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Wang X, Wehbe A, Kaura S, Chaudhry N, Geng X, Ding Y. Updates on Selective Brain Hypothermia: Studies From Bench Work to Clinical Trials. Front Neurol 2022; 13:899547. [PMID: 35599727 PMCID: PMC9120368 DOI: 10.3389/fneur.2022.899547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/13/2022] [Indexed: 12/01/2022] Open
Abstract
Thrombectomy or thrombolysis are the current standards of care for acute ischemic stroke (AIS), however, due to time constraints regarding operations and a multitude of contraindications, AIS remains one of the leading causes of death and chronic disability worldwide. In recent years, therapeutic hypothermia has been explored as an adjuvant therapy for AIS treatment and has shown potential to improve outcomes in patients with AIS. In particular, selective therapeutic hypothermia has shown to markedly reduce infarct volumes and have neuroprotective effects, while also minimizing many systemic side effects seen with systemic therapeutic hypothermia. Both preclinical and clinical trials have demonstrated that selective therapeutic hypothermia is a safe and feasible therapy for patients who have suffered an AIS. In this review, we summarize the current update on selective hypothermia through major studies that have been conducted in rodents, large animals, and clinical trials, and briefly discuss the prospects of selective hypothermic research. We hope this review helps facilitate the exploration of other possible adjuvant treatment modalities in the neuroprotection of ischemic stroke, whether upon symptom onset or after vascular recanalization.
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Affiliation(s)
- Xiaoyu Wang
- Department of Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Alexandra Wehbe
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
| | - Shawn Kaura
- Lake Erie College of Osteopathic Medicine at Seton Hill, Greensburg, PA, United States
| | - Naveed Chaudhry
- Lake Erie College of Osteopathic Medicine at Seton Hill, Greensburg, PA, United States
| | - Xiaokun Geng
- Department of Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
- *Correspondence: Xiaokun Geng
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
- Yuchuan Ding
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Chen S, Lachance BB, Gao L, Jia X. Targeted temperature management and early neuro-prognostication after cardiac arrest. J Cereb Blood Flow Metab 2021; 41:1193-1209. [PMID: 33444088 PMCID: PMC8142127 DOI: 10.1177/0271678x20970059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Targeted temperature management (TTM) is a recommended neuroprotective intervention for coma after out-of-hospital cardiac arrest (OHCA). However, controversies exist concerning the proper implementation and overall efficacy of post-CA TTM, particularly related to optimal timing and depth of TTM and cooling methods. A review of the literature finds that optimizing and individualizing TTM remains an open question requiring further clinical investigation. This paper will summarize the preclinical and clinical trial data to-date, current recommendations, and future directions of this therapy, including new cooling methods under investigation. For now, early induction, maintenance for at least 24 hours, and slow rewarming utilizing endovascular methods may be preferred. Moreover, timely and accurate neuro-prognostication is valuable for guiding ethical and cost-effective management of post-CA coma. Current evidence for early neuro-prognostication after TTM suggests that a combination of initial prediction models, biomarkers, neuroimaging, and electrophysiological methods is the optimal strategy in predicting neurological functional outcomes.
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Affiliation(s)
- Songyu Chen
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Brittany Bolduc Lachance
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Liang Gao
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ferreira RES, de Paiva BLC, de Freitas FGR, Machado FR, Silva GS, Raposo RM, Silveira CF, Centeno RS. Efficacy and Safety of a Nasopharyngeal Catheter for Selective Brain Cooling in Patients with Traumatic Brain Injury: A Prospective, Non-randomized Pilot Study. Neurocrit Care 2021; 34:581-592. [PMID: 32676873 DOI: 10.1007/s12028-020-01052-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 07/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The efficacy objective was to determine whether a novel nasopharyngeal catheter could be used to cool the human brain after traumatic brain injury, and the safety objective was to assess the local and systemic effects of this therapeutic strategy. METHODS This was a prospective, non-randomized, interventional clinical trial that involved five patients with severe traumatic brain injury. The intervention consisted of inducing and maintaining selective brain cooling for 24 h by positioning a catheter in the nasopharynx and circulating cold water inside the catheter in a closed-loop arrangement. Core temperature was maintained at ≥ 35 °C using counter-warming. RESULTS In all study participants, a brain temperature reduction of ≥ 2 °C was achieved. The mean brain temperature reduction from baseline was 2.5 ± 0.9 °C (P = .04, 95% confidence interval). The mean systemic temperature was 37.3 ± 1.1 °C at baseline and 36.0 ± 0.8 °C during the intervention. The mean difference between the brain temperature and the systemic temperature during intervention was - 1.2 ± 0.8 °C (P = .04). The intervention was well tolerated with no significant changes observed in the hemodynamic parameters. No relevant variations in intracranial pressure and transcranial Doppler were observed. The laboratory results underwent no major changes, aside from the K+ levels and blood counts. The K+ levels significantly varied (P = .04); however, the variation was within the normal range. Only one patient experienced an event of mild localized and superficial nasal discoloration, which was re-evaluated on the seventh day and indicated complete recovery. CONCLUSION The results suggest that our noninvasive method for selective brain cooling, using a novel nasopharyngeal catheter, was effective and safe for use in humans.
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Affiliation(s)
- Raphael Einsfeld Simões Ferreira
- Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, Av. Moema 170, Cj. 83. Moema, São Paulo, SP, 04077-020, Brazil.
| | | | | | - Flávia Ribeiro Machado
- Departamento de Anestesiologia, Dor e Terapia Intensiva, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Gisele Sampaio Silva
- Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, Av. Moema 170, Cj. 83. Moema, São Paulo, SP, 04077-020, Brazil
| | - Rafael Mônaco Raposo
- Serviço de Otorrinolaringologia UNIFESP e Serviço de Otorrinolaringologia, Hospital Santa Paula, São Paulo, Brazil
| | - Conrado Feisthauer Silveira
- Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, Av. Moema 170, Cj. 83. Moema, São Paulo, SP, 04077-020, Brazil
| | - Ricardo Silva Centeno
- Departamento de Neurologia e Neurocirurgia, Universidade Federal de São Paulo, Av. Moema 170, Cj. 83. Moema, São Paulo, SP, 04077-020, Brazil
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de Paiva BLC, Bor-Seng-Shu E, Silva E, Barreto ÍBM, de Lima Oliveira M, Ferreira RES, Cavalcanti AB, Teixeira MJ. Inducing Brain Cooling Without Core Temperature Reduction in Pigs Using a Novel Nasopharyngeal Method: An Effectiveness and Safety Study. Neurocrit Care 2020; 32:564-574. [PMID: 31317319 PMCID: PMC7223440 DOI: 10.1007/s12028-019-00789-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Acute brain lesions constitute an alarming public health concern. Neuroprotective therapies have been implemented to stabilize, prevent, or reduce brain lesions, thus improving neurological outcomes and survival rates. Hypothermia is the most effective approach, mainly attributed to the reduction in cellular metabolic activity. Whole-body cooling is currently implemented by healthcare professionals; however, adverse events are frequent, limiting the potential benefits of therapeutic hypothermia. Therefore, selective methods have been developed to reduce adverse events while delivering neuroprotection. Nasopharyngeal approaches are the safest and most effective methods currently considered. Our primary objective was to determine the effects of a novel nasopharyngeal catheter on the brain temperature of pigs. METHODS In this prospective, non-randomized, interventional experimental trial, 10 crossbred pigs underwent nasopharyngeal cooling for 60 min followed by 15 min of rewarming. Nasopharyngeal catheters were inserted into the left nostril and properly positioned at the nasopharyngeal cavity. RESULTS Nasopharyngeal cooling was associated with a decrease in brain temperature, which was more significant in the left cerebral hemisphere (p = 0.01). There was a reduction of 1.47 ± 0.86 °C in the first 5 min (p < 0.001), 2.45 ± 1.03 °C within 10 min (p < 0.001), and 4.45 ± 1.36 °C after 1 h (p < 0.001). The brain-core gradient was 4.57 ± 0.87 °C (p < 0.001). Rectal, esophageal, and pulmonary artery temperatures and brain and systemic hemodynamic parameters, remained stable during the procedure. Following brain cooling, values of oxygen partial pressure in brain tissue significantly decreased. No mucosal lesions were detected during nasal, pharyngeal, or oral inspection after nasopharyngeal catheter removal. CONCLUSIONS In this study, a novel nasopharyngeal cooling catheter effectively induced and maintained exclusive brain cooling when combined with effective counter-warming methods. Exclusive brain cooling was safe with no device-related local or systemic complications and may be desired in selected patient populations.
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Affiliation(s)
- Bernardo Lembo Conde de Paiva
- Neurology Department, School of Medicine, University of São Paulo, Avenida Moema, 170, Cj. 83 - Moema, São Paulo, SP, CEP: 04077-020, Brazil.
- Neurocritical Care Unit, Hospital Santa Paula, São Paulo, SP, Brazil.
| | - Edson Bor-Seng-Shu
- Neurology Department, School of Medicine, University of São Paulo, Avenida Moema, 170, Cj. 83 - Moema, São Paulo, SP, CEP: 04077-020, Brazil
- Neurocritical Care Unit, Hospital Santa Paula, São Paulo, SP, Brazil
| | - Eliezer Silva
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Marcelo de Lima Oliveira
- Neurology Department, School of Medicine, University of São Paulo, Avenida Moema, 170, Cj. 83 - Moema, São Paulo, SP, CEP: 04077-020, Brazil
- Neurocritical Care Unit, Hospital Santa Paula, São Paulo, SP, Brazil
| | - Raphael Einsfeld Simões Ferreira
- Neurocritical Care Unit, Hospital Santa Paula, São Paulo, SP, Brazil
- Research Centre, Centro Universitário São Camilo, São Paulo, SP, Brazil
| | | | - Manoel Jacobsen Teixeira
- Neurology Department, School of Medicine, University of São Paulo, Avenida Moema, 170, Cj. 83 - Moema, São Paulo, SP, CEP: 04077-020, Brazil
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Walsh JJ, Huang Y, Simmons JW, Goodrich JA, McHugh B, Rothman DL, Elefteriades JA, Hyder F, Coman D. Dynamic Thermal Mapping of Localized Therapeutic Hypothermia in the Brain. J Neurotrauma 2019; 37:55-65. [PMID: 31311414 DOI: 10.1089/neu.2019.6485] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Although whole body cooling is used widely to provide therapeutic hypothermia for the brain, there are undesirable clinical side effects. Selective brain cooling may allow for rapid and controllable neuroprotection while mitigating these undesirable side effects. We evaluated an innovative cerebrospinal fluid (CSF) cooling platform that utilizes chilled saline pumped through surgically implanted intraventricular catheters to induce hypothermia. Magnetic resonance thermal imaging of the healthy sheep brain (n = 4) at 7.0T provided dynamic temperature measurements from the whole brain. Global brain temperature was 38.5 ± 0.8°C at baseline (body temperature of 39.2 ± 0.4°C), and decreased by 3.1 ± 0.3°C over ∼30 min of cooling (p < 0.0001). Significant cooling was achieved in all defined regions across both the ipsilateral and contralateral hemispheres relative to catheter placement. On cooling cessation, global brain temperature increased by 3.1 ± 0.2°C over ∼20 min (p < 0.0001). Rapid and synchronized temperature fall/rise on cooling onset/offset was observed reproducibly with rates ranging from 0.06-0.21°C/min, where rewarming was faster than cooling (p < 0.0001) signifying the importance of thermoregulation in the brain. Although core regions (including the subcortex, midbrain, olfactory tract, temporal lobe, occipital lobe, and parahippocampal cortex) had slightly warmer (∼0.2°C) baseline temperatures, after cooling, temperatures reached the same level as the non-core regions (35.6 ± 0.2°C), indicating the cooling effectiveness of the CSF-based cooling device. In summary, CSF-based intraventricular cooling reliably reduces temperature in all identified brain regions to levels known to be neuroprotective, while maintaining overall systemic normothermia. Dynamic thermal mapping provides high spatiotemporal temperature measurements that can aid in optimizing selective neuroprotective protocols.
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Affiliation(s)
- John J Walsh
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
| | - Yuegao Huang
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
| | | | - James A Goodrich
- Department of Comparative Medicine, Yale University, New Haven, Connecticut
| | - Brian McHugh
- Department of Neurosurgery, Yale University, New Haven, Connecticut.,Inova Medical Group Neurosurgery, Fairfax, Virginia
| | - Douglas L Rothman
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut.,Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
| | | | - Fahmeed Hyder
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut.,Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
| | - Daniel Coman
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
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