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Then J, Tawfik S, Law T, Brown A, Carnegie V, Udy A, Jeffcote T. The Impact of Sedative Choice in the Management of Aneurysmal Subarachnoid Hemorrhage: A Scoping Review. Neurocrit Care 2024:10.1007/s12028-024-02111-1. [PMID: 39266867 DOI: 10.1007/s12028-024-02111-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 08/16/2024] [Indexed: 09/14/2024]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is characterized by high mortality and morbidity. This scoping review assesses the current evidence regarding the use of sedatives and analgesics in the acute intensive care unit management of aSAH. We conducted a systematic search of Ovid MEDLINE, Ovid Embase, Ovid EmCare, APA PsycInfo, CINAHL, and the Cochrane Database of Systematic Reviews from inception to June 2023. Studies were included if they enrolled intensive care unit patients aged 18 or older with a significant proportion (> 20%) who had aSAH and evaluated the impact of one or more commonly used analgosedatives on physiological parameters in the management of aSAH. The methodological quality of the studies was assessed using the Methodological Index for Nonrandomized Studies score. Of 2,583 articles, 11 met the inclusion criteria. The median sample size was 47 (interquartile range 10-127), and the median Methodological Index for Nonrandomized Studies score was 9.5 (interquartile range 8-11). The studies' publication years ranged from 1980 to 2023. Dexmedetomidine and ketamine showed potential benefits in reducing the incidence of cortical spreading depolarization and delayed cerebral ischemia. Propofol and opioids appeared safe but lacked robust evidence for efficacy. Benzodiazepines were associated with increased delayed cerebral ischemia-related cerebral infarctions and cortical spreading depolarization events. The evidence available to guide the use of analgosedative medications in aSAH is critically inadequate. Dexmedetomidine and ketamine warrant further exploration in large-scale prospective studies because of their potential benefits. Improved study designs with consistent definitions and a focus on patient-centered outcomes are necessary to inform clinical practice.
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Affiliation(s)
- James Then
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - Samuel Tawfik
- The Victorian Brain and Spine Centre, St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Timothy Law
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Alastair Brown
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, VIC, Australia
- Australia and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Vanessa Carnegie
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Andrew Udy
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - Toby Jeffcote
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
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2
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Carlson AP, Mayer AR, Cole C, van der Horn HJ, Marquez J, Stevenson TC, Shuttleworth CW. Cerebral autoregulation, spreading depolarization, and implications for targeted therapy in brain injury and ischemia. Rev Neurosci 2024; 35:651-678. [PMID: 38581271 PMCID: PMC11297425 DOI: 10.1515/revneuro-2024-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Cerebral autoregulation is an intrinsic myogenic response of cerebral vasculature that allows for preservation of stable cerebral blood flow levels in response to changing systemic blood pressure. It is effective across a broad range of blood pressure levels through precapillary vasoconstriction and dilation. Autoregulation is difficult to directly measure and methods to indirectly ascertain cerebral autoregulation status inherently require certain assumptions. Patients with impaired cerebral autoregulation may be at risk of brain ischemia. One of the central mechanisms of ischemia in patients with metabolically compromised states is likely the triggering of spreading depolarization (SD) events and ultimately, terminal (or anoxic) depolarization. Cerebral autoregulation and SD are therefore linked when considering the risk of ischemia. In this scoping review, we will discuss the range of methods to measure cerebral autoregulation, their theoretical strengths and weaknesses, and the available clinical evidence to support their utility. We will then discuss the emerging link between impaired cerebral autoregulation and the occurrence of SD events. Such an approach offers the opportunity to better understand an individual patient's physiology and provide targeted treatments.
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Affiliation(s)
- Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Andrew R. Mayer
- Mind Research Network, 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Chad Cole
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | | | - Joshua Marquez
- University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Taylor C. Stevenson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - C. William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
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3
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Kowoll CM, Schumm L, Gieffers A, Lemale CL, Major S, Dohmen C, Fink GR, Brinker G, von Pidoll T, Dömer P, Dreier JP, Hecht N, Woitzik J. Duration of spreading depression is the electrophysiological correlate of infarct growth in malignant hemispheric stroke. J Cereb Blood Flow Metab 2024:271678X241262203. [PMID: 38902207 DOI: 10.1177/0271678x241262203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
Spreading depolarizations (SD) contribute to lesion progression after experimental focal cerebral ischemia while such correlation has never been shown in stroke patients. In this prospective, diagnostic study, we investigate the association of SDs and secondary infarct progression after malignant hemispheric stroke. SDs were continuously monitored for 3-9 days with electrocorticography after decompressive hemicraniectomy for malignant hemispheric stroke. To ensure valid detection and analysis of SDs, a threshold based on the electrocorticographic baseline activity was calculated to identify valid electrocorticographic recordings. Subsequently SD characteristics were analyzed in association to infarct progression based on serial MRI. Overall, 62 patients with a mean stroke volume of 289.6 ± 68 cm3 were included. Valid electrocorticographic recordings were found in 44/62 patients with a mean recording duration of 139.6 ± 26.5 hours and 52.5 ± 39.5 SDs per patient. Infarct progression of more than 5% was found in 21/44 patients. While the number of SDs was similar between patients with and without infarct progression, the SD-induced depression duration per day was significantly longer in patients with infarct progression (593.8 vs. 314.1 minutes; *p = 0.046). Therefore, infarct progression is associated with a prolonged SD-induced depression duration. Real-time analysis of electrocorticographic recordings may identify secondary stroke progression and help implementing targeted management strategies.
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Affiliation(s)
- Christina M Kowoll
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Neurology, Märkische Kliniken Lüdenscheid, Lüdenscheid, Germany
| | - Leonie Schumm
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alexandra Gieffers
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christian Dohmen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Neurology, LVR-Klinik Bonn, Bonn, Germany
| | - Gereon R Fink
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich, Jülich, Germany
| | - Gerrit Brinker
- Department of Neurosurgery, University of Cologne, Cologne, Germany
| | - Tilmann von Pidoll
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Trauma Surgery, SANA-Dreifaltigkeitskrankenhaus Cologne, Cologne, Germany
| | - Patrick Dömer
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
- Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Bernstein Centre for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Centre for Neurosciences Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
- Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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4
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Schoknecht K, Maechler M, Wallach I, Dreier JP, Liotta A, Berndt N. Isoflurane lowers the cerebral metabolic rate of oxygen and prevents hypoxia during cortical spreading depolarization in vitro: An integrative experimental and modeling study. J Cereb Blood Flow Metab 2024; 44:1000-1012. [PMID: 38140913 PMCID: PMC11318408 DOI: 10.1177/0271678x231222306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 10/23/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023]
Abstract
Cortical spreading depolarization (SD) imposes a massive increase in energy demand and therefore evolves as a target for treatment following acute brain injuries. Anesthetics are empirically used to reduce energy metabolism in critical brain conditions, yet their effect on metabolism during SD remains largely unknown. We investigated oxidative metabolism during SD in brain slices from Wistar rats. Extracellular potassium ([K+]o), local field potential and partial tissue oxygen pressure (ptiO2) were measured simultaneously. The cerebral metabolic rate of oxygen (CMRO2) was calculated using a reaction-diffusion model. By that, we tested the effect of clinically relevant concentrations of isoflurane on CMRO2 during SD and modeled tissue oxygenation for different capillary pO2 values. During SD, CMRO2 increased 2.7-fold, resulting in transient hypoxia in the slice core. Isoflurane decreased CMRO2, reduced peak [K+]o, and prolonged [K+]o clearance, which indicates reduced synaptic transmission and sodium-potassium ATPase inhibition. Modeling tissue oxygenation during SD illustrates the need for increased capillary pO2 levels to prevent hypoxia. In the absence thereof, isoflurane could improve tissue oxygenation by lowering CMRO2. Therefore, isoflurane is a promising candidate for pre-clinical studies on neuronal survival in conditions involving SD.
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Affiliation(s)
- Karl Schoknecht
- Carl-Ludwig-Institute of Physiology, Medical Faculty, Leipzig University, Leipzig, Germany
| | - Mathilde Maechler
- Department of Anesthesiology and Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Neurophysiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - Iwona Wallach
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jens P Dreier
- Centre for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Bernstein Centre for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Centre for Neurosciences Berlin, Berlin, Germany
| | - Agustin Liotta
- Department of Anesthesiology and Intensive Care, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Neurophysiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Health at Charité – Universitätsmedizin Berlin, Berlin
- Neuroscience Research Center, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nikolaus Berndt
- Institute of Computer-Assisted Cardiovascular Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Department of Molecular Toxicology, Nuthetal, Germany
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5
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Zdunczyk A, Schumm L, Helgers SOA, Nieminen-Kelhä M, Bai X, Major S, Dreier JP, Hecht N, Woitzik J. Ketamine-induced prevention of SD-associated late infarct progression in experimental ischemia. Sci Rep 2024; 14:10186. [PMID: 38702377 PMCID: PMC11068759 DOI: 10.1038/s41598-024-59835-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/16/2024] [Indexed: 05/06/2024] Open
Abstract
Spreading depolarizations (SDs) occur frequently in patients with malignant hemispheric stroke. In animal-based experiments, SDs have been shown to cause secondary neuronal damage and infarct expansion during the initial period of infarct progression. In contrast, the influence of SDs during the delayed period is not well characterized yet. Here, we analyzed the impact of SDs in the delayed phase after cerebral ischemia and the potential protective effect of ketamine. Focal ischemia was induced by distal occlusion of the left middle cerebral artery in C57BL6/J mice. 24 h after occlusion, SDs were measured using electrocorticography and laser-speckle imaging in three different study groups: control group without SD induction, SD induction with potassium chloride, and SD induction with potassium chloride and ketamine administration. Infarct progression was evaluated by sequential MRI scans. 24 h after occlusion, we observed spontaneous SDs with a rate of 0.33 SDs/hour which increased during potassium chloride application (3.37 SDs/hour). The analysis of the neurovascular coupling revealed prolonged hypoemic and hyperemic responses in this group. Stroke volume increased even 24 h after stroke onset in the SD-group. Ketamine treatment caused a lesser pronounced hypoemic response and prevented infarct growth in the delayed phase after experimental ischemia. Induction of SDs with potassium chloride was significantly associated with stroke progression even 24 h after stroke onset. Therefore, SD might be a significant contributor to delayed stroke progression. Ketamine might be a possible drug to prevent SD-induced delayed stroke progression.
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Affiliation(s)
- A Zdunczyk
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - L Schumm
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - S O A Helgers
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
- Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - M Nieminen-Kelhä
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - X Bai
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - S Major
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - J P Dreier
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - N Hecht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
- Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
- University Clinic for Neurosurgery, Marienstr. 11, 26121, Oldenburg, Germany.
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6
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Joya A, Plaza-García S, Padro D, Aguado L, Iglesias L, Garbizu M, Gómez-Vallejo V, Laredo C, Cossío U, Torné R, Amaro S, Planas AM, Llop J, Ramos-Cabrer P, Justicia C, Martín A. Multimodal imaging of the role of hyperglycemia following experimental subarachnoid hemorrhage. J Cereb Blood Flow Metab 2024; 44:726-741. [PMID: 37728631 PMCID: PMC11197138 DOI: 10.1177/0271678x231197946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/27/2023] [Accepted: 08/06/2023] [Indexed: 09/21/2023]
Abstract
Hyperglycemia has been linked to worsening outcomes after subarachnoid hemorrhage (SAH). Nevertheless, the mechanisms involved in the pathogenesis of SAH have been scarcely evaluated so far. The role of hyperglycemia was assessed in an experimental model of SAH by T2 weighted, dynamic contrast-enhanced magnetic resonance imaging (T2W and DCE-MRI), [18F]BR-351 PET imaging and immunohistochemistry. Measures included the volume of bleeding, the extent of cerebral infarction and brain edema, blood brain barrier disruption (BBBd), neutrophil infiltration and matrix metalloprotease (MMP) activation. The neurofunctional outcome, neurodegeneration and myelinization were also investigated. The induction of hyperglycemia increased mortality, the size of the ischemic lesion, brain edema, neurodegeneration and worsened neurological outcome during the first 3 days after SAH in rats. In addition, these results show for the first time the exacerbating effect of hyperglycemia on in vivo MMP activation, Intercellular Adhesion Molecule 1 (ICAM-1) expression and neutrophil infiltration together with increased BBBd, bleeding volume and fibrinogen accumulation at days 1 and 3 after SAH. Notably, these data provide valuable insight into the detrimental effect of hyperglycemia on early BBB damage mediated by neutrophil infiltration and MMP activation that could explain the worse prognosis in SAH.
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Affiliation(s)
- Ana Joya
- Achucarro Basque Center for Neuroscience, Leioa, Spain
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | - Sandra Plaza-García
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | - Daniel Padro
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | - Laura Aguado
- Achucarro Basque Center for Neuroscience, Leioa, Spain
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | - Leyre Iglesias
- Achucarro Basque Center for Neuroscience, Leioa, Spain
- Neurovascular Group, Biocruces Health Research Institute, Barakaldo, Spain
| | - Maider Garbizu
- Achucarro Basque Center for Neuroscience, Leioa, Spain
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | | | - Carlos Laredo
- Institute of Neuroscience, Comprehensive Stroke Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Unai Cossío
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
| | - Ramon Torné
- Institute of Neuroscience, Neurosurgery Department, Hospital Clinic of Barcelona, Spain
| | - Sergio Amaro
- Institute of Neuroscience, Comprehensive Stroke Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Anna M Planas
- Area of Neurosciences. Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Neuroscience and Experimental Therapeutics, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), Barcelona, Spain
| | - Jordi Llop
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
- Centro de Investigación Biomédica en Red - Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Pedro Ramos-Cabrer
- CIC biomaGUNE, Basque Research and Technology Alliance, San Sebastian, Spain
- Ikerbasque Basque Foundation for Science, Bilbao, Spain
| | - Carles Justicia
- Area of Neurosciences. Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Neuroscience and Experimental Therapeutics, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), Barcelona, Spain
| | - Abraham Martín
- Achucarro Basque Center for Neuroscience, Leioa, Spain
- Ikerbasque Basque Foundation for Science, Bilbao, Spain
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7
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Dreier JP, Joerk A, Uchikawa H, Horst V, Lemale CL, Radbruch H, McBride DW, Vajkoczy P, Schneider UC, Xu R. All Three Supersystems-Nervous, Vascular, and Immune-Contribute to the Cortical Infarcts After Subarachnoid Hemorrhage. Transl Stroke Res 2024:10.1007/s12975-024-01242-z. [PMID: 38689162 DOI: 10.1007/s12975-024-01242-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 05/02/2024]
Abstract
The recently published DISCHARGE-1 trial supports the observations of earlier autopsy and neuroimaging studies that almost 70% of all focal brain damage after aneurysmal subarachnoid hemorrhage are anemic infarcts of the cortex, often also affecting the white matter immediately below. The infarcts are not limited by the usual vascular territories. About two-fifths of the ischemic damage occurs within ~ 48 h; the remaining three-fifths are delayed (within ~ 3 weeks). Using neuromonitoring technology in combination with longitudinal neuroimaging, the entire sequence of both early and delayed cortical infarct development after subarachnoid hemorrhage has recently been recorded in patients. Characteristically, cortical infarcts are caused by acute severe vasospastic events, so-called spreading ischemia, triggered by spontaneously occurring spreading depolarization. In locations where a spreading depolarization passes through, cerebral blood flow can drastically drop within a few seconds and remain suppressed for minutes or even hours, often followed by high-amplitude, sustained hyperemia. In spreading depolarization, neurons lead the event, and the other cells of the neurovascular unit (endothelium, vascular smooth muscle, pericytes, astrocytes, microglia, oligodendrocytes) follow. However, dysregulation in cells of all three supersystems-nervous, vascular, and immune-is very likely involved in the dysfunction of the neurovascular unit underlying spreading ischemia. It is assumed that subarachnoid blood, which lies directly on the cortex and enters the parenchyma via glymphatic channels, triggers these dysregulations. This review discusses the neuroglial, neurovascular, and neuroimmunological dysregulations in the context of spreading depolarization and spreading ischemia as critical elements in the pathogenesis of cortical infarcts after subarachnoid hemorrhage.
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Affiliation(s)
- Jens P Dreier
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.
- Einstein Center for Neurosciences Berlin, Berlin, Germany.
| | - Alexander Joerk
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Hiroki Uchikawa
- Barrow Aneurysm & AVM Research Center, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Viktor Horst
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Helena Radbruch
- Institute of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Devin W McBride
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulf C Schneider
- Department of Neurosurgery, Cantonal Hospital of Lucerne and University of Lucerne, Lucerne, Switzerland
| | - Ran Xu
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK, German Centre for Cardiovascular Research, Berlin, Germany
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8
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Zhou Y, Li R, Wang K, Lin F, Chen Y, Yang J, Han H, Li T, Jia Y, Yuan K, Zhang H, Li R, Li Z, Zhao Y, Hao Q, Chen X, Zhao Y. A retrospective study on the relationship between serum electrolyte disorder and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2024; 33:107579. [PMID: 38325032 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 02/09/2024] Open
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI)-induced cerebral infarction is a major cause of adverse neurological outcomes following aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to investigate the relationship between postoperative serum electrolyte levels and DCI in patients with aSAH. MATERIALS AND METHODS We analyzed the data of patients with aSAH between 2015 and 2022. The patients were classified into two groups according to whether they experienced DCI. Electrolyte levels were categorized into three groups based on the normal ranges for electrolytes. Logistic regression models were used to study the relationship between electrolyte levels and DCI. Another logistic regression analysis was conducted to explore the relationship between the different severity levels of statistically significant indicators and DCI. A restrictive cubic spline model was adopted to assess the potential linear relationship between electrolytes and DCI. Subsequently, sensitivity analysis was performed to assess the impact of collinearity among ions. Finally, subgroup analysis was performed. RESULTS This study included 1,099 patients. Patients with hyperchloremia were more prone to DCI than those with normal chloride levels. Subsequently, excluding the population with hypochloremia, both mild and severe hyperchloremia were found to be associated with an increased risk of DCI compared with normal chloride levels. Within the framework of a restrictive cubic spline, our findings revealed an increased incidence of DCI (P for nonlinear = 0.735) as chloride levels increased. Sensitivity analysis revealed that patients with severe hyperchloremia were more susceptible to DCI. CONCLUSIONS This study found that patients with aSAH and postoperative hyperchloremia are more prone to developing DCI.
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Affiliation(s)
- Yunfan Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ke Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tu Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yitong Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yahui Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Stroke Center, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Stroke Center, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Stroke Center, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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9
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Basilio AV, Zeng D, Pichay LA, Ateshian GA, Xu P, Maas SA, Morrison B. Simulating Cerebral Edema and Ischemia After Traumatic Acute Subdural Hematoma Using Triphasic Swelling Biomechanics. Ann Biomed Eng 2024:10.1007/s10439-024-03496-y. [PMID: 38532172 DOI: 10.1007/s10439-024-03496-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/14/2024] [Indexed: 03/28/2024]
Abstract
Poor outcome following traumatic acute subdural hematoma (ASDH) is associated with the severity of the primary injury and secondary injury including cerebral edema and ischemia. However, the underlying secondary injury mechanism contributing to elevated intracranial pressure (ICP) and high mortality rate remains unclear. Cerebral edema occurs in response to the exposure of the intracellular fixed charge density (FCD) after cell death, causing ICP to increase. The increased ICP from swollen tissue compresses blood vessels in adjacent tissue, restricting blood flow and leading to ischemic damage. We hypothesize that the mass occupying effect of ASDH exacerbates the ischemic injury, leading to ICP elevation, which is an indicator of high mortality rate in the clinic. Using FEBio (febio.org) and triphasic swelling biomechanics, this study modeled clinically relevant ASDHs and simulated post-traumatic brain swelling and ischemia to predict ICP. Results showed that common convexity ASDH significantly increased ICP by exacerbating ischemic injury, and surgical removal of the convexity ASDH may control ICP by preventing ischemia progression. However, in cases where the primary injury is very severe, surgical intervention alone may not effectively decrease ICP, as the contribution of the hematoma to the elevated ICP is insignificant. In addition, interhemispheric ASDH, located between the cerebral hemispheres, does not significantly exacerbate ischemia, supporting the conservative surgical management generally recommended for interhemispheric ASDH. The joint effect of the mass occupying effect of the blood clot and resulting ischemia contributes to elevated ICP which may increase mortality. Our novel approach may improve the fidelity of predicting patient outcome after motor vehicle crashes and traumatic brain injuries due to other causes.
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Affiliation(s)
- Andrew V Basilio
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Delin Zeng
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Leanne A Pichay
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Gerard A Ateshian
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
- Department of Mechanical Engineering, Columbia University, 220 S. W. Mudd Building, 500 West 120th Street, New York, NY, 10027, USA
| | - Peng Xu
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Steve A Maas
- Department of Bioengineering, University of Utah, 36 S. Wasatch Drive, SMBB 3100, Salt Lake City, UT, 84112, USA
| | - Barclay Morrison
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA.
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10
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Díaz-Peregrino R, Kentar M, Trenado C, Sánchez-Porras R, Albiña-Palmarola P, Ramírez-Cuapio FL, San-Juan D, Unterberg A, Woitzik J, Santos E. The neurophysiological effect of mild hypothermia in gyrencephalic brains submitted to ischemic stroke and spreading depolarizations. Front Neurosci 2024; 18:1302767. [PMID: 38567280 PMCID: PMC10986791 DOI: 10.3389/fnins.2024.1302767] [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: 09/27/2023] [Accepted: 02/22/2024] [Indexed: 04/04/2024] Open
Abstract
Objective Characterize the neurophysiological effects of mild hypothermia on stroke and spreading depolarizations (SDs) in gyrencephalic brains. Methods Left middle cerebral arteries (MCAs) of six hypothermic and six normothermic pigs were permanently occluded (MCAo). Hypothermia began 1 h after MCAo and continued throughout the experiment. ECoG signals from both frontoparietal cortices were recorded. Five-minute ECoG epochs were collected 5 min before, at 5 min, 4, 8, 12, and 16 h after MCAo, and before, during, and after SDs. Power spectra were decomposed into fast (alpha, beta, and gamma) and slow (delta and theta) frequency bands. Results In the vascular insulted hemisphere under normothermia, electrodes near the ischemic core exhibited power decay across all frequency bands at 5 min and the 4th hour after MCAo. The same pattern was registered in the two furthest electrodes at the 12th and 16th hour. When mild hypothermia was applied in the vascular insulted hemispheres, the power decay was generalized and seen even in electrodes with uncompromised blood flow. During SD analysis, hypothermia maintained increased delta and beta power during the three phases of SDs in the furthest electrode from the ischemic core, followed by the second furthest and third electrode in the beta band during preSD and postSD segments. However, in hypothermic conditions, the third electrode showed lower delta, theta, and alpha power. Conclusion Mild hypothermia attenuates all frequency bands in the vascularly compromised hemisphere, irrespective of the cortical location. During SD formation, it preserves power spectra more significantly in electrodes further from the ischemic core.
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Affiliation(s)
- Roberto Díaz-Peregrino
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Modar Kentar
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
- Departement of Neurosurgery, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Germany
| | - Carlos Trenado
- Heinrich Heine University, Medical Faculty, Institute of Clinical Neuroscience and Medical Psychology, Düsseldorf, Germany
- Institute for the Future of Education Europe, Tecnológico de Monterrey, Cantabria, Spain
| | - Renán Sánchez-Porras
- Department of Neurosurgery, Evangelisches Krankenhaus, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Pablo Albiña-Palmarola
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
- Department of Anatomy, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco L. Ramírez-Cuapio
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Daniel San-Juan
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Edgar Santos
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
- Department of Neurosurgery, Evangelisches Krankenhaus, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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11
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Zhang X, Zhang Y, Su Q, Liu Y, Li Z, Yong VW, Xue M. Ion Channel Dysregulation Following Intracerebral Hemorrhage. Neurosci Bull 2024; 40:401-414. [PMID: 37755675 PMCID: PMC10912428 DOI: 10.1007/s12264-023-01118-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/14/2023] [Indexed: 09/28/2023] Open
Abstract
Injury to the brain after intracerebral hemorrhage (ICH) results from numerous complex cellular mechanisms. At present, effective therapy for ICH is limited and a better understanding of the mechanisms of brain injury is necessary to improve prognosis. There is increasing evidence that ion channel dysregulation occurs at multiple stages in primary and secondary brain injury following ICH. Ion channels such as TWIK-related K+ channel 1, sulfonylurea 1 transient receptor potential melastatin 4 and glutamate-gated channels affect ion homeostasis in ICH. They in turn participate in the formation of brain edema, disruption of the blood-brain barrier, and the generation of neurotoxicity. In this review, we summarize the interaction between ions and ion channels, the effects of ion channel dysregulation, and we discuss some therapeutics based on ion-channel modulation following ICH.
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Affiliation(s)
- Xiangyu Zhang
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China
| | - Yan Zhang
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China
| | - Qiuyang Su
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China
| | - Yang Liu
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China
| | - Zhe Li
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China
| | - V Wee Yong
- Hotchkiss Brain Institute and Department of Clinical Neurosciences, University of Calgary, Calgary, AB, T2N 1N4, Canada.
| | - Mengzhou Xue
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China.
- Academy of Medical Science, Zhengzhou University, Zhengzhou, 450000, China.
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12
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Dreier JP, Lemale CL, Horst V, Major S, Kola V, Schoknecht K, Scheel M, Hartings JA, Vajkoczy P, Wolf S, Woitzik J, Hecht N. Similarities in the Electrographic Patterns of Delayed Cerebral Infarction and Brain Death After Aneurysmal and Traumatic Subarachnoid Hemorrhage. Transl Stroke Res 2024:10.1007/s12975-024-01237-w. [PMID: 38396252 DOI: 10.1007/s12975-024-01237-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/11/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
While subarachnoid hemorrhage is the second most common hemorrhagic stroke in epidemiologic studies, the recent DISCHARGE-1 trial has shown that in reality, three-quarters of focal brain damage after subarachnoid hemorrhage is ischemic. Two-fifths of these ischemic infarctions occur early and three-fifths are delayed. The vast majority are cortical infarcts whose pathomorphology corresponds to anemic infarcts. Therefore, we propose in this review that subarachnoid hemorrhage as an ischemic-hemorrhagic stroke is rather a third, separate entity in addition to purely ischemic or hemorrhagic strokes. Cumulative focal brain damage, determined by neuroimaging after the first 2 weeks, is the strongest known predictor of patient outcome half a year after the initial hemorrhage. Because of the unique ability to implant neuromonitoring probes at the brain surface before stroke onset and to perform longitudinal MRI scans before and after stroke, delayed cerebral ischemia is currently the stroke variant in humans whose pathophysiological details are by far the best characterized. Optoelectrodes located directly over newly developing delayed infarcts have shown that, as mechanistic correlates of infarct development, spreading depolarizations trigger (1) spreading ischemia, (2) severe hypoxia, (3) persistent activity depression, and (4) transition from clustered spreading depolarizations to a negative ultraslow potential. Furthermore, traumatic brain injury and subarachnoid hemorrhage are the second and third most common etiologies of brain death during continued systemic circulation. Here, we use examples to illustrate that although the pathophysiological cascades associated with brain death are global, they closely resemble the local cascades associated with the development of delayed cerebral infarcts.
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Affiliation(s)
- Jens P Dreier
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.
- Einstein Center for Neurosciences Berlin, Berlin, Germany.
| | - Coline L Lemale
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Viktor Horst
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Vasilis Kola
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Karl Schoknecht
- Medical Faculty, Carl Ludwig Institute for Physiology, University of Leipzig, Leipzig, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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13
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Kang J, Tian S, Zhang L, Yang G. Ferroptosis in early brain injury after subarachnoid hemorrhage: review of literature. Chin Neurosurg J 2024; 10:6. [PMID: 38347652 PMCID: PMC10863120 DOI: 10.1186/s41016-024-00357-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/28/2024] [Indexed: 02/15/2024] Open
Abstract
Spontaneous subarachnoid hemorrhage (SAH), mainly caused by ruptured intracranial aneurysms, is a serious acute cerebrovascular disease. Early brain injury (EBI) is all brain injury occurring within 72 h after SAH, mainly including increased intracranial pressure, decreased cerebral blood flow, disruption of the blood-brain barrier, brain edema, oxidative stress, and neuroinflammation. It activates cell death pathways, leading to neuronal and glial cell death, and is significantly associated with poor prognosis. Ferroptosis is characterized by iron-dependent accumulation of lipid peroxides and is involved in the process of neuron and glial cell death in early brain injury. This paper reviews the research progress of ferroptosis in early brain injury after subarachnoid hemorrhage and provides new ideas for future research.
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Affiliation(s)
- Junlin Kang
- The First Hospital of Lanzhou University, Lanzhou City, Gansu Province, China
| | - Shilai Tian
- The First Hospital of Lanzhou University, Lanzhou City, Gansu Province, China
| | - Lei Zhang
- Gansu Provincial Hospital, Lanzhou City, Gansu Province, China
| | - Gang Yang
- The First Hospital of Lanzhou University, Lanzhou City, Gansu Province, China.
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14
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Takasugi Y, Hishikawa T, Shimizu T, Murai S, Haruma J, Hiramatsu M, Tokunaga K, Takeda Y, Sugiu K, Morimatsu H, Date I. Power suppression in EEG after the onset of SAH is a significant marker of early brain injury in rat models. Sci Rep 2024; 14:2277. [PMID: 38280926 PMCID: PMC10821948 DOI: 10.1038/s41598-024-52527-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 01/19/2024] [Indexed: 01/29/2024] Open
Abstract
We analyzed the correlation between the duration of electroencephalogram (EEG) recovery and histological outcome in rats in the acute stage of subarachnoid hemorrhage (SAH) to find a new predictor of the subsequent outcome. SAH was induced in eight rats by cisternal blood injection, and the duration of cortical depolarization was measured. EEG power spectrums were given by time frequency analysis, and histology was evaluated. The appropriate frequency band and recovery percentage of EEG (defined as EEG recovery time) to predict the neuronal damage were determined from 25 patterns (5 bands × 5 recovery rates) of receiver operating characteristic (ROC) curves. Probit regression curves were depicted to evaluate the relationships between neuronal injury and duration of depolarization and EEG recovery. The optimal values of the EEG band and the EEG recovery time to predict neuronal damage were 10-15 Hz and 40%, respectively (area under the curve [AUC]: 0.97). There was a close relationship between the percentage of damaged neurons and the duration of depolarization or EEG recovery time. These results suggest that EEG recovery time, under the above frequency band and recovery rate, may be a novel marker to predict the outcome after SAH.
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Affiliation(s)
- Yuji Takasugi
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Neurosurgery, Okayama City Hospital, Okayama, Japan
| | - Tomohito Hishikawa
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tomohisa Shimizu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Satoshi Murai
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Jun Haruma
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masafumi Hiramatsu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Tokunaga
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- Department of Neurosurgery, Okayama City Hospital, Okayama, Japan
| | - Yoshimasa Takeda
- Department of Anesthesiology, Faculty of Medicine, Toho University, 6-11-1 Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Kenji Sugiu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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15
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MacLean MA, Muradov JH, Greene R, Van Hameren G, Clarke DB, Dreier JP, Okonkwo DO, Friedman A. Memantine inhibits cortical spreading depolarization and improves neurovascular function following repetitive traumatic brain injury. SCIENCE ADVANCES 2023; 9:eadj2417. [PMID: 38091390 PMCID: PMC10848720 DOI: 10.1126/sciadv.adj2417] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/14/2023] [Indexed: 12/18/2023]
Abstract
Cortical spreading depolarization (CSD) is a promising target for neuroprotective therapy in traumatic brain injury (TBI). We explored the effect of NMDA receptor antagonism on electrically triggered CSDs in healthy and brain-injured animals. Rats received either one moderate or four daily repetitive mild closed head impacts (rmTBI). Ninety-three animals underwent craniectomy with electrocorticographic (ECoG) and local blood flow monitoring. In brain-injured animals, ketamine or memantine inhibited CSDs in 44 to 88% and 50 to 67% of cases, respectively. Near-DC/AC-ECoG amplitude was reduced by 44 to 75% and 52 to 67%, and duration by 39 to 87% and 61 to 78%, respectively. Daily memantine significantly reduced spreading depression and oligemia following CSD. Animals (N = 31) were randomized to either memantine (10 mg/kg) or saline with daily neurobehavioral testing. Memantine-treated animals had higher neurological scores. We demonstrate that memantine improved neurovascular function following CSD in sham and brain-injured animals. Memantine also prevented neurological decline in a blinded, preclinical randomized rmTBI trial.
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Affiliation(s)
- Mark A. MacLean
- Division of Neurosurgery, Dalhousie University, Halifax, Canada
| | - Jamil H. Muradov
- Department of Medical Neuroscience, Dalhousie University, Halifax, Canada
| | - Ryan Greene
- Department of Medical Neuroscience, Dalhousie University, Halifax, Canada
| | - Gerben Van Hameren
- Department of Medical Neuroscience, Dalhousie University, Halifax, Canada
| | - David B. Clarke
- Division of Neurosurgery, Dalhousie University, Halifax, Canada
| | - Jens P. Dreier
- Center for Stroke Research Berlin, Charite University, Berlin, Germany
| | - David O. Okonkwo
- Division of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alon Friedman
- Division of Neurosurgery, Dalhousie University, Halifax, Canada
- Department of Medical Neuroscience, Dalhousie University, Halifax, Canada
- Departments of Brain and Cognitive Sciences, Physiology and Cell Biology, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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16
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Andersen S, Western E, Sorteberg W, Sorteberg A. The impact of pre-ictal statin use on vasospasm and outcome in aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:3325-3338. [PMID: 37792050 PMCID: PMC10624707 DOI: 10.1007/s00701-023-05812-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/12/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Pleiotropic effects of statins may be beneficial in alleviating cerebral vasospasm (VS) and improving outcome after aneurysmal subarachnoid hemorrhage (aSAH). Initiation of statin treatment at aSAH is not recommended; however, the effect of pre-ictal and continued statin use is not fully investigated. METHODS Retrospective study comparing aSAH patients admitted in 2012 to 2021 with pre-ictal statin use versus those not using statins. Patient entry variables, radiological/sonological VS, symptomatic VS, and radiologically documented delayed cerebral ischemia (DCI) were registered. Outcome was scored in terms of mortality, modified Rankin score, Glasgow outcome score extended, and levels of fatigue. Patients were compared on group level and in a case-control design. RESULTS We included 961 patients, with 204 (21.2%) statin users. Statin users were older and had more often hypertension. Severe radiological/sonological VS, symptomatic VS, and DCI were less frequent in statin users, and their length of stay was shorter. Mortality, functional outcome, and levels of fatigue were similar in both groups. When analyzing 89 pairs of statin users and non-statin users matched for age, aSAH severity, gender, and hypertension, we confirmed decreased radiological/sonological and symptomatic VS as well as shorter length of stay in statin users. They also had more often a favorable functional outcome and lower levels of fatigue. CONCLUSIONS Patients with pre-ictal and continued use of statins have a reduced occurrence of radiological/sonological and symptomatic VS, shorter length of stay, and more often favorable functional outcome, whereas mortality is similar to non-statin users. Even though larger multicenter studies with common, strict protocols for prevention, diagnosis, and treatment of vasospasm are needed to finally establish the value of statins in aSAH, continuation of pre-ictal statin use seems worthwhile.
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Affiliation(s)
- S Andersen
- Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway
| | - E Western
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Nydalen, P.B. 4950, 0424, Oslo, Norway
| | - W Sorteberg
- Department of Neurosurgery, Oslo University Hospital, Nydalen, P.B. 0454, 0424, Oslo, Norway
| | - A Sorteberg
- Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway.
- Department of Neurosurgery, Oslo University Hospital, Nydalen, P.B. 0454, 0424, Oslo, Norway.
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17
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Fischer P, Tamim I, Sugimoto K, Morais A, Imai T, Takizawa T, Qin T, Schlunk F, Endres M, Yaseen MA, Chung DY, Sakadzic S, Ayata C. Spreading Depolarizations Suppress Hematoma Growth in Hyperacute Intracerebral Hemorrhage in Mice. Stroke 2023; 54:2640-2651. [PMID: 37610105 PMCID: PMC10530404 DOI: 10.1161/strokeaha.123.042632] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Spreading depolarizations (SDs) occur in all types of brain injury and may be associated with detrimental effects in ischemic stroke and subarachnoid hemorrhage. While rapid hematoma growth during intracerebral hemorrhage triggers SDs, their role in intracerebral hemorrhage is unknown. METHODS We used intrinsic optical signal and laser speckle imaging, combined with electrocorticography, to investigate the effects of SD on hematoma growth during the hyperacute phase (0-4 hours) after intracortical collagenase injection in mice. Hematoma expansion, SDs, and cerebral blood flow were simultaneously monitored under normotensive and hypertensive conditions. RESULTS Spontaneous SDs erupted from the vicinity of the hematoma during rapid hematoma growth. We found that hematoma growth slowed down by >60% immediately after an SD. This effect was even stronger in hypertensive animals with faster hematoma growth. To establish causation, we exogenously induced SDs (every 30 minutes) at a remote site by topical potassium chloride application and found reduced hematoma growth rate and final hemorrhage volume (18.2±5.8 versus 10.7±4.1 mm3). Analysis of cerebral blood flow using laser speckle flowmetry revealed that suppression of hematoma growth by spontaneous or induced SDs coincided and correlated with the characteristic oligemia in the wake of SD, implicating the vasoconstrictive effect of SD as one potential mechanism of action. CONCLUSIONS Our findings reveal that SDs limit hematoma growth during the early hours of intracerebral hemorrhage and decrease final hematoma volume.
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Affiliation(s)
- Paul Fischer
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin, NeuroCure Excellence Cluster and Center for Stroke Research, 10117 Berlin, Germany
| | - Isra Tamim
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin, NeuroCure Excellence Cluster and Center for Stroke Research, 10117 Berlin, Germany
| | - Kazutaka Sugimoto
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
| | - Andreia Morais
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
| | - Takahiko Imai
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
| | - Tsubasa Takizawa
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Tao Qin
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
| | - Frieder Schlunk
- Department of Neuroradiology, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Matthias Endres
- Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin, NeuroCure Excellence Cluster and Center for Stroke Research, 10117 Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), partner site 10117 Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site 10117 Berlin, Germany
| | - Mohammad A. Yaseen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
| | - David Y. Chung
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, 02114 Massachusetts, USA
| | - Sava Sakadzic
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
| | - Cenk Ayata
- Neurovascular Research Unit, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, 02129 Massachusetts, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, 02114 Massachusetts, USA
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18
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Kerschbaumer J, Freyschlag CF, Petr O, Adage T, Breitenbach J J, Wessels L, Wolf S, Hecht N, Gempt J, Wostrack M, Gmeiner M, Gollwitzer M, Stefanits H, Bendszus M M, Gruber A, Meyer B, Vajkoczy P, Thomé C. A randomized, single ascending dose safety, tolerability and pharmacokinetics study of NicaPlant® in aneurysmal subarachnoid hemorrhage patients undergoing clipping. BRAIN & SPINE 2023; 3:102673. [PMID: 38021019 PMCID: PMC10668089 DOI: 10.1016/j.bas.2023.102673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 12/01/2023]
Abstract
Introduction Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Post-hemorrhagic vasospasm with neurological deterioration is a major concern in this context. NicaPlant®, a modified release formulation of the calcium channel blocker nicardipine, has shown vasodilator efficacy preclinically and a similar formulation known as NPRI has shown anti-vasospasm activity in aSAH patients under compassionate use. Research question The study aimed to assess pharmacokinetics and pharmacodynamics of NicaPlant® pellets to prevent vasospasm after clip ligation in aSAH. Material and methods In this multicenter, controlled, randomized, dose escalation trial we assessed the safety and tolerability of NicaPlant®. aSAH patients treated by clipping were randomized to receive up to 13 NicaPlant® implants, similarly to the dose of NPRIs previous used, or standard of care treatment. Results Ten patients across four dose groups were treated with NicaPlant® (3-13 implants) while four patients received standard of care. 45 non-serious and 13 serious adverse events were reported, 4 non-serious adverse events and 5 serious adverse events assessed a probable or possible causal relationship to the investigational medical product. Across the NicaPlant® groups there was 1 case of moderate vasospasm, while in the standard of care group there were 2 cases of severe vasospasm. Discussion and conclusion The placement of NicaPlant® during clip ligation of a ruptured cerebral aneurysm raised no safety concern. The dose of 10 NicaPlant® implants was selected for further clinical studies.
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Affiliation(s)
| | | | - Ondra Petr
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | | | | | - Lars Wessels
- Department of Neurosurgery, Charité Berlin, Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité Berlin, Berlin, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Matthias Gmeiner
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Maria Gollwitzer
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Harald Stefanits
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Martin Bendszus M
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Andreas Gruber
- Department of Neurosurgery, Kepler University Hospital and Johannes Kepler University, Linz, Austria
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | | | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
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19
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Cao J, Grover P, Kainerstorfer JM. A model of neurovascular coupling and its application to cortical spreading depolarization. J Theor Biol 2023; 572:111580. [PMID: 37459953 DOI: 10.1016/j.jtbi.2023.111580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 06/09/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
Cortical spreading depolarization (CSD) is a neuropathological condition involving propagating waves of neuronal silence, and is related to multiple diseases, such as migraine aura, traumatic brain injury (TBI), stroke, and cardiac arrest, as well as poor outcome of patients. While CSDs of different severity share similar roots on the ion exchange level, they can lead to different vascular responses (namely spreading hyperemia and spreading ischemia). In this paper, we propose a mathematical model relating neuronal activities to predict vascular changes as measured with near-infrared spectroscopy (NIRS) and fMRI recordings, and apply it to the extreme case of CSD, where sustained near-complete neuronal depolarization is seen. We utilize three serially connected models (namely, ion exchange, neurovascular coupling, and hemodynamic model) which are described by differential equations. Propagating waves of ion concentrations, as well as the associated vasodynamics and hemodynamics, are simulated by solving these equations. Our proposed model predicts vasodynamics and hemodynamics that agree both qualitatively and quantitatively with experimental literature. Mathematical modeling and simulation offer a powerful tool to help understand the underlying mechanisms of CSD and help interpret the data. In addition, it helps develop novel monitoring techniques prior to data collection. Our simulated results strongly suggest that fMRI is unable to reliably distinguish between spreading hyperemia and spreading ischemia, while NIRS signals are substantially distinct in the two cases.
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Affiliation(s)
- Jiaming Cao
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, 15213, PA, United States
| | - Pulkit Grover
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, 15213, PA, United States; Department of Electrical and Computer Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, 15213, PA, United States; Neuroscience Institute, Carnegie Mellon University, 4400 Fifth Avenue, Pittsburgh, 15213, PA, United States
| | - Jana M Kainerstorfer
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, 15213, PA, United States; Department of Electrical and Computer Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, 15213, PA, United States; Neuroscience Institute, Carnegie Mellon University, 4400 Fifth Avenue, Pittsburgh, 15213, PA, United States.
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20
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Chamanzar A, Elmer J, Shutter L, Hartings J, Grover P. Noninvasive and reliable automated detection of spreading depolarization in severe traumatic brain injury using scalp EEG. COMMUNICATIONS MEDICINE 2023; 3:113. [PMID: 37598253 PMCID: PMC10439895 DOI: 10.1038/s43856-023-00344-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 08/04/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Spreading depolarizations (SDs) are a biomarker and a potentially treatable mechanism of worsening brain injury after traumatic brain injury (TBI). Noninvasive detection of SDs could transform critical care for brain injury patients but has remained elusive. Current methods to detect SDs are based on invasive intracranial recordings with limited spatial coverage. In this study, we establish the feasibility of automated SD detection through noninvasive scalp electroencephalography (EEG) for patients with severe TBI. METHODS Building on our recent WAVEFRONT algorithm, we designed an automated SD detection method. This algorithm, with learnable parameters and improved velocity estimation, extracts and tracks propagating power depressions using low-density EEG. The dataset for testing our algorithm contains 700 total SDs in 12 severe TBI patients who underwent decompressive hemicraniectomy (DHC), labeled using ground-truth intracranial EEG recordings. We utilize simultaneously recorded, continuous, low-density (19 electrodes) scalp EEG signals, to quantify the detection accuracy of WAVEFRONT in terms of true positive rate (TPR), false positive rate (FPR), as well as the accuracy of estimating SD frequency. RESULTS WAVEFRONT achieves the best average validation accuracy using Delta band EEG: 74% TPR with less than 1.5% FPR. Further, preliminary evidence suggests WAVEFRONT can estimate how frequently SDs may occur. CONCLUSIONS We establish the feasibility, and quantify the performance, of noninvasive SD detection after severe TBI using an automated algorithm. The algorithm, WAVEFRONT, can also potentially be used for diagnosis, monitoring, and tailoring treatments for worsening brain injury. Extension of these results to patients with intact skulls requires further study.
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Grants
- K23 NS097629 NINDS NIH HHS
- National Science Foundation (NSF)
- This work was supported, in part, by grants from the National Science Foundation (NSF), Chuck Noll Foundation for Brain Injury Research, the Office of the Assistant Secretary of Defense for Health Affairs through the Defense Medical Research and Development Program under Award No. W81XWH-16-2-0020, and the Center for Machine Learning and Health at CMU, under Pittsburgh Health Data Alliance. A Chamanzar was also supported by Neil and Jo Bushnell Fellowship in Engineering, Hsu Chang Memorial Fellowship, CMU Swartz Center for Entrepreneurship Innovation Commercialization Fellows program. Dr. Elmer’s research time was supported by the National Institutes of Health (NIH) through grant 5K23NS097629. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense.
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Affiliation(s)
- Alireza Chamanzar
- Electrical and Computer Engineering Department, Carnegie Mellon University, Pittsburgh, PA, USA.
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA, USA.
| | - Jonathan Elmer
- Departments of Emergency Medicine, Critical Care Medicine and Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jed Hartings
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Pulkit Grover
- Electrical and Computer Engineering Department, Carnegie Mellon University, Pittsburgh, PA, USA.
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA, USA.
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21
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Sanchez-Porras R, Ramírez-Cuapio FL, Hecht N, Seule M, Díaz-Peregrino R, Unterberg A, Woitzik J, Dreier JP, Sakowitz OW, Santos E. Cerebrovascular Pressure Reactivity According to Long-Pressure Reactivity Index During Spreading Depolarizations in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:135-144. [PMID: 36697998 PMCID: PMC10499750 DOI: 10.1007/s12028-022-01669-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/19/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Spreading depolarization (SD) has been linked to the impairment of neurovascular coupling. However, the association between SD occurrence and cerebrovascular pressure reactivity as a surrogate of cerebral autoregulation (CA) remains unclear. Therefore, we analyzed CA using the long-pressure reactivity index (L-PRx) during SDs in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A retrospective study of patients with aSAH who were recruited at two centers, Heidelberg (HD) and Berlin (BE), was performed. Continuous monitoring of mean arterial pressure (MAP) and intracranial pressure (ICP) was recorded. ICP was measured using an intraparenchymal probe in HD patients and was measure in BE patients through external ventricular drainage. Electrocorticographic (ECoG) activity was continuously recorded between 3 and 13 days after hemorrhage. Autoregulation according to L-PRx was calculated as a moving linear Pearson's correlation of 20-min averages of MAP and ICP. For every identified SD, 60-min intervals of L-PRx were averaged, plotted, and analyzed depending on SD occurrence. Random L-PRx recording periods without SDs served as the control. RESULTS A total of 19 patients (HD n = 14, BE n = 5, mean age 50.4 years, 9 female patients) were monitored for a mean duration of 230.4 h (range 96-360, STD ± 69.6 h), during which ECoG recordings revealed a total number of 277 SDs. Of these, 184 represented a single SD, and 93 SDs presented in clusters. In HD patients, mean L-PRx values were 0.12 (95% confidence interval [CI] 0.11-0.13) during SDs and 0.07 (95% CI 0.06-0.08) during control periods (p < 0.001). Similarly, in BE patients, a higher L-PRx value of 0.11 (95% CI 0.11-0.12) was detected during SDs than that during control periods (0.08, 95% CI 0.07-0.09; p < 0.001). In a more detailed analysis, CA changes registered through an intraparenchymal probe (HD patients) revealed that clustered SD periods were characterized by signs of more severely impaired CA (L-PRx during SD in clusters: 0.23 [95% CI 0.20-0.25]; single SD: 0.09 [95% CI 0.08-0.10]; control periods: 0.07 [95% CI 0.06-0.08]; p < 0.001). This group also showed significant increases in ICP during SDs in clusters compared with single SD and control periods. CONCLUSIONS Neuromonitoring for simultaneous assessment of cerebrovascular pressure reactivity using 20-min averages of MAP and ICP measured by L-PRx during SD events is feasible. SD occurrence was associated with significant increases in L-PRx values indicative of CA disturbances. An impaired CA was found during SD in clusters when using an intraparenchymal probe. This preliminary study validates the use of cerebrovascular reactivity indices to evaluate CA disturbances during SDs. Our results warrant further investigation in larger prospective patient cohorts.
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Affiliation(s)
- Renan Sanchez-Porras
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Francisco L Ramírez-Cuapio
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Nils Hecht
- Department of Neurosurgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Seule
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Roberto Díaz-Peregrino
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Edgar Santos
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany.
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
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22
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Li X, Zeng L, Lu X, Chen K, Yu M, Wang B, Zhao M. Early Brain Injury and Neuroprotective Treatment after Aneurysmal Subarachnoid Hemorrhage: A Literature Review. Brain Sci 2023; 13:1083. [PMID: 37509013 PMCID: PMC10376973 DOI: 10.3390/brainsci13071083] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Early brain injury (EBI) subsequent to subarachnoid hemorrhage (SAH) is strongly associated with delayed cerebral ischemia and poor patient prognosis. Based on investigations into the molecular mechanisms underlying EBI, neurovascular dysfunction resulting from SAH can be attributed to a range of pathological processes, such as microvascular alterations in brain tissue, ionic imbalances, blood-brain barrier disruption, immune-inflammatory responses, oxidative stress, and activation of cell death pathways. Research progress presents a variety of promising therapeutic approaches for the preservation of neurological function following SAH, including calcium channel antagonists, endothelin-1 receptor blockers, antiplatelet agents, anti-inflammatory agents, and anti-oxidative stress agents. EBI can be mitigated following SAH through neuroprotective measures. To enhance our comprehension of the relevant molecular pathways involved in brain injury, including brain ischemia-hypoxic injury, neuroimmune inflammation activation, and the activation of various cell-signaling pathways, following SAH, it is essential to investigate the evolution of these multifaceted pathophysiological processes. Facilitating neural repair following a brain injury is critical for improving patient survival rates and quality of life.
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Affiliation(s)
- Xiaopeng Li
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Lang Zeng
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xuanzhen Lu
- Department of Neurology, The Third Hospital of Wuhan, Wuhan 430073, China
| | - Kun Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Maling Yu
- Department of Neurology, The Third Hospital of Wuhan, Wuhan 430073, China
| | - Baofeng Wang
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Min Zhao
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Mehra A, Gomez F, Bischof H, Diedrich D, Laudanski K. Cortical Spreading Depolarization and Delayed Cerebral Ischemia; Rethinking Secondary Neurological Injury in Subarachnoid Hemorrhage. Int J Mol Sci 2023; 24:9883. [PMID: 37373029 DOI: 10.3390/ijms24129883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
Poor outcomes in Subarachnoid Hemorrhage (SAH) are in part due to a unique form of secondary neurological injury known as Delayed Cerebral Ischemia (DCI). DCI is characterized by new neurological insults that continue to occur beyond 72 h after the onset of the hemorrhage. Historically, it was thought to be a consequence of hypoperfusion in the setting of vasospasm. However, DCI was found to occur even in the absence of radiographic evidence of vasospasm. More recent evidence indicates that catastrophic ionic disruptions known as Cortical Spreading Depolarizations (CSD) may be the culprits of DCI. CSDs occur in otherwise healthy brain tissue even without demonstrable vasospasm. Furthermore, CSDs often trigger a complex interplay of neuroinflammation, microthrombi formation, and vasoconstriction. CSDs may therefore represent measurable and modifiable prognostic factors in the prevention and treatment of DCI. Although Ketamine and Nimodipine have shown promise in the treatment and prevention of CSDs in SAH, further research is needed to determine the therapeutic potential of these as well as other agents.
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Affiliation(s)
- Ashir Mehra
- Department of Neurology, University of Missouri, Columbia, MO 65212, USA
| | - Francisco Gomez
- Department of Neurology, University of Missouri, Columbia, MO 65212, USA
| | - Holly Bischof
- Penn Presbyterian Medical Center, Philadelphia, PA 19104, USA
| | - Daniel Diedrich
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN 55905, USA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN 55905, USA
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Luo Y, Chen J, Huang HY, Lam ESY, Wong GKC. Narrative review of roles of astrocytes in subarachnoid hemorrhage. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:302. [PMID: 37181334 PMCID: PMC10170286 DOI: 10.21037/atm-22-5486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 03/16/2023] [Indexed: 03/28/2023]
Abstract
Background and Objective Astrocytes play an important role in healthy brain function, including the development and maintenance of blood-brain barrier (BBB), structural support, brain homeostasis, neurovascular coupling and secretion of neuroprotective factors. Reactive astrocytes participate in various pathophysiology after subarachnoid hemorrhage (SAH) including neuroinflammation, glutamate toxicity, brain edema, vasospasm, BBB disruption, cortical spreading depolarization (SD). Methods We searched PubMed up to 31 May, 2022 and evaluated the articles for screening and inclusion for subsequent systemic review. We found 198 articles with the searched terms. After exclusion based on the selection criteria, we selected 30 articles to start the systemic review. Key Content and Findings We summarized the response of astrocytes induced by SAH. Astrocytes are critical for brain edema formation, BBB reconstruction and neuroprotection in the acute stage of SAH. Astrocytes clear extracellular glutamate by increasing the uptake of glutamate and Na+/K+ ATPase activity after SAH. Neurotrophic factors released by astrocytes contribute to neurological recovery after SAH. Meanwhile, Astrocytes also form glial scars which hinder axon regeneration, produce proinflammatory cytokines, free radicals, and neurotoxic molecules. Conclusions Preclinical studies showed that therapeutic targeting the astrocytes response could have a beneficial effect in ameliorating neuronal injury and cognitive impairment after SAH. Clinical trials and preclinical animal studies are still urgently needed in order to determine where astrocytes stand in various pathway of brain damage and repair after SAH and, above all, to develop therapeutic approaches which benefit patient outcomes.
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Affiliation(s)
- Yujie Luo
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Junfan Chen
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Hiu Yin Huang
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Erica Sin Yu Lam
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - George Kwok-Chu Wong
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
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25
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Kang EJ, Prager O, Lublinsky S, Oliveira-Ferreira AI, Reiffurth C, Major S, Müller DN, Friedman A, Dreier JP. Stroke-prone salt-sensitive spontaneously hypertensive rats show higher susceptibility to spreading depolarization (SD) and altered hemodynamic responses to SD. J Cereb Blood Flow Metab 2023; 43:210-230. [PMID: 36329390 PMCID: PMC9903222 DOI: 10.1177/0271678x221135085] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spreading depolarization (SD) occurs in a plethora of clinical conditions including migraine aura, delayed ischemia after subarachnoid hemorrhage and malignant hemispheric stroke. It describes waves of near-breakdown of ion homeostasis, particularly Na+ homeostasis in brain gray matter. SD induces tone alterations in resistance vessels, causing either hyperperfusion in healthy tissue; or hypoperfusion (inverse hemodynamic response = spreading ischemia) in tissue at risk. Observations from mice with genetic dysfunction of the ATP1A2-encoded α2-isoform of Na+/K+-ATPase (α2NaKA) suggest a mechanistic link between (1) SD, (2) vascular dysfunction, and (3) salt-sensitive hypertension via α2NaKA. Thus, α2NaKA-dysfunctional mice are more susceptible to SD and show a shift toward more inverse hemodynamic responses. α2NaKA-dysfunctional patients suffer from familial hemiplegic migraine type 2, a Mendelian model disease of SD. α2NaKA-dysfunctional mice are also a genetic model of salt-sensitive hypertension. To determine whether SD thresholds and hemodynamic responses are also altered in other genetic models of salt-sensitive hypertension, we examined these variables in stroke-prone spontaneously hypertensive rats (SHRsp). Compared with Wistar Kyoto control rats, we found in SHRsp that electrical SD threshold was significantly reduced, propagation speed was increased, and inverse hemodynamic responses were prolonged. These results may have relevance to both migraine with aura and stroke.
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Affiliation(s)
- Eun-Jeung Kang
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ofer Prager
- Department of Physiology & Cell Biology, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Cognitive & Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Svetlana Lublinsky
- Department of Cognitive & Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ana I Oliveira-Ferreira
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Clemens Reiffurth
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dominik N Müller
- Experimental and Clinical Research Center (ECRC), a Joint Cooperation between the Charité - Universitätsmedizin Berlin and Max-Delbrück-Center for Molecular Medicine, Berlin, Germany.,Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Alon Friedman
- Department of Physiology & Cell Biology, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Cognitive & Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Medical Neuroscience and Brain Repair Center, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Berlin, Germany
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26
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Luckl J, Baker W, Boda K, Emri M, Yodh AG, Greenberg JH. Oxyhemoglobin and Cerebral Blood Flow Transients Detect Infarction in Rat Focal Brain Ischemia. Neuroscience 2023; 509:132-144. [PMID: 36460221 PMCID: PMC9852213 DOI: 10.1016/j.neuroscience.2022.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
Spreading depolarizations (SD) refer to the near-complete depolarization of neurons that is associated with brain injuries such as ischemic stroke. The present gold standard for SD monitoring in humans is invasive electrocorticography (ECoG). A promising non-invasive alternative to ECoG is diffuse optical monitoring of SD-related flow and hemoglobin transients. To investigate the clinical utility of flow and hemoglobin transients, we analyzed their association with infarction in rat focal brain ischemia. Optical images of flow, oxy-hemoglobin, and deoxy-hemoglobin were continuously acquired with Laser Speckle and Optical Intrinsic Signal imaging for 2 h after photochemically induced distal middle cerebral artery occlusion in Sprague-Dawley rats (n = 10). Imaging was performed through a 6 × 6 mm window centered 3 mm posterior and 4 mm lateral to Bregma. Rats were sacrificed after 24 h, and the brain slices were stained for assessment of infarction. We mapped the infarcted area onto the imaging data and used nine circular regions of interest (ROI) to distinguish infarcted from non-infarcted tissue. Transients propagating through each ROI were characterized with six parameters (negative, positive, and total amplitude; negative and positive slope; duration). Transients were also classified into three morphology types (positive monophasic, biphasic, negative monophasic). Flow transient morphology, positive amplitude, positive slope, and total amplitude were all strongly associated with infarction (p < 0.001). Associations with infarction were also observed for oxy-hemoglobin morphology, oxy-hemoglobin positive amplitude and slope, and deoxy-hemoglobin positive slope and duration (all p < 0.01). These results suggest that flow and hemoglobin transients accompanying SD have value for detecting infarction.
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Affiliation(s)
- Janos Luckl
- Department of Neurology, University of Pennsylvania, Philadelphia, USA; Department of Neurology, University of Szeged, Szeged, Hungary; Department of Medical Physics and Informatics, Szeged, Hungary
| | - Wesley Baker
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, USA; Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, USA
| | - Krisztina Boda
- Department of Medical Physics and Informatics, Szeged, Hungary
| | - Miklos Emri
- Division of Nuclear Medicine and Translational Imaging, Department of Medical Imaging, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, USA
| | - Joel H Greenberg
- Department of Neurology, University of Pennsylvania, Philadelphia, USA.
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27
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Meinert F, Lemâle CL, Major S, Helgers SOA, Dömer P, Mencke R, Bergold MN, Dreier JP, Hecht N, Woitzik J. Less-invasive subdural electrocorticography for investigation of spreading depolarizations in patients with subarachnoid hemorrhage. Front Neurol 2023; 13:1091987. [PMID: 36686541 PMCID: PMC9849676 DOI: 10.3389/fneur.2022.1091987] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/08/2022] [Indexed: 01/06/2023] Open
Abstract
Introduction Wyler-strip electrodes for subdural electrocorticography (ECoG) are the gold standard for continuous bed-side monitoring of pathological cortical network events, such as spreading depolarizations (SD) and electrographic seizures. Recently, SD associated parameters were shown to be (1) a marker of early brain damage after aneurysmal subarachnoid hemorrhage (aSAH), (2) the strongest real-time predictor of delayed cerebral ischemia currently known, and (3) the second strongest predictor of patient outcome at 7 months. The strongest predictor of patient outcome at 7 months was focal brain damage segmented on neuroimaging 2 weeks after the initial hemorrhage, whereas the initial focal brain damage was inferior to the SD variables as a predictor for patient outcome. However, the implantation of Wyler-strip electrodes typically requires either a craniotomy or an enlarged burr hole. Neuromonitoring via an enlarged burr hole has been performed in only about 10% of the total patients monitored. Methods In the present pilot study, we investigated the feasibility of ECoG monitoring via a less invasive burrhole approach using a Spencer-type electrode array, which was implanted subdurally rather than in the depth of the parenchyma. Seven aSAH patients requiring extraventricular drainage (EVD) were included. For electrode placement, the burr hole over which the EVD was simultaneously placed, was used in all cases. After electrode implantation, continuous, direct current (DC)/alternating current (AC)-ECoG monitoring was performed at bedside in our Neurointensive Care unit. ECoGs were analyzed following the recommendations of the Co-Operative Studies on Brain Injury Depolarizations (COSBID). Results Subdural Spencer-type electrode arrays permitted high-quality ECoG recording. During a cumulative monitoring period of 1,194.5 hours and a median monitoring period of 201.3 (interquartile range: 126.1-209.4) hours per patient, 84 SDs were identified. Numbers of SDs, isoelectric SDs and clustered SDs per recording day, and peak total SD-induced depression duration of a recording day were not significantly different from the previously reported results of the prospective, observational, multicenter, cohort, diagnostic phase III trial, DISCHARGE-1. No adverse events related to electrode implantation were noted. Discussion In conclusion, our findings support the safety and feasibility of less-invasive subdural electrode implantation for reliable SD-monitoring.
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Affiliation(s)
- Franziska Meinert
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Coline L. Lemâle
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Simeon O. A. Helgers
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Patrick Dömer
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Rik Mencke
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Martin N. Bergold
- Department of Anaesthesiology and Intensive Care Medicine, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Jens P. Dreier
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany,Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Nils Hecht
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany,Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,*Correspondence: Johannes Woitzik ✉
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Pastor J, Vega-Zelaya L. Titration of Pharmacological Responses in ICU Patients by Quantified EEG. Curr Neuropharmacol 2023; 21:4-9. [PMID: 35410601 PMCID: PMC10193762 DOI: 10.2174/1570159x20666220411083213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/31/2022] [Accepted: 03/31/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jesús Pastor
- Clinical Neurophysiology, Hospital Universitario La Princesa, Diego de León, 62, Madrid, Spain
- Fundación de Investigación Biomédica La Princesa, Diego de León, 62, Madrid, Spain
| | - Lorena Vega-Zelaya
- Clinical Neurophysiology, Hospital Universitario La Princesa, Diego de León, 62, Madrid, Spain
- Fundación de Investigación Biomédica La Princesa, Diego de León, 62, Madrid, Spain
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29
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Cattaneo A, Wipplinger C, Geske C, Semmler F, Wipplinger TM, Griessenauer CJ, Weiland J, Beez A, Ernestus RI, Westermaier T, Kunze E, Stetter C. Investigating the relationship between high-dose norepinephrine administration and the incidence of delayed cerebral infarction in patients with aneurysmal subarachnoid hemorrhage: A single-center retrospective evaluation. PLoS One 2023; 18:e0283180. [PMID: 36943859 PMCID: PMC10030022 DOI: 10.1371/journal.pone.0283180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/05/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND One of the longest-standing treatments to prevent delayed cerebral infarction (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH) remains raising the blood pressure to a certain level of mean arterial pressure. This may require high doses of norepinephrine, which has been associated with severe end organ damage. With this study, we aimed to investigate the effects of norepinephrine on the incidence of DCI in a clinical setting. METHODS We conducted a retrospective evaluation of patients with aSAH admitted to our institution between November 2018 and March 2021. Potential risk factors for DCI were analyzed and significant predictors were assessed by means of a logistic regression analysis to account for potential confounders. RESULTS In this study, 104 patients were included. Hereof, 39 (38%) showed radiologic signs of DCI between day three and 14 post-intervention. These patients had more frequent vasospasms (n = 37 vs. 30, p = 0.022), a higher Hunt & Hess score (3 ± 2 vs. 2 ± 1, p = 0.004), a lower initial Glasgow Coma Scale score (9 ± 5 vs. 12 ± 4, p = 0.003) and received a higher median norepinephrine dose (20,356μg vs. 6,508μg, p < 0.001). A logistic regression analysis revealed that only high-dose norepinephrine administration (OR 2.84, CI 1.56-7.8) and vasospasm (OR 3.07, CI 1.2-7.84) appeared to be significant independent risk factors for DCI. CONCLUSION Our results indicate a significant association between higher dose norepinephrine administration and the occurrence of DCI. Future research including greater sample sizes and a prospective setting will be necessary to further investigate the relationship.
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Affiliation(s)
- Andrea Cattaneo
- Department of Neurosurgery, University Hospital Würzburg, Würzburg, Germany
| | | | - Caroline Geske
- Department of Neurosurgery, University Hospital Würzburg, Würzburg, Germany
| | - Florian Semmler
- Department of Neurosurgery, University Hospital Würzburg, Würzburg, Germany
| | - Tamara M Wipplinger
- Department of Neurosurgery, University Hospital Würzburg, Würzburg, Germany
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, NY, United States of America
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Judith Weiland
- Department of Neurosurgery, University Hospital Würzburg, Würzburg, Germany
| | - Alexandra Beez
- Department of Neurosurgery, University Hospital Würzburg, Würzburg, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Würzburg, Würzburg, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios-Amper Klinikum Dachau, Dachau, Germany
| | - Ekkehard Kunze
- Department of Neurosurgery, University Hospital Würzburg, Würzburg, Germany
| | - Christian Stetter
- Department of Neurosurgery, University Hospital Würzburg, Würzburg, Germany
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Medina-Suárez J, Rodríguez-Esparragón F, Sosa-Pérez C, Cazorla-Rivero S, Torres-Mata LB, Jiménez-O’Shanahan A, Clavo B, Morera-Molina J. A Review of Genetic Polymorphisms and Susceptibilities to Complications after Aneurysmal Subarachnoid Hemorrhage. Int J Mol Sci 2022; 23:ijms232315427. [PMID: 36499752 PMCID: PMC9739720 DOI: 10.3390/ijms232315427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Delayed cerebral ischemia (DCI) and vasospasm are two complications of subarachnoid hemorrhages (SAHs) which entail high risks of morbidity and mortality. However, it is unknown why only some patients who suffer SAHs will experience DCI and vasospasm. The purpose of this review is to describe the main genetic single nucleotide polymorphisms (SNPs) that have demonstrated a relationship with these complications. The SNP of the nitric oxide endothelial synthase (eNOS) has been related to the size and rupture of an aneurysm, as well as to DCI, vasospasm, and poor neurological outcome. The SNPs responsible for the asymmetric dimetilarginine and the high-mobility group box 1 have also been associated with DCI. An association between vasospasm and the SNPs of the eNOS, the haptoglobin, and the endothelin-1 receptor has been found. The SNPs of the angiotensin-converting enzyme have been related to DCI and poor neurological outcome. Studies on the SNPs of the Ryanodine Receptor yielded varying results regarding their association with vasospasm.
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Affiliation(s)
- Jose Medina-Suárez
- Research Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Department of Specific Teaching Methodologies, University of Las Palmas de Gran Canaria, 35004 Gran Canaria, Spain
- Correspondence: (J.M.-S.); (F.R.-E.)
| | - Francisco Rodríguez-Esparragón
- Research Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Instituto Universitario de Enfermedades Tropicales y Salud Pública de Canarias, Universidad de La Laguna, 38296 Tenerife, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: (J.M.-S.); (F.R.-E.)
| | - Coralia Sosa-Pérez
- Neurosurgery Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Department of Medical and Surgery Sciences, University of Las Palmas de Gran Canaria, 35016 Gran Canaria, Spain
| | - Sara Cazorla-Rivero
- Research Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- University of La Laguna, 38200 Tenerife, Spain
| | - Laura B. Torres-Mata
- Research Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
| | | | - Bernardino Clavo
- Research Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Instituto Universitario de Enfermedades Tropicales y Salud Pública de Canarias, Universidad de La Laguna, 38296 Tenerife, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- RETIC de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), 28029 Madrid, Spain
- Instituto de Salud Carlos III, 28029 Madrid, Spain
- Chronic Pain Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Radiation Oncology Department, University Hospital of Gran Canaria Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain
| | - Jesús Morera-Molina
- Neurosurgery Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Department of Medical and Surgery Sciences, University of Las Palmas de Gran Canaria, 35016 Gran Canaria, Spain
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Kentar M, Díaz-Peregrino R, Trenado C, Sánchez-Porras R, San-Juan D, Ramírez-Cuapio FL, Holzwarth N, Maier-Hein L, Woitzik J, Santos E. Spatial and temporal frequency band changes during infarct induction, infarct progression, and spreading depolarizations in the gyrencephalic brain. Front Neurosci 2022; 16:1025967. [PMID: 36570832 PMCID: PMC9769704 DOI: 10.3389/fnins.2022.1025967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/18/2022] [Indexed: 12/07/2022] Open
Abstract
Aim To describe the spatial and temporal electrocorticographic (ECoG) changes after middle cerebral artery occlusion (MCAo), including those caused by spreading depolarization (SD) in the pig brain. Methods The left middle cerebral arteries (MCAs) were clipped in six pigs. The clipping procedure lasted between 8 and 12 min, achieving a permanent occlusion (MCAo). Five-contact ECoG stripes were placed bilaterally over the frontoparietal cortices corresponding to the irrigation territory of the MCA and anterior cerebral artery (ACA). ECoG recordings were performed around 24 h: 1 h before and 23 h after the MCAo, and SDs were quantified. Five-minute ECoG signal segments were sampled before, 5 min, and 4, 8, and 12 h after cerebral artery occlusion and before, during, and after the negative direct current shift of the SDs. The power spectrum of the signals was decomposed into delta, theta, alpha, beta, and gamma bands. Descriptive statistics, Wilcoxon matched-pairs signed-rank tests, and Friedman tests were performed. Results Electrodes close to the MCAo showed instant decay in all frequency bands and SD onset during the first 5 h. Electrodes far from the MCAo exhibited immediate loss of fast frequencies and progressive decline of slow frequencies with an increased SD incidence between 6 and 14 h. After 8 h, the ACA electrode reported a secondary reduction of all frequency bands except gamma and high SD incidence within 12-17 h. During the SD, all electrodes showed a decline in all frequency bands. After SD passage, frequency band recovery was impaired only in MCA electrodes. Conclusion ECoG can identify infarct progression and secondary brain injury. Severe disturbances in all the frequency bands are generated in the cortices where the SDs are passing by.
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Affiliation(s)
- Modar Kentar
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Roberto Díaz-Peregrino
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Carlos Trenado
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Renán Sánchez-Porras
- Department of Neurosurgery, Evangelisches Krankenhaus, Carl-von-Ossietzky University, Oldenburg, Germany
| | - Daniel San-Juan
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
| | - F. Leonardo Ramírez-Cuapio
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Niklas Holzwarth
- Division of Intelligent Medical Systems, German Cancer Research Center, Heidelberg, Germany
| | - Lena Maier-Hein
- Division of Intelligent Medical Systems, German Cancer Research Center, Heidelberg, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus, Carl-von-Ossietzky University, Oldenburg, Germany
| | - Edgar Santos
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany,Department of Neurosurgery, Evangelisches Krankenhaus, Carl-von-Ossietzky University, Oldenburg, Germany,*Correspondence: Edgar Santos,
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32
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Qureshi AI, Akhtar IN, Ma X, Lodhi A, Bhatti I, Beall J, Broderick JP, Cassarly CN, Martin RH, Sharma R, Thakkar M, Suarez JI. Effect of Cilostazol in Animal Models of Cerebral Ischemia and Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Neurocrit Care 2022:10.1007/s12028-022-01637-6. [DOI: 10.1007/s12028-022-01637-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/27/2022] [Indexed: 12/03/2022]
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33
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Hsieh BY, Kao YCJ, Zhou N, Lin YP, Mei YY, Chu SY, Wu DC. Vascular responses of penetrating vessels during cortical spreading depolarization with ultrasound dynamic ultrafast Doppler imaging. Front Neurosci 2022; 16:1015843. [PMID: 36466181 PMCID: PMC9714680 DOI: 10.3389/fnins.2022.1015843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2023] Open
Abstract
The dynamic vascular responses during cortical spreading depolarization (CSD) are causally related to pathophysiological consequences in numerous neurovascular conditions, including ischemia, traumatic brain injury, cerebral hemorrhage, and migraine. Monitoring of the hemodynamic responses of cerebral penetrating vessels during CSD is motivated to understand the mechanism of CSD and related neurological disorders. Six SD rats were used, and craniotomy surgery was performed before imaging. CSDs were induced by topical KCl application. Ultrasound dynamic ultrafast Doppler was used to access hemodynamic changes, including cerebral blood volume (CBV) and flow velocity during CSD, and further analyzed those in a single penetrating arteriole or venule. The CSD-induced hemodynamic changes with typical duration and propagation speed were detected by ultrafast Doppler in the cerebral cortex ipsilateral to the induction site. The hemodynamics typically showed triphasic changes, including initial hypoperfusion and prominent hyperperfusion peak, followed by a long-period depression in CBV. Moreover, different hemodynamics between individual penetrating arterioles and venules were proposed by quantification of CBV and flow velocity. The negative correlation between the basal CBV and CSD-induced change was also reported in penetrating vessels. These results indicate specific vascular dynamics of cerebral penetrating vessels and possibly different contributions of penetrating arterioles and venules to the CSD-related pathological vascular consequences. We proposed using ultrasound dynamic ultrafast Doppler imaging to investigate CSD-induced cerebral vascular responses. With this imaging platform, it has the potential to monitor the hemodynamics of cortical penetrating vessels during brain injuries to understand the mechanism of CSD in advance.
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Affiliation(s)
- Bao-Yu Hsieh
- Department of Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Yu-Chieh Jill Kao
- Department of Biomedical Imaging and Radiological Sciences, College of Biomedical Science and Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ning Zhou
- iHuman Institute, ShanghaiTech University, Shanghai, China
| | - Yi-Pei Lin
- Department of Biomedical Imaging and Radiological Science, College of Medicine, China Medical University, Taichung, Taiwan
| | - Yu-Ying Mei
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
| | - Sung-Yu Chu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Dong-Chuan Wu
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
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34
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Mauritzon S, Ginstman F, Hillman J, Wårdell K. Analysis of laser Doppler flowmetry long-term recordings for investigation of cerebral microcirculation during neurointensive care. Front Neurosci 2022; 16:1030805. [PMID: 36408392 PMCID: PMC9671599 DOI: 10.3389/fnins.2022.1030805] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/18/2022] [Indexed: 11/19/2023] Open
Abstract
Cerebral blood flow is monitored in the neurointensive care unit (NICU) to avoid further brain damage caused by secondary insults following subarachnoid hemorrhage and brain trauma. Current techniques are mainly snap-shot based and focus on larger vessels. However, continuous monitoring of the smaller vessels may help detect the onset of secondary insults at an earlier stage. In this study, long-term measurements of brain microcirculation with laser Doppler flowmetry (LDF) were performed and evaluated. The aim was to identify and describe physiological signal variations and separate these from movement artifacts. Fiberoptic probes for subcortical LDF recordings of perfusion and total light intensity (TLI) were implanted in three patients with subarachnoid hemorrhage. Data were successfully collected and visualized in real-time over 4 days, resulting in 34, 12, and 8.5 h per patient. Visual observation, wavelet transforms, moving medians, and peak envelopes were used to identify and describe movement artifacts and physiological changes. Artifacts occurred in <5% of the total recording time and could be identified through signal processing. Identified physiological signal patterns included a slowly increasing perfusion trend over hours, vasomotion mainly at 2 cycles/min both in the perfusion and the TLI, and rapid, synchronized changes in the TLI and the perfusion on 38 occasions. Continuous LDF recordings indicating changes in the microvascular blood flow can increase the understanding of the microcirculation in the injured brain. In the long run, this may become a complement for the detection of secondary insults at an earlier stage than possible with today's techniques.
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Affiliation(s)
- Stina Mauritzon
- Neuroengineering Lab, Department of Biomedical Engineering, Linköping University, Linköping, Sweden
| | - Fredrik Ginstman
- Department of Neurosurgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Jan Hillman
- Department of Neurosurgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Karin Wårdell
- Neuroengineering Lab, Department of Biomedical Engineering, Linköping University, Linköping, Sweden
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35
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Zheng WL, Kim JA, Elmer J, Zafar SF, Ghanta M, Moura Junior V, Patel A, Rosenthal E, Brandon Westover M. Automated EEG-based prediction of delayed cerebral ischemia after subarachnoid hemorrhage. Clin Neurophysiol 2022; 143:97-106. [PMID: 36182752 PMCID: PMC9847346 DOI: 10.1016/j.clinph.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 08/01/2022] [Accepted: 08/31/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) is a leading complication of aneurysmal subarachnoid hemorrhage (SAH) and electroencephalography (EEG) is increasingly used to evaluate DCI risk. Our goal is to develop an automated DCI prediction algorithm integrating multiple EEG features over time. METHODS We assess 113 moderate to severe grade SAH patients to develop a machine learning model that predicts DCI risk using multiple EEG features. RESULTS Multiple EEG features discriminate between DCI and non-DCI patients when aligned either to SAH time or to DCI onset. DCI and non-DCI patients have significant differences in alpha-delta ratio (0.08 vs 0.05, p < 0.05) and percent alpha variability (0.06 vs 0.04, p < 0.05), Shannon entropy (p < 0.05) and epileptiform discharge burden (205 vs 91 discharges per hour, p < 0.05) based on whole brain and vascular territory averaging. Our model improves predictions by emphasizing the most informative features at a given time with an area under the receiver-operator curve of 0.73, by day 5 after SAH and good calibration between 48-72 hours (calibration error 0.13). CONCLUSIONS Our proposed model obtains good performance in DCI prediction. SIGNIFICANCE We leverage machine learning to enable rapid, automated, multi-featured EEG assessment and has the potential to increase the utility of EEG for DCI prediction.
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Affiliation(s)
- Wei-Long Zheng
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Jennifer A Kim
- Department of Neurology, Yale University, New Haven, CT 06520, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Manohar Ghanta
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - Aman Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Eric Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
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36
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Gaastra B, Carmichael H, Galea I, Bulters D. Duration and characteristics of persistent headache following aneurysmal subarachnoid hemorrhage. Headache 2022; 62:1376-1382. [PMID: 36426750 PMCID: PMC10099612 DOI: 10.1111/head.14418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the long-term frequency, prognosis, and phenotype of persistent headache following aneurysmal subarachnoid hemorrhage (aSAH). BACKGROUND Very little is known about long-term headache following aSAH with no studies looking beyond 3 years. METHODS Retrospective analysis comparing aSAH cases to matched controls in the UK Biobank, a prospective cohort study. Headache frequency and phenotype were compared using group comparison tests. The relationship between headache frequency and time was assessed using correlation analysis. RESULTS Headache was more frequent following aSAH (aSAH: 258/864 [29.9%] vs. controls: 666/3456 [19.3%], χ2 = 45.5, p < 0.001) at a median follow-up of 7.5 years. Headache frequency decreased over time (RS = -0.71, p = 0.028), affecting 29/58 (50%) patients in the first year and reducing to 13/47 (28%) patients 10 years later. Headache frequency was not related to aSAH severity (z = 0.249, p = 0.803), treatment (z = 0.583, p = 0.560), or hydrocephalus (z = -1.244, p = 0.214). There was a consistently higher frequency of migrainous features following aSAH compared to controls, although this did not reach statistical significance. CONCLUSIONS Persistent headache is more frequent following aSAH compared to controls in the long term and the prevalence reduces gradually over time. The increased frequency of migrainous features suggests that selected patients with post-aSAH headache may benefit from migraine treatment.
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Affiliation(s)
- Ben Gaastra
- Faculty of Medicine, University of Southampton, Southampton, UK.,Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Harry Carmichael
- Faculty of Medicine, University of Southampton, Southampton, UK.,Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Ian Galea
- Faculty of Medicine, University of Southampton, Southampton, UK.,Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Diederik Bulters
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
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37
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Alkhachroum A, Appavu B, Egawa S, Foreman B, Gaspard N, Gilmore EJ, Hirsch LJ, Kurtz P, Lambrecq V, Kromm J, Vespa P, Zafar SF, Rohaut B, Claassen J. Electroencephalogram in the intensive care unit: a focused look at acute brain injury. Intensive Care Med 2022; 48:1443-1462. [PMID: 35997792 PMCID: PMC10008537 DOI: 10.1007/s00134-022-06854-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/31/2022] [Indexed: 02/04/2023]
Abstract
Over the past decades, electroencephalography (EEG) has become a widely applied and highly sophisticated brain monitoring tool in a variety of intensive care unit (ICU) settings. The most common indication for EEG monitoring currently is the management of refractory status epilepticus. In addition, a number of studies have associated frequent seizures, including nonconvulsive status epilepticus (NCSE), with worsening secondary brain injury and with worse outcomes. With the widespread utilization of EEG (spot and continuous EEG), rhythmic and periodic patterns that do not fulfill strict seizure criteria have been identified, epidemiologically quantified, and linked to pathophysiological events across a wide spectrum of critical and acute illnesses, including acute brain injury. Increasingly, EEG is not just qualitatively described, but also quantitatively analyzed together with other modalities to generate innovative measurements with possible clinical relevance. In this review, we discuss the current knowledge and emerging applications of EEG in the ICU, including seizure detection, ischemia monitoring, detection of cortical spreading depolarizations, assessment of consciousness and prognostication. We also review some technical aspects and challenges of using EEG in the ICU including the logistics of setting up ICU EEG monitoring in resource-limited settings.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, FL, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, USA
| | - Brian Appavu
- Department of Child Health and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Neurosciences, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Satoshi Egawa
- Neurointensive Care Unit, Department of Neurosurgery, and Stroke and Epilepsy Center, TMG Asaka Medical Center, Saitama, Japan
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Free University of Brussels, Brussels, Belgium
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Neurocritical Care and Emergency Neurology, Department of Neurology, Ale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Pedro Kurtz
- Department of Intensive Care Medicine, D'or Institute for Research and Education, Rio de Janeiro, Brazil
- Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Virginie Lambrecq
- Department of Clinical Neurophysiology and Epilepsy Unit, AP-HP, Pitié Salpêtrière Hospital, Reference Center for Rare Epilepsies, 75013, Paris, France
| | - Julie Kromm
- Departments of Critical Care Medicine and Clinical Neurosciences, Cumming School of Medicine, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, AB, Canada
| | - Paul Vespa
- Brain Injury Research Center, Department of Neurosurgery, University of California, Los Angeles, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin Rohaut
- Department of Neurology, Sorbonne Université, Pitié-Salpêtrière-AP-HP and Paris Brain Institute, ICM, Inserm, CNRS, Paris, France
| | - Jan Claassen
- Department of Neurology, Neurological Institute, Columbia University, New York Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
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38
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Sorrentino ZA, Laurent D, Hernandez J, Davidson C, Small C, Dodd W, Lucke‐Wold B. Headache persisting after aneurysmal subarachnoid hemorrhage: A narrative review of pathophysiology and therapeutic strategies. Headache 2022; 62:1120-1132. [PMID: 36112096 DOI: 10.1111/head.14394] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Zachary A. Sorrentino
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - Dimitri Laurent
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - Jairo Hernandez
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - Caroline Davidson
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - Coulter Small
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - William Dodd
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
| | - Brandon Lucke‐Wold
- Department of Neurosurgery University of Florida College of Medicine Gainesville Florida USA
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39
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Abstract
Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA.
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
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40
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Pierre K, Dagra A, Siyanaki MRH, Mehkri Y, Woodford S, Hatem R, Lucke-Wold B. Utilization of EEG for Monitoring in Subarachnoid hemorrhage Recovery. BIOMEDICAL AND CLINICAL RESEARCH 2022; 1:10.31579/2834-8486/002. [PMID: 36741905 PMCID: PMC9893888 DOI: 10.31579/2834-8486/002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Seizures and delayed cerebral ischemia following subarachnoid hemorrhage are associated with significant morbidity and mortality. In this article, we briefly review subarachnoid hemorrhage, its complications, and the current literature on information gained from EEG monitoring in subarachnoid hemorrhage. We review when EEG should be used implemented in the multi-modal monitoring of patients with subarachnoid hemorrhage. Finally, we discuss the recent advances and future directions in the field.
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Affiliation(s)
- Kevin Pierre
- University of Florida Department of Radiology, Gainesville, FL, 32603
| | - Abeer Dagra
- University of Florida College of Medicine, Gainesville, FL, 32603
| | | | - Yusuf Mehkri
- University of Florida College of Medicine, Gainesville, FL, 32603
| | - Samuel Woodford
- University of Florida College of Medicine, Gainesville, FL, 32603
| | - Rami Hatem
- University of Florida College of Medicine, Gainesville, FL, 32603
| | - Brandon Lucke-Wold
- University of Florida Department of Neurosurgery, Gainesville, FL, 32603
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41
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Kim JA, Zheng WL, Elmer J, Jing J, Zafar SF, Ghanta M, Moura V, Gilmore EJ, Hirsch LJ, Patel A, Rosenthal E, Westover MB. High epileptiform discharge burden predicts delayed cerebral ischemia after subarachnoid hemorrhage. Clin Neurophysiol 2022; 141:139-146. [PMID: 33812771 PMCID: PMC8429508 DOI: 10.1016/j.clinph.2021.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/30/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate whether epileptiform discharge burden can identify those at risk for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). METHODS Retrospective analysis of 113 moderate to severe grade SAH patients who had continuous EEG (cEEG) recordings during their hospitalization. We calculated the burden of epileptiform discharges (ED), measured as number of ED per hour. RESULTS We find that many SAH patients have an increase in ED burden during the first 3-10 days following rupture, the major risk period for DCI. However, those who develop DCI have a significantly higher hourly burden from days 3.5-6 after SAH vs. those who do not. ED burden is higher in DCI patients when assessed in relation to the onset of DCI (area under the receiver operator curve 0.72). Finally, specific trends of ED burden over time, assessed by group-based trajectory analysis, also help stratify DCI risk. CONCLUSIONS These results suggest that ED burden is a useful parameter for identifying those at higher risk of developing DCI after SAH. The higher burden rate associated with DCI supports the theory of metabolic supply-demand mismatch which contributes to this complication. SIGNIFICANCE ED burden is a novel biomarker for predicting those at high risk of DCI.
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Affiliation(s)
- Jennifer A Kim
- Department of Neurology, Yale University, New Haven, CT 06520, USA.
| | - Wei-Long Zheng
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Jin Jing
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Manohar Ghanta
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Valdery Moura
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Emily J Gilmore
- Department of Neurology, Yale University, New Haven, CT 06520, USA
| | | | - Aman Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Eric Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
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42
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Meinert F, Dömer P, Helgers SOA, Schumm L, Hecht N, Dreier JP, Woitzik J. Subdural Placement of Electrocorticographic Electrode Array Through a Burr Hole Exposure: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e169. [PMID: 35972097 DOI: 10.1227/ons.0000000000000299] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/24/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Franziska Meinert
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Patrick Dömer
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | | | - Leonie Schumm
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jens Peter Dreier
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.,Research Center Neurosensory Science, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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43
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Unekawa M, Tomita Y, Masamoto K, Kanno I, Nakahara J, Izawa Y. Close association between spreading depolarization and development of infarction under experimental ischemia in anesthetized male mice. Brain Res 2022; 1792:148023. [PMID: 35901965 DOI: 10.1016/j.brainres.2022.148023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 11/02/2022]
Abstract
Clinical and experimental evidence suggests that spreading depolarizations (SD) usually occur in patients with ischemic or hemorrhagic stroke when the gray matter of the brain is affected. In this study, we evaluated spatiotemporal changes of cerebral blood flow (CBF) during middle cerebral artery (MCA) occlusion and examined the relationship between SD occurrence and cerebral infarct development. In male isoflurane-anesthetized C57BL/6J mice, CBF changes over the ipsilateral parietal bone were recorded by laser speckle flowgraphy during and after transient (45 min, n = 22) or permanent occlusion (n = 22) of the distal MCA. Infarct volume was evaluated 24 hr after the operation. Upon MCA occlusion, CBF decreased by -55.6 ± 8.5 % in the lowest CBF and linearly recovered with increasing distance from the region. At 1-10 min after onset of occlusion, SD occurred and concentrically propagated from the core region, showing a decrease of CBF in the whole observed area along with a transient hyperemia and oligemia in the normal region. SD spontaneously re-occurred and propagated around the ischemic area in 37 % of mice, accompanied with a marked decrease of CBF in the core or a marked increase of CBF in the normal region. The CBF response to SDs gradually changed from the core to the normal area, depending upon the distance from the core region. Infarction was not observed in transiently (n = 2) or permanently (n = 4) occluded mice without SD. The infarct area tended to be larger with increasing number of SDs in transiently occluded mice. In conclusion, our findings suggest that the occurrence of SD during ischemia might elicit infarct formation and/or influence infarct development.
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Affiliation(s)
- Miyuki Unekawa
- Department of Neurology, Keio University School of Medicine, Shinjuku, Tokyo 160-8582, Japan.
| | - Yutaka Tomita
- Department of Neurology, Keio University School of Medicine, Shinjuku, Tokyo 160-8582, Japan
| | - Kazuto Masamoto
- Center for Neuroscience and Biomedical Engineering, University of Electro-Communications, Chofu, Tokyo 182-8585, Japan; Department of Functional Brain Imaging, National Institutes for Quantum Science and Technology, Inage, Chiba 263-8555, Japan
| | - Iwao Kanno
- Department of Functional Brain Imaging, National Institutes for Quantum Science and Technology, Inage, Chiba 263-8555, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Shinjuku, Tokyo 160-8582, Japan
| | - Yoshikane Izawa
- Department of Neurology, Keio University School of Medicine, Shinjuku, Tokyo 160-8582, Japan
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44
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Cramer SW, Pino IP, Naik A, Carlson D, Park MC, Darrow DP. Mapping spreading depolarisations after traumatic brain injury: a pilot clinical study protocol. BMJ Open 2022; 12:e061663. [PMID: 35831043 PMCID: PMC9280885 DOI: 10.1136/bmjopen-2022-061663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 06/27/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Cortical spreading depolarisation (CSD) is characterised by a near-complete loss of the ionic membrane potential of cortical neurons and glia propagating across the cerebral cortex, which generates a transient suppression of spontaneous neuronal activity. CSDs have become a recognised phenomenon that imparts ongoing secondary insults after brain injury. Studies delineating CSD generation and propagation in humans after traumatic brain injury (TBI) are lacking. Therefore, this study aims to determine the feasibility of using a multistrip electrode array to identify CSDs and characterise their propagation in space and time after TBI. METHODS AND ANALYSIS This pilot, prospective observational study will enrol patients with TBI requiring therapeutic craniotomy or craniectomy. Subdural electrodes will be placed for continuous electrocorticography monitoring for seizures and CSDs as a research procedure, with surrogate informed consent obtained preoperatively. The propagation of CSDs relative to structural brain pathology will be mapped using reconstructed CT and electrophysiological cross-correlations. The novel use of multiple subdural strip electrodes in conjunction with brain morphometric segmentation is hypothesised to provide sufficient spatial information to characterise CSD propagation across the cerebral cortex and identify cortical foci giving rise to CSDs. ETHICS AND DISSEMINATION Ethical approval for the study was obtained from the Hennepin Healthcare Research Institute's ethics committee, HSR 17-4400, 25 October 2017 to present. Study findings will be submitted for publication in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION NUMBER NCT03321370.
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Affiliation(s)
- Samuel W Cramer
- Department of Neurosurgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Isabela Peña Pino
- Department of Neurosurgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Anant Naik
- University of Illinois Urbana-Champaign Carle Illinois College of Medicine, Champaign, Illinois, USA
| | - Danielle Carlson
- Department of Neurosurgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Michael C Park
- Department of Neurosurgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - David P Darrow
- Neurosurgery, University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota, USA
- Division of Neurosurgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
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Yan J, Li W, Zhou C, Wu N, Yang X, Pan Q, He T, Wu Y, Guo Z, Xia Y, Sun X, Cheng C. Dynamic Measurements of Cerebral Blood Flow Responses to Cortical Spreading Depolarization in the Murine Endovascular Perforation Subarachnoid Hemorrhage Model. Transl Stroke Res 2022:10.1007/s12975-022-01052-1. [PMID: 35749033 DOI: 10.1007/s12975-022-01052-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/30/2022] [Accepted: 06/10/2022] [Indexed: 12/13/2022]
Abstract
Delayed cerebral ischemia (DCI) is the most severe complication after subarachnoid hemorrhage (SAH), and cortical spreading depolarization (CSD) is believed to play a vital role in it. However, the dynamic changes in cerebral blood flow (CBF) in response to CSD in typical SAH models have not been well investigated. Here, SAH was established in mice with endovascular perforation. Subsequently, the spontaneous CBF dropped instantly and then returned to baseline rapidly. After KCl application to the cortex, subsequent hypoperfusion waves occurred across the groups, while a lower average perfusion level was found in the SAH groups (days 1-7). Moreover, in the SAH groups, the number of CSD decreased within day 7, and the duration and spreading velocity of the CSD increased within day 3 and day 14, respectively. Next, we continuously monitored the local field potential (LFP) in the prefrontal cortex. The results showed that the decrease in the percentage of gamma oscillations lasted throughout the whole process in the SAH group. In the chronic phase after SAH, we found that the mice still had cognitive deficits but experienced no obvious tissue damage. In summary, SAH negatively affects the CBF responses to CSD and the spontaneous LFP activity and causes long-term cognitive deficits in mice. Based on these findings, in the specific phase after SAH, DCI is induced or exacerbated more easily by potential causers of CSD in clinical practice (edema, erythrocytolysis, inflammation), which may lead to neurological deterioration.
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Affiliation(s)
- Jin Yan
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Wenlang Li
- Department of Anesthesiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chao Zhou
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Na Wu
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Xiaomin Yang
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Qiuling Pan
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Tao He
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Wu
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Zongduo Guo
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Yongzhi Xia
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Xiaochuan Sun
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China.
| | - Chongjie Cheng
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China.
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Depolarization time and extracellular glutamate levels aggravate ultraearly brain injury after subarachnoid hemorrhage. Sci Rep 2022; 12:10256. [PMID: 35715559 PMCID: PMC9205962 DOI: 10.1038/s41598-022-14360-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/06/2022] [Indexed: 11/15/2022] Open
Abstract
Early brain injury after aneurysmal subarachnoid hemorrhage (SAH) worsens the neurological outcome. We hypothesize that a longer duration of depolarization and excessive release of glutamate aggravate neurological outcomes after SAH, and that brain hypothermia can accelerate repolarization and inhibit the excessive release of extracellular glutamate and subsequent neuronal damage. So, we investigated the influence of depolarization time and extracellular glutamate levels on the neurological outcome in the ultra-early phase of SAH using a rat injection model as Experiment 1 and then evaluated the efficacy of brain hypothermia targeting ultra-early brain injury as Experiment 2. Dynamic changes in membrane potentials, intracranial pressure, cerebral perfusion pressure, cerebral blood flow, and extracellular glutamate levels were observed within 30 min after SAH. A prolonged duration of depolarization correlated with peak extracellular glutamate levels, and these two factors worsened the neuronal injury. Under brain hypothermia using pharyngeal cooling after SAH, cerebral perfusion pressure in the hypothermia group recovered earlier than that in the normothermia group. Extracellular glutamate levels in the hypothermia group were significantly lower than those in the normothermia group. The early induction of brain hypothermia could facilitate faster recovery of cerebral perfusion pressure, repolarization, and the inhibition of excessive glutamate release, which would prevent ultra-early brain injury following SAH.
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Andrew RD, Farkas E, Hartings JA, Brennan KC, Herreras O, Müller M, Kirov SA, Ayata C, Ollen-Bittle N, Reiffurth C, Revah O, Robertson RM, Dawson-Scully KD, Ullah G, Dreier JP. Questioning Glutamate Excitotoxicity in Acute Brain Damage: The Importance of Spreading Depolarization. Neurocrit Care 2022; 37:11-30. [PMID: 35194729 PMCID: PMC9259542 DOI: 10.1007/s12028-021-01429-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Within 2 min of severe ischemia, spreading depolarization (SD) propagates like a wave through compromised gray matter of the higher brain. More SDs arise over hours in adjacent tissue, expanding the neuronal damage. This period represents a therapeutic window to inhibit SD and so reduce impending tissue injury. Yet most neuroscientists assume that the course of early brain injury can be explained by glutamate excitotoxicity, the concept that immediate glutamate release promotes early and downstream brain injury. There are many problems with glutamate release being the unseen culprit, the most practical being that the concept has yielded zero therapeutics over the past 30 years. But the basic science is also flawed, arising from dubious foundational observations beginning in the 1950s METHODS: Literature pertaining to excitotoxicity and to SD over the past 60 years is critiqued. RESULTS Excitotoxicity theory centers on the immediate and excessive release of glutamate with resulting neuronal hyperexcitation. This instigates poststroke cascades with subsequent secondary neuronal injury. By contrast, SD theory argues that although SD evokes some brief glutamate release, acute neuronal damage and the subsequent cascade of injury to neurons are elicited by the metabolic stress of SD, not by excessive glutamate release. The challenge we present here is to find new clinical targets based on more informed basic science. This is motivated by the continuing failure by neuroscientists and by industry to develop drugs that can reduce brain injury following ischemic stroke, traumatic brain injury, or sudden cardiac arrest. One important step is to recognize that SD plays a central role in promoting early neuronal damage. We argue that uncovering the molecular biology of SD initiation and propagation is essential because ischemic neurons are usually not acutely injured unless SD propagates through them. The role of glutamate excitotoxicity theory and how it has shaped SD research is then addressed, followed by a critique of its fading relevance to the study of brain injury. CONCLUSIONS Spreading depolarizations better account for the acute neuronal injury arising from brain ischemia than does the early and excessive release of glutamate.
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Affiliation(s)
| | - Eszter Farkas
- Hungarian Centre of Excellence for Molecular Medicine-University of Szeged, Cerebral Blood Flow and Metabolism Research Group, Department of Cell Biology and Molecular Medicine, University of Szeged, Szeged, Hungary
| | | | | | | | | | | | - Cenk Ayata
- Harvard Medical School, Harvard University, Boston, MA USA
| | | | - Clemens Reiffurth
- Center for Stroke Research Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Omer Revah
- School of Medicine, Stanford University, Stanford, CA USA
| | | | | | | | - Jens P. Dreier
- Center for Stroke Research Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Corporate Member of Freie Universität Berlin, Berlin, Germany
- Department of Neurology, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Berlin Institute of Health, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
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Hund SJ, Brown BR, Lemale CL, Menon PG, Easley KA, Dreier JP, Jones SC. Numerical Simulation of Concussive-Generated Cortical Spreading Depolarization to Optimize DC-EEG Electrode Spacing for Noninvasive Visual Detection. Neurocrit Care 2022; 37:67-82. [PMID: 35233716 PMCID: PMC9262830 DOI: 10.1007/s12028-021-01430-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 12/29/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cortical spreading depolarization (SD) is a propagating depolarization wave of neurons and glial cells in the cerebral gray matter. SD occurs in all forms of severe acute brain injury, as documented by using invasive detection methods. Based on many experimental studies of mechanical brain deformation and concussion, the occurrence of SDs in human concussion has often been hypothesized. However, this hypothesis cannot be confirmed in humans, as SDs can only be detected with invasive detection methods that would require either a craniotomy or a burr hole to be performed on athletes. Typical electroencephalography electrodes, placed on the scalp, can help detect the possible presence of SD but have not been able to accurately and reliably identify SDs. METHODS To explore the possibility of a noninvasive method to resolve this hurdle, we developed a finite element numerical model that simulates scalp voltage changes that are induced by a brain surface SD. We then compared our simulation results with retrospectively evaluated data in patients with aneurysmal subarachnoid hemorrhage from Drenckhahn et al. (Brain 135:853, 2012). RESULTS The ratio of peak scalp to simulated peak cortical voltage, Vscalp/Vcortex, was 0.0735, whereas the ratio from the retrospectively evaluated data was 0.0316 (0.0221, 0.0527) (median [1st quartile, 3rd quartile], n = 161, p < 0.001, one sample Wilcoxon signed-rank test). These differing values provide validation because their differences can be attributed to differences in shape between concussive SDs and aneurysmal subarachnoid hemorrhage SDs, as well as the inherent limitations in human study voltage measurements. This simulated scalp surface potential was used to design a virtual scalp detection array. Error analysis and visual reconstruction showed that 1 cm is the optimal electrode spacing to visually identify the propagating scalp voltage from a cortical SD. Electrode spacings of 2 cm and above produce distorted images and high errors in the reconstructed image. CONCLUSIONS Our analysis suggests that concussive (and other) SDs can be detected from the scalp, which could confirm SD occurrence in human concussion, provide concussion diagnosis on the basis of an underlying physiological mechanism, and lead to noninvasive SD detection in the setting of severe acute brain injury.
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Affiliation(s)
- Samuel J Hund
- CerebroScope, SciencePlusPlease LLC, Pittsburgh, PA, USA
- SimulationSolutions, Pittsburgh, PA, USA
| | | | - Coline L Lemale
- Center for Stroke Research, Charité, - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité, - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Prahlad G Menon
- CerebroScope, SciencePlusPlease LLC, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kirk A Easley
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jens P Dreier
- Center for Stroke Research, Charité, - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Department of Experimental Neurology, Charité, - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Department of Neurology, Charité, - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
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Owen B, Vangala A, Fritch C, Alsarah AA, Jones T, Davis H, Shuttleworth CW, Carlson AP. Cerebral Autoregulation Correlation With Outcomes and Spreading Depolarization in Aneurysmal Subarachnoid Hemorrhage. Stroke 2022; 53:1975-1983. [PMID: 35196873 PMCID: PMC9133018 DOI: 10.1161/strokeaha.121.037184] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Delayed cerebral ischemia remains one of the principal therapeutic targets after aneurysmal subarachnoid hemorrhage. While large vessel vasospasm may contribute to ischemia, increasing evidence suggests that physiological impairment through disrupted impaired cerebral autoregulation (CA) and spreading depolarizations (SDs) also contribute to delayed cerebral ischemia and poor neurological outcome. This study seeks to explore the intermeasure correlation of different measures of CA, as well as correlation with SD and neurological outcome. METHODS Simultaneous measurement of 7 continuous indices of CA was calculated in 19 subjects entered in a prospective study of SD in aneurysmal subarachnoid hemorrhage undergoing surgical aneurysm clipping. Intermeasure agreement was assessed, and the association of each index with modified Rankin Scale score at 90 days and occurrence of SD was assessed. RESULTS There were 4102 hours of total monitoring time across the 19 subjects. In time-resolved assessment, no CA measures demonstrated significant correlation; however, most demonstrate significant correlation averaged over 1 hour. Pressure reactivity (PRx), oxygen reactivity, and oxygen saturation reactivity were significantly correlated with modified Rankin Scale score at 90 days. PRx and oxygen reactivity also were correlated with the occurrence of SD events. Across multiple CA measure reactivity indices, a threshold between 0.3 and 0.5 was most associated with intervals containing SD. CONCLUSIONS Different continuous CA indices do not correlate well with each other on a highly time-resolved basis, so should not be viewed as interchangeable. PRx and oxygen reactivity are the most reliable indices in identifying risk of worse outcome in patients with aneurysmal subarachnoid hemorrhage undergoing surgical treatment. SD occurrence is correlated with impaired CA across multiple CA measurement techniques and may represent the pathological mechanism of delayed cerebral ischemia in patients with impaired CA. Optimization of CA in patients with aneurysmal subarachnoid hemorrhage may lead to decreased incidence of SD and improved neurological outcomes. Future studies are needed to evaluate these hypotheses and approaches.
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Affiliation(s)
- Bryce Owen
- University of New Mexico, School of Medicine
| | - Adarsh Vangala
- University of Arizona College of Medicine, Department of Internal Medicine
| | - Chanju Fritch
- Penn State School of Medicine, Department of Neurosurgery
| | - Ali A. Alsarah
- University of New Mexico School of Medicine, Department of Neurology
| | - Tom Jones
- University of New Mexico School of Medicine, Department of Psychiatry
| | - Herbert Davis
- University of New Mexico School of Medicine, Department of Internal Medicine, Division of Epidemiology, Biostatistics, and Preventive Medicine
| | | | - Andrew P. Carlson
- University of New Mexico School of Medicine, Department of Neurosurgery
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Witsch J, Spalart V, Martinod K, Schneider H, Oertel J, Geisel J, Hendrix P, Hemmer S. Neutrophil Extracellular Traps and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Crit Care Explor 2022; 4:e0692. [PMID: 35620772 PMCID: PMC9116951 DOI: 10.1097/cce.0000000000000692] [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] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Myeloperoxidase (MPO)-DNA complexes, biomarkers of neutrophil extracellular traps (NETs), have been associated with arterial and venous thrombosis. Their role in aneurysmal subarachnoid hemorrhage (aSAH) is unknown. OBJECTIVES To assess whether serum MPO-DNA complexes are present in patients with aSAH and whether they are associated with delayed cerebral ischemia (DCI). DESIGN SETTING AND PARTICIPANTS Post-hoc analysis of a prospective, observational single-center study, with de novo serum biomarker measurements in consecutive patients with aSAH between July 2018 and September 2020, admitted to a tertiary care neuroscience ICU. MAIN OUTCOMES AND MEASURES We analyzed serum obtained at admission and hospital day 4 for concentrations of MPO-DNA complexes. The primary outcome was DCI, defined as new infarction on brain CT. The secondary outcome was clinical vasospasm, a composite of clinical and transcranial Doppler parameters. We used Wilcoxon signed-rank-test to assess for differences between paired measures. RESULTS Among 100 patients with spontaneous subarachnoid hemorrhage, mean age 59 years (sd ± 13 yr), 55% women, 78 had confirmed aSAH. Among these, 29 (37%) developed DCI. MPO-DNA complexes were detected in all samples. The median MPO-DNA level was 33 ng/mL (interquartile range [IQR], 18-43 ng/mL) at admission, and 22 ng/mL (IQR, 11-31 ng/mL) on day 4 (unpaired test; p = 0.015). We found a significant reduction in MPO-DNA levels from admission to day 4 in patients with DCI (paired test; p = 0.036) but not in those without DCI (p = 0.17). There was a similar reduction in MPO-DNA levels between admission and day 4 in patients with (p = 0.006) but not in those without clinical vasospasm (p = 0.47). CONCLUSIONS AND RELEVANCE This is the first study to detect the NET biomarkers MPO-DNA complexes in peripheral serum of patients with aSAH and to associate them with DCI. A pronounced reduction in MPO-DNA levels might serve as an early marker of DCI. This diagnostic potential of MPO-DNA complexes and their role as potential therapeutic targets in aSAH should be explored further.
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Affiliation(s)
- Jens Witsch
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Valérie Spalart
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Kimberly Martinod
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Jürgen Geisel
- Department of Clinical Chemistry and Laboratory Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Philipp Hendrix
- Department of Neurosurgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Sina Hemmer
- Department of Neurosurgery, Saarland University Medical Center, Homburg/Saar, Germany
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