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Ferrazzano PA, Rebsamen S, Field AS, Broman AT, Mayampurath A, Rosario B, Buttram S, Willyerd FA, Rathouz PJ, Bell MJ, Alexander AL. MRI and Clinical Variables for Prediction of Outcomes After Pediatric Severe Traumatic Brain Injury. JAMA Netw Open 2024; 7:e2425765. [PMID: 39102267 DOI: 10.1001/jamanetworkopen.2024.25765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024] Open
Abstract
Importance Traumatic brain injury (TBI) is a leading cause of death and disability in children, and predicting functional outcome after TBI is challenging. Magnetic resonance imaging (MRI) is frequently conducted after severe TBI; however, the predictive value of MRI remains uncertain. Objectives To identify early MRI measures that predict long-term outcome after severe TBI in children and to assess the added predictive value of MRI measures over well-validated clinical predictors. Design, Setting, and Participants This preplanned prognostic study used data from the Approaches and Decisions in Acute Pediatric TBI (ADAPT) prospective observational comparative effectiveness study. The ADAPT study enrolled 1000 consecutive children (aged <18 years) with severe TBI between February 1, 2014, and September 30, 2017. Participants had a Glasgow Coma Scale (GCS) score of 8 or less and received intracranial pressure monitoring. Magnetic resonance imaging scans performed as part of standard clinical care within 30 days of injury were collected at 24 participating sites in the US, UK, and Australia. Summary imaging measures were correlated with the Glasgow Outcome Scale-Extended for Pediatrics (GOSE-Peds), and the predictive value of MRI measures was compared with the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) core clinical predictors. Data collection, image analysis, and data analyses were completed in July 2023. Exposures Pediatric severe TBI with an MRI scan performed as part of clinical care. Main Outcomes and Measures All measures were selected a priori. Magnetic resonance imaging measures included contusion, ischemia, diffuse axonal injury, intracerebral hemorrhage, and brainstem injury. Clinical predictors included the IMPACT core measures (GCS motor score and pupil reactivity). All models adjusted for age and sex. Outcome measures included the GOSE-Peds score obtained at 3, 6, and 12 months after injury. Results This study included 233 children with severe TBI who were enrolled at participating sites and had an MRI scan and preselected clinical predictors available. Their median age was 6.9 (IQR, 3.0-13.3) years, and more than half of participants (134 [57.5%]) were male. In a multivariable model including MRI measures and IMPACT core clinical variables, contusion volume (odds ratio [OR], 1.13; 95% CI, 1.02-1.26), brain ischemia (OR, 2.11; 95% CI, 1.58-2.81), brainstem lesions (OR, 5.40; 95% CI, 1.90-15.35), and pupil reactivity were each independently associated with GOSE-Peds score. Adding MRI measures to the IMPACT clinical predictors significantly improved model fit and discrimination between favorable and unfavorable outcomes compared with IMPACT predictors alone (area under the receiver operating characteristic curve, 0.77; 95% CI, 0.72-0.85 vs 0.67; 95% CI, 0.61-0.76 for GOSE-Peds score >3 at 6 months after injury). Conclusions and Relevance In this prognostic study of children with severe TBI, the addition of MRI measures significantly improved outcome prediction over well-established and validated clinical predictors. Magnetic resonance imaging should be considered in children with severe TBI to inform prognosis and may also promote stratification of patients in future clinical trials.
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Affiliation(s)
- Peter A Ferrazzano
- Department of Pediatrics, University of Wisconsin-Madison
- Waisman Center, University of Wisconsin-Madison
| | - Susan Rebsamen
- Department of Radiology, University of Wisconsin-Madison
| | - Aaron S Field
- Department of Radiology, University of Wisconsin-Madison
| | - Aimee T Broman
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison
| | - Anoop Mayampurath
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison
| | - Bedda Rosario
- Department of Epidemiology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sandra Buttram
- Department of Child Health, Phoenix Children's Hospital, Phoenix, Arizona
| | - F Anthony Willyerd
- Department of Child Health, Phoenix Children's Hospital, Phoenix, Arizona
- Barrow Neurological Institute, Phoenix, Arizona
| | - Paul J Rathouz
- Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin
| | - Michael J Bell
- Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Andrew L Alexander
- Waisman Center, University of Wisconsin-Madison
- Department of Medical Physics, University of Wisconsin-Madison
- Department of Psychiatry, University of Wisconsin-Madison
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Liu F, Yao Y, Zhu B, Yu Y, Ren R, Hu Y. The novel imaging methods in diagnosis and assessment of cerebrovascular diseases: an overview. Front Med (Lausanne) 2024; 11:1269742. [PMID: 38660416 PMCID: PMC11039813 DOI: 10.3389/fmed.2024.1269742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
Cerebrovascular diseases, including ischemic strokes, hemorrhagic strokes, and vascular malformations, are major causes of morbidity and mortality worldwide. The advancements in neuroimaging techniques have revolutionized the field of cerebrovascular disease diagnosis and assessment. This comprehensive review aims to provide a detailed analysis of the novel imaging methods used in the diagnosis and assessment of cerebrovascular diseases. We discuss the applications of various imaging modalities, such as computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and angiography, highlighting their strengths and limitations. Furthermore, we delve into the emerging imaging techniques, including perfusion imaging, diffusion tensor imaging (DTI), and molecular imaging, exploring their potential contributions to the field. Understanding these novel imaging methods is necessary for accurate diagnosis, effective treatment planning, and monitoring the progression of cerebrovascular diseases.
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Affiliation(s)
- Fei Liu
- Neuroscience Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Yao
- Neuroscience Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Bingcheng Zhu
- Department of Radiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yue Yu
- Neuroscience Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Reng Ren
- Neuroscience Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yinghong Hu
- Neuroscience Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Lee J, Baniewicz E, Peterkin NL, Greenman D, Griffin AD, Jikaria N, Turtzo LC, Luby M, Latour LL. Edema progression in proximity to traumatic microbleeds: evolution of cytotoxic and vasogenic edema on serial MRI. NEUROIMAGE. REPORTS 2024; 4:100199. [PMID: 38558768 PMCID: PMC10976922 DOI: 10.1016/j.ynirp.2024.100199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Introduction Although cerebral edema is common following traumatic brain injury (TBI), its formation and progression are poorly understood. This is especially true for the mild TBI population, who rarely undergo magnetic resonance imaging (MRI) studies, which can pick up subtle structural details not visualized on computed tomography, in the first few days after injury. This study aimed to visually classify and quantitatively measure edema progression in relation to traumatic microbleeds (TMBs) in a cohort of primarily mild TBI patients up to 30 days after injury. Researchers hypothesized that hypointense lesions on Apparent Diffusion Coefficient (ADC) detected acutely after injury would evolve into hyperintense Fluid Attenuated Inversion Recover (FLAIR) lesions. Methods This study analyzed the progression of cerebral edema after acute injury using multimodal MRI to classify TMBs as potential edema-related biomarkers. ADC and FLAIR MRI were utilized for edema classification at three different timepoints: ≤48 hours, ~1 week, and 30 days after injury. Hypointense lesions on ADC (ADC+) suggested the presence of cytotoxic edema while hyperintense lesions on FLAIR (FLAIR+) suggested vasogenic edema. Signal intensity Ratio (SIR) calculations were made using ADC and FLAIR to quantitatively confirm edema progression. Results Our results indicated the presence of ADC+ lesions ≤48 hours and ~1 week were associated with FLAIR+ lesions at ~1 week and 30 days, respectively, suggesting some progression of cytotoxic edema to vasogenic edema over time. Ten out of 15 FLAIR+ lesions at 30 days (67%) were ADC+ ≤48 hours. However, ADC+ lesions ≤48 hours were not associated with FLAIR+ lesions at 30 days; 10 out of 25 (40%) ADC+ lesions ≤48 hours were FLAIR+ at 30 days, which could indicate that some lesions resolved or were not visualized due to associated atrophy or tissue necrosis. Quantitative analysis confirmed the visual progression of some TMB lesions from ADC+ to FLAIR+. FLAIR SIRs at ~1 week were significantly higher when lesions were ADC+ ≤48 hours (1.22 [1.08-1.32] vs 1.03 [0.97-1.11], p=0.002). Conclusion Awareness of how cerebral edema can evolve in proximity to TMBs acutely after injury may facilitate identification and monitoring of patients with traumatic cerebrovascular injury and assist in development of novel therapeutic strategies.
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Affiliation(s)
- Jacquie Lee
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, Bethesda (MD), United States
- American University, Washington (DC), United States
| | - Emily Baniewicz
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, Bethesda (MD), United States
| | - Nicole L. Peterkin
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, Bethesda (MD), United States
| | - Danielle Greenman
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, Bethesda (MD), United States
- University of California Riverside, Department of Psychology, Riverside, (CA), United States
| | - Allison D. Griffin
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, Bethesda (MD), United States
- Vanderbilt University Institute of Imaging Science, Department of Radiology & Radiological Sciences, Nashville, (TN), United States
| | - Neekita Jikaria
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, Bethesda (MD), United States
- Penn State College of Medicine, Department of Surgery, Hershey, (PA), United States
| | - L. Christine Turtzo
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, Bethesda (MD), United States
| | - Marie Luby
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, Bethesda (MD), United States
| | - Lawrence L. Latour
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, Bethesda (MD), United States
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Precision Effects of Glibenclamide on MRI Endophenotypes in Clinically Relevant Murine Traumatic Brain Injury. Crit Care Med 2023; 51:e45-e59. [PMID: 36661464 PMCID: PMC9848216 DOI: 10.1097/ccm.0000000000005749] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Addressing traumatic brain injury (TBI) heterogeneity is increasingly recognized as essential for therapy translation given the long history of failed clinical trials. We evaluated differential effects of a promising treatment (glibenclamide) based on dose, TBI type (patient selection), and imaging endophenotype (outcome selection). Our goal to inform TBI precision medicine is contextually timely given ongoing phase 2/planned phase 3 trials of glibenclamide in brain contusion. DESIGN Blinded randomized controlled preclinical trial of glibenclamide on MRI endophenotypes in two established severe TBI models: controlled cortical impact (CCI, isolated brain contusion) and CCI+hemorrhagic shock (HS, clinically common second insult). SETTING Preclinical laboratory. SUBJECTS Adult male C57BL/6J mice (n = 54). INTERVENTIONS Mice were randomized to naïve, CCI±HS with vehicle/low-dose (20 μg/kg)/high-dose glibenclamide (10 μg/mouse). Seven-day subcutaneous infusions (0.4 μg/hr) were continued. MEASUREMENTS AND MAIN RESULTS Serial MRI (3 hr, 6 hr, 24 hr, and 7 d) measured hematoma and edema volumes, T2 relaxation (vasogenic edema), apparent diffusion coefficient (ADC, cellular/cytotoxic edema), and 7-day T1-post gadolinium values (blood-brain-barrier [BBB] integrity). Linear mixed models assessed temporal changes. Marked heterogeneity was observed between CCI versus CCI+HS in terms of different MRI edema endophenotypes generated (all p < 0.05). Glibenclamide had variable impact. High-dose glibenclamide reduced hematoma volume ~60% after CCI (p = 0.0001) and ~48% after CCI+HS (p = 4.1 × 10-6) versus vehicle. Antiedema benefits were primarily in CCI: high-dose glibenclamide normalized several MRI endophenotypes in ipsilateral cortex (all p < 0.05, hematoma volume, T2, ADC, and T1-post contrast). Acute effects (3 hr) were specific to hematoma (p = 0.001) and cytotoxic edema reduction (p = 0.0045). High-dose glibenclamide reduced hematoma volume after TBI with concomitant HS, but antiedema effects were not robust. Low-dose glibenclamide was not beneficial. CONCLUSIONS High-dose glibenclamide benefitted hematoma volume, vasogenic edema, cytotoxic edema, and BBB integrity after isolated brain contusion. Hematoma and cytotoxic edema effects were acute; longer treatment windows may be possible for vasogenic edema. Our findings provide new insights to inform interpretation of ongoing trials as well as precision design (dose, sample size estimation, patient selection, outcome selection, and Bayesian analysis) of future TBI trials of glibenclamide.
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He Z, Lang L, Hui J, Ma Y, Yang C, Weng W, Huang J, Zhao X, Zhang X, Liang Q, Jiang J, Feng J. Brain Extract of Subacute Traumatic Brain Injury Promotes the Neuronal Differentiation of Human Neural Stem Cells via Autophagy. J Clin Med 2022; 11:jcm11102709. [PMID: 35628836 PMCID: PMC9145659 DOI: 10.3390/jcm11102709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/03/2022] [Accepted: 05/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background: After a traumatic brain injury (TBI), the cell environment is dramatically changed, which has various influences on grafted neural stem cells (NSCs). At present, these influences on NSCs have not been fully elucidated, which hinders the finding of an optimal timepoint for NSC transplantation. Methods: Brain extracts of TBI mice were used in vitro to simulate the different phase TBI influences on the differentiation of human NSCs. Protein profiles of brain extracts were analyzed. Neuronal differentiation and the activation of autophagy and the WNT/CTNNB pathway were detected after brain extract treatment. Results: Under subacute TBI brain extract conditions, the neuronal differentiation of hNSCs was significantly higher than that under acute brain extract conditions. The autophagy flux and WNT/CTNNB pathway were activated more highly within the subacute brain extract than in the acute brain extract. Autophagy activation by rapamycin could rescue the neuronal differentiation of hNSCs within acute TBI brain extract. Conclusions: The subacute phase around 7 days after TBI in mice could be a candidate timepoint to encourage more neuronal differentiation after transplantation. The autophagy flux played a critical role in regulating neuronal differentiation of hNSCs and could serve as a potential target to improve the efficacy of transplantation in the early phase.
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Affiliation(s)
- Zhenghui He
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (Z.H.); (L.L.); (J.H.); (Y.M.); (C.Y.); (J.J.)
| | - Lijian Lang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (Z.H.); (L.L.); (J.H.); (Y.M.); (C.Y.); (J.J.)
| | - Jiyuan Hui
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (Z.H.); (L.L.); (J.H.); (Y.M.); (C.Y.); (J.J.)
| | - Yuxiao Ma
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (Z.H.); (L.L.); (J.H.); (Y.M.); (C.Y.); (J.J.)
| | - Chun Yang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (Z.H.); (L.L.); (J.H.); (Y.M.); (C.Y.); (J.J.)
| | - Weiji Weng
- Department of Biochemistry and Molecular Cell Biology, Shanghai Key Laboratory for Tumor Microenvironment and Inflammation, School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China;
| | - Jialin Huang
- Shanghai Institute of Head Trauma, Shanghai 200127, China;
| | - Xiongfei Zhao
- Shanghai Angecon Biotechnology Co., Ltd., Shanghai 201318, China; (X.Z.); (X.Z.)
| | - Xiaoqi Zhang
- Shanghai Angecon Biotechnology Co., Ltd., Shanghai 201318, China; (X.Z.); (X.Z.)
| | - Qian Liang
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Jiyao Jiang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (Z.H.); (L.L.); (J.H.); (Y.M.); (C.Y.); (J.J.)
- Shanghai Institute of Head Trauma, Shanghai 200127, China;
| | - Junfeng Feng
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China; (Z.H.); (L.L.); (J.H.); (Y.M.); (C.Y.); (J.J.)
- Shanghai Institute of Head Trauma, Shanghai 200127, China;
- Correspondence: ; Tel.: +86-136-1186-0825
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Munoz-Ballester C, Mahmutovic D, Rafiqzad Y, Korot A, Robel S. Mild Traumatic Brain Injury-Induced Disruption of the Blood-Brain Barrier Triggers an Atypical Neuronal Response. Front Cell Neurosci 2022; 16:821885. [PMID: 35250487 PMCID: PMC8894613 DOI: 10.3389/fncel.2022.821885] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/17/2022] [Indexed: 12/03/2022] Open
Abstract
Mild TBI (mTBI), which affects 75% of TBI survivors or more than 50 million people worldwide each year, can lead to consequences including sleep disturbances, cognitive impairment, mood swings, and post-traumatic epilepsy in a subset of patients. To interrupt the progression of these comorbidities, identifying early pathological events is key. Recent studies have shown that microbleeds, caused by mechanical impact, persist for months after mTBI and are correlated to worse mTBI outcomes. However, the impact of mTBI-induced blood-brain barrier damage on neurons is yet to be revealed. We used a well-characterized mouse model of mTBI that presents with frequent and widespread but size-restricted damage to the blood-brain barrier to assess how neurons respond to exposure of blood-borne factors in this pathological context. We used immunohistochemistry and histology to assess the expression of neuronal proteins in excitatory and inhibitory neurons after mTBI. We observed that the expression of NeuN, Parvalbumin, and CamKII was lost within minutes in areas with blood-brain barrier disruption. Yet, the neurons remained alive and could be detected using a fluorescent Nissl staining even 6 months later. A similar phenotype was observed after exposure of neurons to blood-borne factors due to endothelial cell ablation in the absence of a mechanical impact, suggesting that entrance of blood-borne factors into the brain is sufficient to induce the neuronal atypical response. Changes in postsynaptic spines were observed indicative of functional changes. Thus, this study demonstrates That exposure of neurons to blood-borne factors causes a rapid and sustained loss of neuronal proteins and changes in spine morphology in the absence of neurodegeneration, a finding that is likely relevant to many neuropathologies.
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Affiliation(s)
- Carmen Munoz-Ballester
- Fralin Biomedical Research Institute, Virginia Tech Carilion, Roanoke, VA, United States
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Dzenis Mahmutovic
- Fralin Biomedical Research Institute, Virginia Tech Carilion, Roanoke, VA, United States
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Yusuf Rafiqzad
- Fralin Biomedical Research Institute, Virginia Tech Carilion, Roanoke, VA, United States
- School of Neuroscience, Virginia Tech Carilion, Blacksburg, VA, United States
| | - Alia Korot
- Fralin Biomedical Research Institute, Virginia Tech Carilion, Roanoke, VA, United States
- Kenyon College, Gambier, OH, United States
| | - Stefanie Robel
- Fralin Biomedical Research Institute, Virginia Tech Carilion, Roanoke, VA, United States
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, United States
- School of Neuroscience, Virginia Tech Carilion, Blacksburg, VA, United States
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