as curcumin, resveratrol, and sulforaphane, have been shown to attenuate TBI-induced damage in preclinical studies. These dietary antioxidants can increase antioxidant defenses via transcriptional activation of NRF2 and are also known as carbonyl scavengers, two potential mechanisms for neuroprotection. This paper reviews the relevance of redox biology in TBI, highlighting perspectives for future studies.
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Affiliation(s)
- André Mendes Arent
- Department of Biochemistry, Federal University of Santa Catarina, Biological Sciences Centre, 88040-900 Florianópolis, SC, Brazil
- Faculty of Medicine, University of South Santa Catarina (Unisul), 88137-270 Palhoça, SC, Brazil
- Neurosurgery Service, São José Regional Hospital (HRSJ-HMG), 88103-901 São José, SC, Brazil
| | - Luiz Felipe de Souza
- Department of Biochemistry, Federal University of Santa Catarina, Biological Sciences Centre, 88040-900 Florianópolis, SC, Brazil
| | - Roger Walz
- Applied Neurosciences Centre (CeNAp) and Department of Medical Clinics, University Hospital, Federal University of Santa Catarina, 88040-900 Florianópolis, SC, Brazil
| | - Alcir Luiz Dafre
- Department of Biochemistry, Federal University of Santa Catarina, Biological Sciences Centre, 88040-900 Florianópolis, SC, Brazil
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Disorders of consciousness after acquired brain injury: the state of the science. Nat Rev Neurol 2014; 10:99-114. [PMID: 24468878 DOI: 10.1038/nrneurol.2013.279] [Citation(s) in RCA: 445] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The concept of consciousness continues to defy definition and elude the grasp of philosophical and scientific efforts to formulate a testable construct that maps to human experience. Severe acquired brain injury results in the dissolution of consciousness, providing a natural model from which key insights about consciousness may be drawn. In the clinical setting, neurologists and neurorehabilitation specialists are called on to discern the level of consciousness in patients who are unable to communicate through word or gesture, and to project outcomes and recommend approaches to treatment. Standards of care are not available to guide clinical decision-making for this population, often leading to inconsistent, inaccurate and inappropriate care. In this Review, we describe the state of the science with regard to clinical management of patients with prolonged disorders of consciousness. We review consciousness-altering pathophysiological mechanisms, specific clinical syndromes, and novel diagnostic and prognostic applications of advanced neuroimaging and electrophysiological procedures. We conclude with a provocative discussion of bioethical and medicolegal issues that are unique to this population and have a profound impact on care, as well as raising questions of broad societal interest.
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The prognostic reliability of the Glasgow coma score in traumatic brain injuries: evaluation of MRI data. Eur J Trauma Emerg Surg 2012; 39:79-86. [DOI: 10.1007/s00068-012-0240-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 11/14/2012] [Indexed: 10/27/2022]
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Carter E, Coles JP. Imaging in the diagnosis and prognosis of traumatic brain injury. EXPERT OPINION ON MEDICAL DIAGNOSTICS 2012; 6:541-554. [PMID: 23480836 DOI: 10.1517/17530059.2012.707188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a major cause of death and disability worldwide. Improved understanding of the impact of head injury and the extent and development of neuronal loss and cognitive dysfunction could lead to improved therapy and outcome for patients. AREAS COVERED This paper reviews the currently available imaging techniques and defines their role in the diagnosis, management and prediction of outcome following traumatic brain injury. These imaging techniques provide delineation of the structural, physiological and functional derangements that result following acute injury, and map their development and association with late functional deficits. Imaging tools also have a role in defining the pathophysiological mechanisms responsible for further neuronal loss following the primary injury. Finally, this paper provides an overview of the role of functional imaging in classifying unresponsive coma and defining functional reorganisation of the brain following injury. EXPERT OPINION Brain imaging is of key importance in TBI management, enabling efficient and accurate diagnoses to be made, informing management decisions and contributing to prognostication. Developments in imaging techniques promise to improve understanding of the structural and functional derangements, improve management and guide the development and implementation of novel neuroprotective strategies following head injury.
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Affiliation(s)
- Eleanor Carter
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital , Cambridge, CB2 0AA , UK +01223 217889 ; +01223 217887 ;
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Geurts BHJ, Andriessen TMJC, Goraj BM, Vos PE. The reliability of magnetic resonance imaging in traumatic brain injury lesion detection. Brain Inj 2012; 26:1439-50. [PMID: 22731791 DOI: 10.3109/02699052.2012.694563] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study compares inter-rater-reliability, lesion detection and clinical relevance of T2-weighted imaging (T2WI), Fluid Attenuated Inversion Recovery (FLAIR), T2*-gradient recalled echo (T2*-GRE) and Susceptibility Weighted Imaging (SWI) in Traumatic Brain Injury (TBI). METHODS Three raters retrospectively scored 56 TBI patients' MR images (12-76 years old, median TBI-MRI interval 7 weeks) on number, volume, location and intensity. Punctate lesions (diameter <10 mm) were scored separately from large lesions (diameter ≥ 10 mm). Injury severity was assessed with the Glasgow Coma Scale (GCS), outcome with the Glasgow Outcome Scale-Extended (GOSE). RESULTS Inter-rater-reliability for lesion volume and punctate lesion count was good (ICC = 0.69-0.94) except for punctate lesion count on T2WI (ICC = 0.19) and FLAIR (ICC = 0.15). SWI showed the highest number of lesions (mean = 30.0), followed by T2*-GRE (mean = 15.4), FLAIR (mean = 3.1) and T2WI (mean = 2.2). Sequences did not differ in detected lesion volume. Punctate lesion count on T2*-GRE (r = -0.53) and SWI (r = -0.49) correlated with the GCS (p < 0.001). CONCLUSIONS T2*-GRE and SWI are more sensitive than T2WI and FLAIR in detecting (haemorrhagic) traumatic punctate lesions. The correlation between number of punctate lesions on T2*-GRE/SWI and the GCS indicates that haemorrhagic lesions are clinically relevant. The considerable inter-rater-disagreement in this study advocates cautiousness in interpretation of punctate lesions using T2WI and FLAIR.
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Affiliation(s)
- Bram H J Geurts
- Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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Kim HJ. The prognostic factors related to traumatic brain stem injury. J Korean Neurosurg Soc 2012; 51:24-30. [PMID: 22396839 PMCID: PMC3291702 DOI: 10.3340/jkns.2012.51.1.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 12/09/2011] [Accepted: 01/25/2012] [Indexed: 11/27/2022] Open
Abstract
Objective This study was conducted to assess the clinical significance of traumatic brain stem injury (TBSI) reflected on Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS) by various clinical variables. Methods A total of 136 TBSI patients were selected out of 2695 head-injured patients. All initial computerized tomography and/or magnetic resonance imaging studies were retrospectively analyzed according to demographic- and injury variables which result in GCS and GOS. Results In univariate analysis, mode of injury showed a significant effect on combined injury (p<0.001), as were the cases with skull fracture on radiologic finding (p<0.000). The GCS showed a various correlation with radiologic finding (p<0.000), mode of injury (p<0.002), but less favorably with impact site (p<0.052), age (p<0.054) and skull fracture (p<0.057), in order of statistical significances. However, only GOS showed a definite correlation to radiologic finding (p<0.000). In multivariate analysis, the individual variables to enhance an unfavorable effect on GCS were radiologic finding [odds ratio (OR) 7.327, 95% confidence interval (CI)], mode of injury (OR; 4.499, 95% CI) and age (OR; 3.141, 95% CI). Those which influence an unfavorable effect on GOS were radiologic finding (OR; 25.420, 95% CI) and age (OR; 2.674, 95% CI). Conclusion In evaluation of TBSI on outcome, the variables such as radiological finding, mode of injury, and age were revealed as three important ones to have an unfavorable effect on early stage outcome expressed as GCS. However, mode of injury was shown not to have an unfavorable effect on late stage outcome as GOS. Among all unfavorable variables, radiological finding was confirmed as the only powerful prognostic variable both on GCS and GOS.
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Affiliation(s)
- Hun Joo Kim
- Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Korea
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Abstract
Sports-related concussions are complex injuries with biomechanical and biochemical etiology that present with central and autonomic nervous system dysfunction. Current methods for assessing concussions and basing return-to-play decisions rely on symptom resolution, rating scales, and neuropsychological testing, all of which are indirect measures of injury severity and detect functional capabilities but do not directly measure injury location or severity. In addition, these downstream measures are susceptible to false negatives because compensatory mechanism, such as unmasking and redundancies in brain circuitry can return functional capabilities before injury resolution. The multifactorial nature of concussion necessitates rapid, inexpensive, and easily applied multimodal analysis methods that can offer greater sensitivity and specificity. This article discusses how new approaches utilizing electrophysiology (e.g., QEEG, ERP, ECG, HRV), quantified balance measures, and biochemistry are necessary to advance the science of concussion assessment, treatment, recovery projections, and return-to-play decisions. These additional assessment tools offer a more direct window into the severity and location of the injury, real-time measures of brain function, and the ability to measure the multiple body systems negatively affected by concussion.
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Abstract
This article discusses brain trauma and impaired consciousness. It reviews the various states of impaired consciousness related to trauma, with an historical and current literature viewpoint. The causes and pathophysiology of impaired consciousness in concussion, diffuse axonal injury, and focal brain lesions are discussed and management options evaluated.
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Affiliation(s)
- Sandrine de Ribaupierre
- Division of Neurosurgery, Department of Clinical Neurological Sciences, University of Western Ontario, Victoria Hospital, 800 Commissioners Road East, London, ON N6A 5W9, Canada.
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Marino S, Ciurleo R, Bramanti P, Federico A, De Stefano N. 1H-MR spectroscopy in traumatic brain injury. Neurocrit Care 2011; 14:127-33. [PMID: 20737247 DOI: 10.1007/s12028-010-9406-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Traumatic brain injury (TBI) is a common cause of neurological damage and disability. Conventional imaging (CT scan or MRI) is highly sensitive in detecting lesions and provides important clinical information regarding the need for acute intervention. However, abnormalities detected by CT scan or conventional MRI have limited importance in the classification of the degree of clinical severity and in predicting patients' outcome. This can be explained by the widespread microscopic tissue damage occurring after trauma, which is not observable with the conventional structural imaging methods. Advances in neuroimaging over the past two decades have greatly helped in the clinical care and management of patients with TBI. The advent of newer and more sensitive imaging techniques is now being used to better characterize the nature and evolution of injury and the underlying mechanisms that lead to progressive neurodegeneration, recovery or subsequent plasticity. This review will describe the role of proton magnetic resonance spectroscopic (MRS), an advanced MRI technique as related to its use in TBI. Proton MRS is a noninvasive approach that acquires metabolite information reflecting neuronal integrity and function from multiple brain regions and allows to assess clinical severity and to predict disease outcome.
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Affiliation(s)
- Silvia Marino
- IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy.
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Skandsen T, Kvistad KA, Solheim O, Lydersen S, Strand IH, Vik A. Prognostic value of magnetic resonance imaging in moderate and severe head injury: a prospective study of early MRI findings and one-year outcome. J Neurotrauma 2011; 28:691-9. [PMID: 21401308 DOI: 10.1089/neu.2010.1590] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The clinical benefit of early magnetic resonance imaging (MRI) in severe and moderate head injury is unclear. We sought to explore the prognostic value of the depth of lesions depicted with early MRI, and also to describe the prevalence and impact of traumatic brainstem lesions. In a cohort of 159 consecutive patients with moderate to severe head injury (age 5-65 years and surviving the acute phase) admitted to a regional level 1 trauma center, 106 (67%) were examined with MRI within 4 weeks post-injury. Depth of lesions in MRI was categorized as: hemisphere level, central level, and brainstem injury (BSI). The outcome measure was Glasgow Outcome Scale Extended (GOSE) 12 months post-injury. Forty-six percent of patients with severe injuries and 14% of patients with moderate injuries had BSI. In severe head injury, central or brainstem lesions in MRI, together with higher Rotterdam CT score, pupillary dilation, and secondary adverse events were significantly associated with a worse outcome in age-adjusted analyses. Bilateral BSI was strongly associated with a poor outcome in severe injury, with positive and negative predictive values of 0.86 and 0.88, respectively. In moderate injury, only age was significantly associated with outcome in multivariable analyses. Limitations of the current study include lack of blinded outcome evaluations and insufficient statistical power to assess the added prognostic value of MRI when combined with clinical information. We conclude that in patients with severe head injury surviving the acute phase, depth of lesion on the MRI was associated with outcome, and in particular, bilateral brainstem injury was strongly associated with poor outcomes. In moderate head injury, surprisingly, there was no association between MRI findings and outcome when using the GOSE score as outcome measure.
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Affiliation(s)
- Toril Skandsen
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.
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Demertzi A, Schnakers C, Soddu A, Bruno MA, Gosseries O, Vanhaudenhuyse A, Laureys S. Neural plasticity lessons from disorders of consciousness. Front Psychol 2011; 1:245. [PMID: 21833298 PMCID: PMC3153849 DOI: 10.3389/fpsyg.2010.00245] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Accepted: 12/24/2010] [Indexed: 11/20/2022] Open
Abstract
Communication and intentional behavior are supported by the brain's integrity at a structural and a functional level. When widespread loss of cerebral connectivity is brought about as a result of a severe brain injury, in many cases patients are not capable of conscious interactive behavior and are said to suffer from disorders of consciousness (e.g., coma, vegetative state/unresponsive wakefulness syndrome, minimally conscious states). This lesion paradigm has offered not only clinical insights, as how to improve diagnosis, prognosis, and treatment, but also put forward scientific opportunities to study the brain's plastic abilities. We here review interventional and observational studies performed in severely brain-injured patients with regards to recovery of consciousness. The study of the recovered conscious brain (spontaneous and/or after surgical or pharmacologic interventions), suggests a link between some specific brain areas and the capacity of the brain to sustain conscious experience, challenging at the same time the notion of fixed temporal boundaries in rehabilitative processes. Altered functional connectivity, cerebral structural reorganization as well as behavioral amelioration after invasive treatments will be discussed as the main indices for plasticity in these challenging patients. The study of patients with chronic disorders of consciousness may, thus, provide further insights not only at a clinical level (i.e., medical management and rehabilitation) but also from a scientific-theoretical perspective (i.e., the brain's plastic abilities and the pursuit of the neural correlate of consciousness).
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Affiliation(s)
- Athena Demertzi
- Coma Science Group, Cyclotron Research Centre and Neurology Department, Sart Tilman, University and University Hospital of Liège Liège, Belgium
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Skandsen T, Kvistad KA, Solheim O, Strand IH, Folvik M, Vik A. Prevalence and impact of diffuse axonal injury in patients with moderate and severe head injury: a cohort study of early magnetic resonance imaging findings and 1-year outcome. J Neurosurg 2010; 113:556-63. [PMID: 19852541 DOI: 10.3171/2009.9.jns09626] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this prospective cohort study the authors examined patients with moderate to severe head injuries using MR imaging in the early phase. The objective was to explore the occurrence of diffuse axonal injury (DAI) and determine whether DAI was related to level of consciousness and patient outcome. METHODS One hundred and fifty-nine patients (age range 5-65 years) with traumatic brain injury, who survived the acute phase, and who had a Glasgow Coma Scale (GCS) score of 3-13 were admitted between October 2004 and August 2008. Of these 159 patients, 106 were examined using MR imaging within 4 weeks postinjury. Patients were classified into 1 of 3 stages of DAI: Stage 1, in which lesions were confined to the lobar white matter; Stage 2, in which there were callosal lesions; and Stage 3, in which lesions occurred in the dorsolateral brainstem. The outcome measure used 12 months postinjury was the Glasgow Outcome Scale-Extended (GOSE). RESULTS Diffuse axonal injury was detected in 72% of the patients and a combination of DAI and contusions or hematomas was found in 50%. The GCS score was significantly lower in patients with "pure DAI" (median GCS Score 9) than in patients without DAI (median GCS Score 12; p < 0.001). The GCS score was related to outcome only in those patients with DAI (r = 0.47; p = 0.001). Patients with DAI had a median GOSE score of 7, and patients without DAI had a median GOSE score of 8 (p = 0.10). Outcome was better in patients with DAI Stage 1 (median GOSE Score 8) and DAI Stage 2 (median GOSE Score 7.5) than in patients with DAI Stage 3 (median GOSE Score 4; p < 0.001). Thus, in patients without any brainstem injury, there was no difference in good recovery between patients with DAI (67%) and patients without DAI (66%). CONCLUSIONS Diffuse axonal injury was found in almost three-quarters of the patients with moderate and severe head injury who survived the acute phase. Diffuse axonal injury influenced the level of consciousness, and only in patients with DAI was GCS score related to outcome. Finally, DAI was a negative prognostic sign only when located in the brainstem.
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Affiliation(s)
- Toril Skandsen
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.
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Fernández-Espejo D, Bekinschtein T, Monti MM, Pickard JD, Junque C, Coleman MR, Owen AM. Diffusion weighted imaging distinguishes the vegetative state from the minimally conscious state. Neuroimage 2010; 54:103-12. [PMID: 20728553 DOI: 10.1016/j.neuroimage.2010.08.035] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 08/12/2010] [Accepted: 08/13/2010] [Indexed: 01/12/2023] Open
Abstract
The vegetative (VS) and minimally conscious (MCS) states are currently distinguished on the basis of exhibited behaviour rather than underlying pathology. Although previous histopathological studies have documented different degrees of diffuse axonal injury as well as damage to the thalami and brainstem regions in VS and MCS, these differences have not been assessed in vivo, and therefore, do not provide a measurable pathological marker to aid clinical diagnosis. Currently, the diagnostic decision-making process is highly subjective and prone to error. Indeed, previous work has suggested that up to 43% of patients in this group may be misdiagnosed. We used diffusion tensor imaging (DTI) to study the neuropathology of 25 vegetative and minimally conscious patients in vivo and to identify measures that could potentially distinguish the patients in these two groups. Mean diffusivity (MD) maps of the subcortical white matter, brainstem and thalami were generated. The MCS and VS patients differed significantly in subcortical white matter and thalamic regions, but appeared not to differ in the brainstem. Moreover, the DTI results predicted scores on the Coma Recovery Scale (p<0.001) and successfully classified the patients in to their appropriate diagnostic categories with an accuracy of 95%. The results suggest that this method may provide an objective and highly accurate method for classifying these challenging patient populations and may therefore complement the behavioural assessment to inform the diagnostic decision making process.
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Govind V, Gold S, Kaliannan K, Saigal G, Falcone S, Arheart KL, Harris L, Jagid J, Maudsley AA. Whole-brain proton MR spectroscopic imaging of mild-to-moderate traumatic brain injury and correlation with neuropsychological deficits. J Neurotrauma 2010; 27:483-96. [PMID: 20201668 DOI: 10.1089/neu.2009.1159] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Changes in the distribution of the magnetic resonance (MR)-observable brain metabolites N-acetyl aspartate (NAA), total choline (Cho), and total creatine (Cre), following mild-to-moderate closed-head traumatic brain injury (mTBI) were evaluated using volumetric proton MR spectroscopic imaging (MRSI). Studies were carried out during the subacute time period following injury, and associations of metabolite indices with neuropsychological test (NPT) results were evaluated. Twenty-nine subjects with mTBI and Glasgow Coma Scale (GCS) scores of 10-15 were included. Differences in individual metabolite and metabolite ratio distributions relative to those of age-matched control subjects were evaluated, as well as analyses by hemispheric lobes and tissue types. Primary findings included a widespread decrease of NAA and NAA/Cre, and increases of Cho and Cho/NAA, within all lobes of the TBI subject group, and with the largest differences seen in white matter. Examination of the association between all of the metabolite measures and the NPT scores found the strongest negative correlations to occur in the frontal lobe and for Cho/NAA. No significant correlations were found between any of the MRSI or NPT measures and the GCS. These results demonstrate that significant and widespread alterations of brain metabolites occur as a result of mild-to-moderate TBI, and that these measures correlate with measures of cognitive performance.
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Affiliation(s)
- Varan Govind
- Department of Radiology, University of Miami School of Medicine, Miami, Florida 33136, USA.
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Qian J, Herrera JJ, Narayana PA. Neuronal and axonal degeneration in experimental spinal cord injury: in vivo proton magnetic resonance spectroscopy and histology. J Neurotrauma 2010; 27:599-610. [PMID: 20001674 DOI: 10.1089/neu.2009.1145] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Longitudinal in vivo proton magnetic resonance spectroscopy (1H-MRS) and immunohistochemistry were performed to investigate the tissue degeneration in traumatically injured rat spinal cord rostral and caudal to the lesion epicenter. On 1H-MRS significant decreases in N-acetyl aspartate (NAA) and total creatine (Cr) levels in the rostral, epicenter, and caudal segments were observed by 14 days, and levels remained depressed up to 56 days post-injury (PI). In contrast, the total choline (Cho) levels increased significantly in all three segments by 14 days PI, but recovered in the epicenter and caudal, but not the rostral region, at 56 days PI. Immunohistochemistry demonstrated neuronal cell death in the gray matter, and reactive astrocytes and axonal degeneration in the dorsal, lateral, and ventral white-matter columns. These results suggest delayed tissue degeneration in regions both rostrally and caudally from the epicenter in the injured spinal cord tissue. A rostral-caudal asymmetry in tissue recovery was seen both on MRI-observed hyperintense lesion volume and the Cho, but not NAA and Cr, levels at 56 days PI. These studies suggest that dynamic metabolic changes take place in regions away from the epicenter in injured spinal cord.
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Affiliation(s)
- Junchao Qian
- Department of Diagnostic and Interventional Imaging, The University of Texas Medical School at Houston, Houston, Texas 77030, USA
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Lescot T, Fulla-Oller L, Fulla-Oller L, Po C, Chen XR, Puybasset L, Gillet B, Plotkine M, Meric P, Marchand-Leroux C. Temporal and regional changes after focal traumatic brain injury. J Neurotrauma 2010; 27:85-94. [PMID: 19705964 DOI: 10.1089/neu.2009.0982] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Magnetic resonance imaging (MRI) is widely used to evaluate the consequences of traumatic brain injury (TBI) in both experimental and clinical studies. Improved assessment of experimental TBI using the same methods as those used in clinical investigations would help to translate laboratory research into clinical advances. Here our goal was to characterize lateral fluid percussion-induced TBI, with special emphasis on differentiating the contused cortex from the pericontusional subcortical tissue. We used both in vivo MRI and proton magnetic resonance spectroscopy ((1)H-MRS) to evaluate adult male Sprague-Dawley rats 24 h and 48 h and 7 days after TBI. T2 and apparent diffusion coefficient (ADC) maps were derived from T2-weighted and diffusion-weighted images, respectively. Ratios of N-acetylaspartate (NAA), choline compounds (Cho), and lactate (Lac) over creatine (Cr) were estimated by (1)H-MRS. T2 values were high in the contused cortex 24 h after TBI, suggesting edema development; ADC was low, consistent with cytotoxic edema. At the same site, NAA/Cr was decreased and Lac/Cr elevated during the first week after TBI. In the ipsilateral subcortical area, NAA/Cr was markedly decreased and Lac/Cr was elevated during the first week, although MRI showed no evidence of edema, suggesting that (1)H-MRS detected "invisible" damage. (1)H-MRS combined with MRI may improve the detection of brain injury. Extensive assessments of animal models may increase the chances of developing successful neuroprotective strategies.
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Affiliation(s)
- Thomas Lescot
- Equipe de recherche Pharmacologie de la Circulation Cérébrale (EA 2510), Faculté des Sciences Pharmaceutiques et Biologiques, Université Paris Descartes, Paris, France.
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Golan E, Menon DK. Can computed tomography predict neurological outcomes after cardiac arrest? Resuscitation 2010; 81:509-10. [PMID: 20398846 DOI: 10.1016/j.resuscitation.2010.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Tshibanda L, Vanhaudenhuyse A, Boly M, Soddu A, Bruno MA, Moonen G, Laureys S, Noirhomme Q. Neuroimaging after coma. Neuroradiology 2010; 52:15-24. [PMID: 19862509 DOI: 10.1007/s00234-009-0614-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 10/07/2009] [Indexed: 01/12/2023]
Abstract
Following coma, some patients will recover wakefulness without signs of consciousness (only showing reflex movements, i.e., the vegetative state) or may show non-reflex movements but remain without functional communication (i.e., the minimally conscious state). Currently, there remains a high rate of misdiagnosis of the vegetative state (Schnakers et. al. BMC Neurol, 9:35, 8) and the clinical and electrophysiological markers of outcome from the vegetative and minimally conscious states remain unsatisfactory. This should incite clinicians to use multimodal assessment to detect objective signs of consciousness and validate para-clinical prognostic markers in these challenging patients. This review will focus on advanced magnetic resonance imaging (MRI) techniques such as magnetic resonance spectroscopy, diffusion tensor imaging, and functional MRI (fMRI studies in both "activation" and "resting state" conditions) that were recently introduced in the assessment of patients with chronic disorders of consciousness.
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Affiliation(s)
- Luaba Tshibanda
- Coma Science Group, Cyclotron Research Center, University and University Hospital of Liège, Sart-Tilman, B30 Liège, Belgium
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Schlosser HG, Lindemann JN, Vajkoczy P, Clarke AH. Vestibulo-ocular monitoring as a predictor of outcome after severe traumatic brain injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R192. [PMID: 19948056 PMCID: PMC2811919 DOI: 10.1186/cc8187] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2009] [Revised: 09/23/2009] [Accepted: 11/30/2009] [Indexed: 11/22/2022]
Abstract
Introduction Based on the knowledge that traumatic brainstem damage often leads to alteration in brainstem functions, including the vestibulo-ocular reflex, the present study is designed to determine whether prediction of outcome in the early phase after severe traumatic brain injury is possible by means of vestibulo-ocular monitoring. Methods Vestibulo-ocular monitoring is based on video-oculographic recording of eye movements during galvanic labyrinth polarization. The integrity of vestibulo-ocular reflex is determined from the eye movement response during vestibular galvanic labyrinth polarization stimulation. Vestibulo-ocular monitoring is performed within three days after traumatic brain injury and the oculomotor response compared to outcome after six months (Glasgow Outcome Score). Results Twenty-seven patients underwent vestibulo-ocular monitoring within three days after severe traumatic brain injury. One patient was excluded from the study. In 16 patients oculomotor response was induced, in the remaining 11 patients no oculomotor response was observed. The patients' outcome was classified as Glasgow Outcome Score 1-2 or as Glasgow Outcome Score 3 to 5. Statistical testing supported the hypothesis that those patients with oculomotor response tended to recover (exact two-sided Fisher-Test (P < 10-3)). Conclusions The results indicate that vestibulo-ocular monitoring with galvanic labyrinth polarization performed during the first days after traumatic brain injury helps to predict favourable or unfavourable outcome. As an indicator of brainstem function, vestibulo-ocular monitoring provides a useful, complementary approach to the identification of brainstem lesions by imaging techniques.
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Affiliation(s)
- Hans-Georg Schlosser
- Department of Neurosurgery, Universitätsmedizin Berlin, Charité - Campus Virchow Klinikum, Berlin 13353, Germany.
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Rousseau MC, Confort-Gouny S, Catala A, Graperon J, Blaya J, Soulier E, Viout P, Galanaud D, Fur YL, Cozzone PJ, Ranjeva JP. A MRS-MRI-fMRI exploration of the brain. Impact of long-lasting persistent vegetative state. Brain Inj 2009; 22:123-34. [DOI: 10.1080/02699050801895415] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Experience of diffusion tensor imaging and 1H spectroscopy for outcome prediction in severe traumatic brain injury: Preliminary results. Crit Care Med 2009; 37:1448-55. [PMID: 19242330 DOI: 10.1097/ccm.0b013e31819cf050] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The objective of the study is to test whether multimodal magnetic resonance imaging can provide a reliable outcome prediction of the clinical status, focusing on consciousness at 1 year after severe traumatic brain injury (TBI). DESIGN Single center prospective cohort with consecutive inclusions. SETTING Critical Care Neurosurgical Unit of a university hospital. PATIENTS Forty-three TBI patients not responding to simple orders after sedation cessation and 15 healthy controls. INTERVENTIONS A multimodal magnetic resonance imaging combining morphologic sequences, diffusion tensor imaging (DTI), and H proton magnetic resonance spectroscopy (MRS) was performed 24 +/- 11 days after severe TBI. The ability of DTI and MRS to predict 1-year outcome was assessed by linear discriminant analysis (LDA). Robustness of the classification was tested using a bootstrap procedure. MEASUREMENTS AND MAIN RESULTS Fractional anisotropy (FA) was computed as the mean of values at discrete brain sites in the infratentorial and supratentorial regions. The N-acetyl aspartate/creatine (NAA/Cr) ratio was measured in the thalamus, lenticular nucleus, insular cortex, occipital periventricular white matter, and pons. After 1 year, 19 (44%) patients had unfavorable outcomes (death, persistent vegetative state, or minimally conscious state) and 24 (56%) favorable outcomes (normal consciousness with or without functional impairments). Analysis of variance was performed to compare FA and NAA/Cr in the two outcome groups and controls. FA and MRS findings showed highly significant differences between the outcome groups, with significant variables by LDA being supratentorial FA, NAA/Cr (pons), NAA/Cr (thalamus), NAA/Cr (insula), and infratentorial FA. LDA of combined FA and MRS data clearly separated the unfavorable outcome, favorable outcome, and control groups, with no overlap. Unfavorable outcome was predicted with up to 86% sensitivity and 97% specificity; these values were better than those obtained with DTI or MRS alone. CONCLUSION FA and NAA/Cr hold potential as quantitative outcome-prediction tools at the subacute phase of TBI.
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Lescot T, Galanaud D, Puybasset L. Exploring altered consciousness states by magnetic resonance imaging in brain injury. Ann N Y Acad Sci 2009; 1157:71-80. [PMID: 19351357 DOI: 10.1111/j.1749-6632.2008.04120.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Traumatic brain injury (TBI) occurs abruptly, involves multiple specialized teams, calls on the health-care system in its emergency dimension, and engages the well-being of the patient and his relatives for a lifetime period. Clinicians in charge of these patients are faced with issues of uppermost importance: medical issues such as predicting the long-term neurological outcome of the comatose patient; ethical issues because of the influence of intensive care on the long-term survival of patients in a vegetative and minimally conscious state; legal issues because of the law that has set the concept of proportionality of care as the legal rule; and social issues as the result of the very high cost of these pathologies. Today's larger availability of magnetic resonance imaging (MRI) in ventilated patients and the recent improvements in hardware and in imaging techniques that have made the last-developed imaging techniques such as diffusion tensor imaging and magnetic resonance spectroscopy available in brain-trauma patients, are changing the paradigm in neurointensive care regarding outcome prediction. The old paradigm that no individual prognosis could be made at the subacute phase in TBI patients does not hold true anymore. This major change opens new challenging ethical questions. This review focuses on the brain explorations that are required, such as MRI, magnetic resonance spectroscopy, and diffusion tensor imaging, to provide the clinician with a multimodal assessment of the brain state to predict outcome of coma. Such an assessment will become mandatory in the near future to answer the crucial question of proportionality of care in these patients.
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Affiliation(s)
- Thomas Lescot
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital and Pierre et Marie Curie University, Paris, France
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