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Leppert J, Küchler J, Wagner A, Hinselmann N, Ditz C. Prospective Observational Study of Volatile Sedation with Sevoflurane After Aneurysmal Subarachnoid Hemorrhage Using the Sedaconda Anesthetic Conserving Device. Neurocrit Care 2024; 41:498-510. [PMID: 38485879 DOI: 10.1007/s12028-024-01959-7] [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: 11/06/2023] [Accepted: 02/09/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Volatile sedation is still used with caution in patients with acute brain injury because of safety concerns. We analyzed the effects of sevoflurane sedation on systemic and cerebral parameters measured by multimodal neuromonitoring in patients after aneurysmal subarachnoid hemorrhage (aSAH) with normal baseline intracranial pressure (ICP). METHODS In this prospective observational study, we analyzed a 12-h period before and after the switch from intravenous to volatile sedation with sevoflurane using the Sedaconda Anesthetic Conserving Device with a target Richmond Agitation Sedation Scale score of - 5 to - 4. ICP, cerebral perfusion pressure (CPP), brain tissue oxygenation (PBrO2), metabolic values of cerebral microdialysis, systemic cardiopulmonary parameters, and the administered drugs before and after the sedation switch were analyzed. RESULTS We included 19 patients with a median age of 61 years (range 46-78 years), 74% of whom presented with World Federation of Neurosurgical Societies grade 4 or 5 aSAH. We observed no significant changes in the mean ICP (9.3 ± 4.2 vs. 9.7 ± 4.2 mm Hg), PBrO2 (31.0 ± 13.2 vs. 32.2 ± 12.4 mm Hg), cerebral lactate (5.0 ± 2.2 vs. 5.0 ± 1.9 mmol/L), pyruvate (136.6 ± 55.9 vs. 134.1 ± 53.6 µmol/L), and lactate/pyruvate ratio (37.4 ± 8.7 vs. 39.8 ± 9.2) after the sedation switch to sevoflurane. We found a significant decrease in mean arterial pressure (MAP) (88.6 ± 7.6 vs. 86.3 ± 5.8 mm Hg) and CPP (78.8 ± 8.5 vs. 76.6 ± 6.6 mm Hg) after the initiation of sevoflurane, but the decrease was still within the physiological range requiring no additional hemodynamic support. CONCLUSIONS Sevoflurane appears to be a feasible alternative to intravenous sedation in patients with aSAH without intracranial hypertension, as our study did not show negative effects on ICP, cerebral oxygenation, or brain metabolism. Nevertheless, the risk of a decrease of MAP leading to a consecutive CPP decrease should be considered.
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Affiliation(s)
- Jan Leppert
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Andreas Wagner
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Niclas Hinselmann
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
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Denker N, Dringen R. Modulation of Pyruvate Export and Extracellular Pyruvate Concentration in Primary Astrocyte Cultures. Neurochem Res 2024; 49:1331-1346. [PMID: 38376749 PMCID: PMC10991036 DOI: 10.1007/s11064-024-04120-0] [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: 11/10/2023] [Revised: 02/02/2024] [Accepted: 02/02/2024] [Indexed: 02/21/2024]
Abstract
Astrocyte-derived pyruvate is considered to have neuroprotective functions. In order to investigate the processes that are involved in astrocytic pyruvate release, we used primary rat astrocyte cultures as model system. Depending on the incubation conditions and medium composition, astrocyte cultures established extracellular steady state pyruvate concentrations in the range between 150 µM and 300 µM. During incubations for up to 2 weeks in DMEM culture medium, the extracellular pyruvate concentration remained almost constant for days, while the extracellular lactate concentration increased continuously during the incubation into the millimolar concentration range as long as glucose was present. In an amino acid-free incubation buffer, glucose-fed astrocytes released pyruvate with an initial rate of around 60 nmol/(h × mg) and after around 5 h an almost constant extracellular pyruvate concentration was established that was maintained for several hours. Extracellular pyruvate accumulation was also observed, if glucose had been replaced by mannose, fructose, lactate or alanine. Glucose-fed astrocyte cultures established similar extracellular steady state concentrations of pyruvate by releasing pyruvate into pyruvate-free media or by consuming excess of extracellular pyruvate. Inhibition of the monocarboxylate transporter MCT1 by AR-C155858 lowered extracellular pyruvate accumulation, while inhibition of mitochondrial pyruvate uptake by UK5099 increased the extracellular pyruvate concentration. Finally, the presence of the uncoupler BAM15 or of the respiratory chain inhibitor antimycin A almost completely abolished extracellular pyruvate accumulation. The data presented demonstrate that cultured astrocytes establish a transient extracellular steady state concentration of pyruvate which is strongly affected by modulation of the mitochondrial pyruvate metabolism.
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Affiliation(s)
- Nadine Denker
- Centre for Biomolecular Interactions Bremen, Faculty 2 (Biology/Chemistry) and Centre for Environmental Research and Sustainable Technologies, University of Bremen, P.O. Box 330440, 28334, Bremen, Germany
| | - Ralf Dringen
- Centre for Biomolecular Interactions Bremen, Faculty 2 (Biology/Chemistry) and Centre for Environmental Research and Sustainable Technologies, University of Bremen, P.O. Box 330440, 28334, Bremen, Germany.
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Velle F, Lewén A, Howells T, Hånell A, Nilsson P, Enblad P. The effects of cerebral pressure autoregulation status and CPP levels on cerebral metabolism in pediatric traumatic brain injury. Acta Neurochir (Wien) 2024; 166:190. [PMID: 38653934 DOI: 10.1007/s00701-024-06085-z] [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: 11/16/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Cerebral perfusion pressure (CPP) management in the developing child with traumatic brain injury (TBI) is challenging. The pressure reactivity index (PRx) may serve as marker of cerebral pressure autoregulation (CPA) and optimal CPP (CPPopt) may be assessed by identifying the CPP level with best (lowest) PRx. To evaluate the potential of CPPopt guided management in children with severe TBI, cerebral microdialysis (CMD) monitoring levels of lactate and the lactate/pyruvate ratio (LPR) (indicators of ischemia) were related to actual CPP levels, autoregulatory state (PRx) and deviations from CPPopt (ΔCPPopt). METHODS Retrospective study of 21 children ≤ 17 years with severe TBI who had both ICP and CMD monitoring were included. CPP, PRx, CPPopt and ΔCPPopt where calculated, dichotomized and compared with CMD lactate and lactate-pyruvate ratio. RESULTS Median age was 16 years (range 8-17) and median Glasgow coma scale motor score 5 (range 2-5). Both lactate (p = 0.010) and LPR (p = < 0.001) were higher when CPP ≥ 70 mmHg than when CPP < 70. When PRx ≥ 0.1 both lactate and LPR were higher than when PRx < 0.1 (p = < 0.001). LPR was lower (p = 0.012) when CPPopt ≥ 70 mmHg than when CPPopt < 70, but there were no differences in lactate levels. When ΔCPPopt > 10 both lactate (p = 0.026) and LPR (p = 0.002) were higher than when ΔCPPopt < -10. CONCLUSIONS Increased levels of CMD lactate and LPR in children with severe TBI appears to be related to disturbed CPA (PRx). Increased lactate and LPR also seems to be associated with actual CPP levels ≥ 70 mmHg. However, higher lactate and LPR values were also seen when actual CPP was above CPPopt. Higher CPP appears harmful when CPP is above the upper limit of pressure autoregulation. The findings indicate that CPPopt guided CPP management may have potential in pediatric TBI.
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Affiliation(s)
- Fartein Velle
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, SE 751 85, Uppsala, Sweden.
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, SE 751 85, Uppsala, Sweden
| | - Tim Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, SE 751 85, Uppsala, Sweden
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, SE 751 85, Uppsala, Sweden
| | - Pelle Nilsson
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, SE 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, SE 751 85, Uppsala, Sweden
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Alfouzan RK, Arun Gopinathan P, Ui Haq I, Iyer K, Nawab AA, Alhumaidan A. Bibliometric Evaluation of the 100 Top-Cited Articles on Anesthesiology. Cureus 2023; 15:e50959. [PMID: 38249230 PMCID: PMC10800154 DOI: 10.7759/cureus.50959] [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] [Accepted: 12/22/2023] [Indexed: 01/23/2024] Open
Abstract
This review is a bibliometric analysis based on anesthesiology, which is a medical specialty that deals with a patient's complete preoperative, intraoperative, and postoperative care. The objective of the review attempts to analyze the bibliometric characteristics of the 100 most top-cited articles on anesthesiology. The meta-data of the study were collected from the Core Collection of Web of Science database. A title search option was employed, and "Anesthesia" and "Anesthesiology" were typed in two different search boxes separated with the Boolean operator ''OR''. Further, the data were sorted by highest citation order; later, "article" was selected from the filter of document type, and all other types of documents were excluded. Finally, downloaded the bibliographic details of the 100 top-cited articles. VOSviewer Software (version 1.6.10 by van Eck and Waltman) was used for bibliometric network analysis for co-authors and keywords. Pearson chi-square test was used for statistical analysis. The 100 top-cited articles were published between the years of 1971 and 2018. These articles gained a maximum of 1006 to a minimum of 276 citations with an average of 384.57 cites/article. Open accessed articles gained a slightly higher ratio of citations, while more than half of the articles were published in the two leading journals of "Anesthesiology" and "Anesthesia and Analgesia". There was no statistically significant difference in both citation analysis among open and closed access journals and Anesthesia vs Non-Anesthesia journals. Thirty-six articles were published in journals not specifically related to Anesthesia. Most of the top-cited articles were contributed by the United States, whereas Surgery and General Anesthesia were the two most occurred keywords. We conclude that all the top-cited articles in anesthesiology were contributed by authors who belonged to the developed nations and the United States outclassed the rest of the world. This bibliometric analysis would be valuable to practitioners, academics, researchers, and students to understand the dynamics of progress in the field of anesthesiology.
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Affiliation(s)
- Rakan Khalid Alfouzan
- Department of Anesthesiology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Pillai Arun Gopinathan
- Department of Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, SAU
- Department of Maxillofacial Surgery and Diagnostic Sciences, King Abdullah International Medical Research Centre, Riyadh, SAU
| | - Ikram Ui Haq
- College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Kiran Iyer
- Department of Preventive Dental Sciences, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | | | - Abdullah Alhumaidan
- Department of Medicine and Surgery, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
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Stovell MG, Howe DJ, Thelin EP, Jalloh I, Helmy A, Guilfoyle MR, Grice P, Mason A, Giorgi-Coll S, Gallagher CN, Murphy MP, Menon DK, Carpenter TA, Hutchinson PJ, Carpenter KLH. High-physiological and supra-physiological 1,2- 13C 2 glucose focal supplementation to the traumatised human brain. J Cereb Blood Flow Metab 2023; 43:1685-1701. [PMID: 37157814 PMCID: PMC10581237 DOI: 10.1177/0271678x231173584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 03/12/2023] [Accepted: 04/02/2023] [Indexed: 05/10/2023]
Abstract
How to optimise glucose metabolism in the traumatised human brain remains unclear, including whether injured brain can metabolise additional glucose when supplied. We studied the effect of microdialysis-delivered 1,2-13C2 glucose at 4 and 8 mmol/L on brain extracellular chemistry using bedside ISCUSflex, and the fate of the 13C label in the 8 mmol/L group using high-resolution NMR of recovered microdialysates, in 20 patients. Compared with unsupplemented perfusion, 4 mmol/L glucose increased extracellular concentrations of pyruvate (17%, p = 0.04) and lactate (19%, p = 0.01), with a small increase in lactate/pyruvate ratio (5%, p = 0.007). Perfusion with 8 mmol/L glucose did not significantly influence extracellular chemistry measured with ISCUSflex, compared to unsupplemented perfusion. These extracellular chemistry changes appeared influenced by the underlying metabolic states of patients' traumatised brains, and the presence of relative neuroglycopaenia. Despite abundant 13C glucose supplementation, NMR revealed only 16.7% 13C enrichment of recovered extracellular lactate; the majority being glycolytic in origin. Furthermore, no 13C enrichment of TCA cycle-derived extracellular glutamine was detected. These findings indicate that a large proportion of extracellular lactate does not originate from local glucose metabolism, and taken together with our earlier studies, suggest that extracellular lactate is an important transitional step in the brain's production of glutamine.
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Affiliation(s)
- Matthew G Stovell
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - Duncan J Howe
- Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Eric P Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Ibrahim Jalloh
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Grice
- Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Andrew Mason
- Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Susan Giorgi-Coll
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Clare N Gallagher
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Michael P Murphy
- MRC Mitochondrial Biology Unit, University of Cambridge, Cambridge, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - T Adrian Carpenter
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Keri LH Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Roca E, Ramorino G. Brain retraction injury: systematic literature review. Neurosurg Rev 2023; 46:257. [PMID: 37773226 DOI: 10.1007/s10143-023-02160-8] [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: 02/27/2023] [Revised: 09/04/2023] [Accepted: 09/16/2023] [Indexed: 10/01/2023]
Abstract
Cerebral retraction is frequently required in cranial surgery to access deep areas. Brain retractors have been systematically used in the past, but they have been associated with brain injury. Nonetheless, they are still used and, even recently, new systems have been advocated. The aim of this study is to provide a systematic and critical review of brain retraction injury. A systematic literature review was performed in February 2023 according to PRISMA statement. Search terms included brain retraction and injury, with their variations and pertinent associations. Studies reporting qualitative and quantitative data on brain retraction injury were included. Out of 1689 initially retrieved articles, 90 and 26 were included in the systematic review for qualitative and quantitative data, respectively. The definition of brain retraction injury varies and its reported incidence in clinical studies is 5-10%, up to 47% if cerebral edema is considered. Some studies have hypothesized threshold values of pressures to be respected in order to prevent complications, with most data deriving from animal studies. At present, there are no instruments for brain retraction that can guarantee full safety. Some form of cerebral retraction might always be necessary for specific scenarios. Further studies are needed to collect quantitative and, ideally, clinical and comparative data on pressure thresholds to develop retraction systems that can reduce injury to a minimum.
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Affiliation(s)
- Elena Roca
- Head and Neck Department, Neurosurgery, Istituto Ospedaliero Fondazione Poliambulanza, Via Leonida Bissolati n, °57, Brescia, Italy.
| | - Giorgio Ramorino
- Materials Science and Technology at Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
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Intracranial Pressure Variability: A New Potential Metric of Cerebral Ischemia and Energy Metabolic Dysfunction in Aneurysmal Subarachnoid Hemorrhage? J Neurosurg Anesthesiol 2023; 35:208-214. [PMID: 36877175 DOI: 10.1097/ana.0000000000000816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/08/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND It was recently reported that lower intracranial pressure variability (ICPV) is associated with delayed ischemic neurological deficits and unfavorable outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this study, we aimed to determine whether lower ICPV also correlated with worse cerebral energy metabolism after aSAH. METHODS A total of 75 aSAH patients treated in the neurointensive care unit at Uppsala University Hospital, Sweden between 2008 and 2018 and with both intracranial pressure and cerebral microdialysis (MD) monitoring during the first 10 days after ictus were included in this retrospective study. ICPV was calculated with a bandpass filter limited to intracranial pressure slow waves with a wavelength of 55 to 15 seconds. Cerebral energy metabolites were measured hourly with MD. The monitoring period was divided into 3 phases; early (days 1 to 3), early vasospasm (days 4 to 6.5), and late vasospasm (days 6.5 to 10). RESULTS Lower ICPV was associated with lower MD-glucose in the late vasospasm phase, lower MD-pyruvate in the early vasospasm phases, and higher MD-lactate-pyruvate ratio (LPR) in the early and late vasospasm phases. Lower ICPV was associated with poor cerebral substrate supply (LPR >25 and pyruvate <120 µM) rather than mitochondrial failure (LPR >25 and pyruvate >120 µM). There was no association between ICPV and delayed ischemic neurological deficit, but lower ICPV in both vasospasm phases correlated with unfavorable outcomes. CONCLUSION Lower ICPV was associated with an increased risk for disturbed cerebral energy metabolism and worse clinical outcomes in aSAH patients, possibly explained by a vasospasm-related decrease in cerebral blood volume dynamics and cerebral ischemia.
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Mølstrøm S, Nielsen TH, Nordstrøm CH, Forsse A, Møller S, Venø S, Mamaev D, Tencer T, Theódórsdóttir Á, Krøigård T, Møller J, Hassager C, Kjærgaard J, Schmidt H, Toft P. A randomized, double-blind trial comparing the effect of two blood pressure targets on global brain metabolism after out-of-hospital cardiac arrest. Crit Care 2023; 27:73. [PMID: 36823636 PMCID: PMC9951410 DOI: 10.1186/s13054-023-04376-y] [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: 12/16/2022] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE This study aimed to assess the effect of different blood pressure levels on global cerebral metabolism in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS In a double-blinded trial, we randomly assigned 60 comatose patients following OHCA to low (63 mmHg) or high (77 mmHg) mean arterial blood pressure (MAP). The trial was a sub-study in the Blood Pressure and Oxygenation Targets after Out-of-Hospital Cardiac Arrest-trial (BOX). Global cerebral metabolism utilizing jugular bulb microdialysis (JBM) and cerebral oxygenation (rSO2) was monitored continuously for 96 h. The lactate-to-pyruvate (LP) ratio is a marker of cellular redox status and increases during deficient oxygen delivery (ischemia, hypoxia) and mitochondrial dysfunction. The primary outcome was to compare time-averaged means of cerebral energy metabolites between MAP groups during post-resuscitation care. Secondary outcomes included metabolic patterns of cerebral ischemia, rSO2, plasma neuron-specific enolase level at 48 h and neurological outcome at hospital discharge (cerebral performance category). RESULTS We found a clear separation in MAP between the groups (15 mmHg, p < 0.001). Cerebral biochemical variables were not significantly different between MAP groups (LPR low MAP 19 (16-31) vs. high MAP 23 (16-33), p = 0.64). However, the LP ratio remained high (> 16) in both groups during the first 30 h. During the first 24 h, cerebral lactate > 2.5 mM, pyruvate levels > 110 µM, LP ratio > 30, and glycerol > 260 µM were highly predictive for poor neurological outcome and death with AUC 0.80. The median (IQR) rSO2 during the first 48 h was 69.5% (62.0-75.0%) in the low MAP group and 69.0% (61.3-75.5%) in the high MAP group, p = 0.16. CONCLUSIONS Among comatose patients resuscitated from OHCA, targeting a higher MAP 180 min after ROSC did not significantly improve cerebral energy metabolism within 96 h of post-resuscitation care. Patients with a poor clinical outcome exhibited significantly worse biochemical patterns, probably illustrating that insufficient tissue oxygenation and recirculation during the initial hours after ROSC were essential factors determining neurological outcome.
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Affiliation(s)
- Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.
| | - Troels Halfeld Nielsen
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Carl-Henrik Nordstrøm
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Axel Forsse
- grid.4973.90000 0004 0646 7373Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Møller
- grid.7143.10000 0004 0512 5013OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Venø
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Dmitry Mamaev
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Tomas Tencer
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Ásta Theódórsdóttir
- grid.7143.10000 0004 0512 5013Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Thomas Krøigård
- grid.7143.10000 0004 0512 5013Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Jacob Møller
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark ,grid.7143.10000 0004 0512 5013Department of Cardiology, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Medicine, University of Southern, Odense, Denmark
| | - Christian Hassager
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kjærgaard
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Schmidt
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Palle Toft
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
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Consumption and Metabolism of Extracellular Pyruvate by Cultured Rat Brain Astrocytes. Neurochem Res 2022; 48:1438-1454. [PMID: 36495387 PMCID: PMC10066139 DOI: 10.1007/s11064-022-03831-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022]
Abstract
AbstractBrain astrocytes are considered as glycolytic cell type, but these cells also produce ATP via mitochondrial oxidative phosphorylation. Exposure of cultured primary astrocytes in a glucose-free medium to extracellular substrates that are known to be metabolised by mitochondrial pathways, including pyruvate, lactate, beta-hydroxybutyrate, alanine and acetate, revealed that among the substrates investigated extracellular pyruvate was most efficiently consumed by astrocytes. Extracellular pyruvate was consumed by the cells almost proportional to time over hours in a concentration-dependent manner with apparent Michaelis–Menten kinetics [Km = 0.6 ± 0.1 mM, Vmax = 5.1 ± 0.8 nmol/(min × mg protein)]. The astrocytic consumption of pyruvate was strongly impaired in the presence of the monocarboxylate transporter 1 (MCT1) inhibitor AR-C155858 or by application of a 10-times excess of the MCT1 substrates lactate or beta-hydroxybutyrate. Pyruvate consumption by viable astrocytes was inhibited in the presence of UK5099, an inhibitor of the mitochondrial pyruvate carrier, or after application of the respiratory chain inhibitor antimycin A. In contrast, the mitochondrial uncoupler BAM15 strongly accelerated cellular pyruvate consumption. Lactate and alanine accounted after 3 h of incubation with pyruvate for around 60% and 10%, respectively, of the pyruvate consumed by the cells. These results demonstrate that consumption of extracellular pyruvate by astrocytes involves uptake via MCT1 and that the velocity of pyruvate consumption is strongly modified by substances that affect the entry of pyruvate into mitochondria or the activity of mitochondrial respiration.
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Correlation of Cerebral Microdialysis with Non-Invasive Diffuse Optical Cerebral Hemodynamic Monitoring during Deep Hypothermic Cardiopulmonary Bypass. Metabolites 2022; 12:metabo12080737. [PMID: 36005609 PMCID: PMC9416552 DOI: 10.3390/metabo12080737] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022] Open
Abstract
Neonates undergoing cardiac surgery involving aortic arch reconstruction are at an increased risk for hypoxic-ischemic brain injury. Deep hypothermia is utilized to help mitigate this risk when periods of circulatory arrest are needed for surgical repair. Here, we investigate correlations between non-invasive optical neuromonitoring of cerebral hemodynamics, which has recently shown promise for the prediction of postoperative white matter injury in this patient population, and invasive cerebral microdialysis biomarkers. We compared cerebral tissue oxygen saturation (StO2), relative total hemoglobin concentration (rTHC), and relative cerebral blood flow (rCBF) measured by optics against the microdialysis biomarkers of metabolic stress and injury (lactate–pyruvate ratio (LPR) and glycerol) in neonatal swine models of deep hypothermic cardiopulmonary bypass (DHCPB), selective antegrade cerebral perfusion (SACP), and deep hypothermic circulatory arrest (DHCA). All three optical parameters were negatively correlated with LPR and glycerol in DHCA animals. Elevation of LPR was found to precede the elevation of glycerol by 30–60 min. From these data, thresholds for the detection of hypoxic-ischemia-associated cerebral metabolic distress and neurological injury are suggested. In total, this work provides insight into the timing and mechanisms of neurological injury following hypoxic-ischemia and reports a quantitative relationship between hypoxic-ischemia severity and neurological injury that may inform DHCA management.
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11
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Svedung Wettervik TM, Hånell A, Howells T, Enblad P, Lewén A. Females Exhibit Better Cerebral Pressure Autoregulation, Less Mitochondrial Dysfunction, and Reduced Excitotoxicity following Severe Traumatic Brain Injury. J Neurotrauma 2022; 39:1507-1517. [PMID: 35587145 DOI: 10.1089/neu.2022.0097] [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] [Indexed: 12/22/2022] Open
Abstract
The aim of the study was to investigate sex-related differences in intracranial pressure (ICP) dynamics, cerebral pressure autoregulation (PRx55-15), cerebral energy metabolism, and clinical outcome after severe traumatic brain injury (TBI). One-hundred sixty-nine adult TBI patients, treated at the neurointensive care (NIC) unit, at Uppsala University Hospital, 2008-2020, with ICP and cerebral microdialysis (MD) monitoring, were included. Of the 169 TBI patients, 131 (78%) were male and 38 (22%) female. Male patients were more often injured by motor vehicle accidents and less often by bicycle accidents (p < 0.05). There were otherwise no difference in age, neurological status at admission, and types of intracranial hemorrhages between the sexes. The percent of monitoring time with ICP above 20 mmHg and CPP below 60 mmHg were similar for both sexes. Males exhibited more disturbed cerebral pressure autoregulation (PRx55-15 (mean ± SD); 0.28 ± 0.18 vs. 0.17 ± 0.23, p < 0.05) day 1, worse cerebral energy metabolism (MD-lactate-/pyruvate-ratio (median (IQR)); 25 (19-31) vs. 20 (17-25), p < 0.01) and mitochondrial dysfunction (higher burden of MD-LPR > 25 and MD-pyruvate > 120 µM (median (IQR)); 13 (0-58) % vs. 3 (0-17) %, p < 0.05) day 2 to 5, increased excitotoxicity (MD-glutamate median (IQR); 9 (4-32) µM vs. 5 (3-10) µM, p < 0.05) day 2 to 5, and higher biomarker levels of cellular injury (MD-glycerol median (IQR); 103 (66-193) µM vs. 68 (49-106) µM, p < 0.01) most pronounced day 6 to 10. There was no difference in mortality or the degree of favorable outcome between the sexes. Altogether, females exhibited more favorable cerebral physiology post-TBI, particularly better mitochondrial function and reduced excitotoxicity, but this did not translate into better clinical outcome compared to males. Future studies needs to further explore potential sex differences in secondary injury mechanisms in TBI.
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Affiliation(s)
| | | | | | - Per Enblad
- Uppsala Universitet, 8097, Uppsala, Sweden;
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12
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Winberg J, Holm I, Cederberg D, Rundgren M, Kronvall E, Marklund N. Cerebral Microdialysis-Based Interventions Targeting Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2022; 37:255-266. [PMID: 35488171 PMCID: PMC9283139 DOI: 10.1007/s12028-022-01492-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/14/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI), a complication of subarachnoid hemorrhage (SAH), is linked to cerebral vasospasm and associated with poor long-term outcome. We implemented a structured cerebral microdialysis (CMD) based protocol using the lactate/pyruvate ratio (LPR) as an indicator of the cerebral energy metabolic status in the neurocritical care decision making, using an LPR ≥ 30 as a cutoff suggesting an energy metabolic disturbance. We hypothesized that CMD monitoring could contribute to active, protocol-driven therapeutic interventions that may lead to the improved management of patients with SAH. METHODS Between 2018 and 2020, 49 invasively monitored patients with SAH, median Glasgow Coma Scale 11 (range 3-15), and World Federation of Neurosurgical Societies scale 4 (range 1-5) on admission receiving CMD were included. We defined a major CMD event as an LPR ≥ 40 for ≥ 2 h and a minor CMD event as an LPR ≥ 30 for ≥ 2 h. RESULTS We analyzed 7,223 CMD samples over a median of 6 days (5-8). Eight patients had no CMD events. In 41 patients, 113 minor events were recorded, and in 23 patients 42 major events were recorded. Our local protocols were adhered to in 40 major (95%) and 98 minor events (87%), with an active intervention in 32 (76%) and 71 (63%), respectively. Normalization of energy metabolic status (defined as four consecutive samples with LPR < 30 for minor and LPR < 40 for major events) was seen after 69% of major and 59% of minor events. The incidence of DCI-related infarcts was 10% (five patients), with only two observed in a CMD-monitored brain region. CONCLUSIONS Active interventions were initiated in a majority of LPR events based on CMD monitoring. A low DCI incidence was observed, which may be associated with the active interventions. The potential aid of CMD in the clinical decision-making targeting DCI needs confirmation in additional SAH studies.
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Affiliation(s)
- Jakob Winberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Isabella Holm
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - David Cederberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Malin Rundgren
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Erik Kronvall
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Neurosurgery, EA-blocket plan 4, Entrégatan 7, 222 42, Lund, Sweden.
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13
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Intracranial pressure- and cerebral perfusion pressure threshold-insults in relation to cerebral energy metabolism in aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2022; 164:1001-1014. [PMID: 35233663 PMCID: PMC8967735 DOI: 10.1007/s00701-022-05169-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/22/2022] [Indexed: 11/15/2022]
Abstract
Background The aim was to investigate the association between intracranial pressure (ICP)- and cerebral perfusion pressure (CPP) threshold-insults in relation to cerebral energy metabolism and clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH). Methods In this retrospective study, 75 aSAH patients treated in the neurointensive care unit, Uppsala, Sweden, 2008–2018, with ICP and cerebral microdialysis (MD) monitoring were included. The first 10 days were divided into early (day 1–3), early vasospasm (day 4–6.5), and late vasospasm phase (day 6.5–10). The monitoring time (%) of ICP insults (> 20 mmHg and > 25 mmHg), CPP insults (< 60 mmHg, < 70 mmHg, < 80 mmHg, and < 90 mmHg), and autoregulatory CPP optimum (CPPopt) insults (∆CPPopt = CPP-CPPopt < − 10 mmHg, ∆CPPopt > 10 mmHg, and within the optimal interval ∆CPPopt ± 10 mmHg) were calculated in each phase. Results Higher percent of ICP above the 20 mmHg and 25 mmHg thresholds correlated with lower MD-glucose and increased MD-lactate-pyruvate ratio (LPR), particularly in the vasospasm phases. Higher percentage of CPP below all four thresholds (60/70/80//90 mmHg) also correlated with a MD pattern of poor cerebral substrate supply (MD-LPR > 40 and MD-pyruvate < 120 µM) in the vasospasm phase and higher burden of CPP below 60 mmHg was independently associated with higher MD-LPR in the late vasospasm phase. Higher percentage of CPP deviation from CPPopt did not correlate with worse cerebral energy metabolism. Higher burden of CPP-insults below all fixed thresholds in both vasospasm phases were associated with worse clinical outcome. The percentage of ICP-insults and CPP close to CPPopt were not associated with clinical outcome. Conclusions Keeping ICP below 20 mmHg and CPP at least above 60 mmHg may improve cerebral energy metabolism and clinical outcome. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05169-y.
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14
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Khellaf A, Garcia NM, Tajsic T, Alam A, Stovell MG, Killen MJ, Howe DJ, Guilfoyle MR, Jalloh I, Timofeev I, Murphy MP, Carpenter TA, Menon DK, Ercole A, Hutchinson PJ, Carpenter KL, Thelin EP, Helmy A. Focally administered succinate improves cerebral metabolism in traumatic brain injury patients with mitochondrial dysfunction. J Cereb Blood Flow Metab 2022; 42:39-55. [PMID: 34494481 PMCID: PMC8721534 DOI: 10.1177/0271678x211042112] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Following traumatic brain injury (TBI), raised cerebral lactate/pyruvate ratio (LPR) reflects impaired energy metabolism. Raised LPR correlates with poor outcome and mortality following TBI. We prospectively recruited patients with TBI requiring neurocritical care and multimodal monitoring, and utilised a tiered management protocol targeting LPR. We identified patients with persistent raised LPR despite adequate cerebral glucose and oxygen provision, which we clinically classified as cerebral 'mitochondrial dysfunction' (MD). In patients with TBI and MD, we administered disodium 2,3-13C2 succinate (12 mmol/L) by retrodialysis into the monitored region of the brain. We recovered 13C-labelled metabolites by microdialysis and utilised nuclear magnetic resonance spectroscopy (NMR) for identification and quantification.Of 33 patients with complete monitoring, 73% had MD at some point during monitoring. In 5 patients with multimodality-defined MD, succinate administration resulted in reduced LPR(-12%) and raised brain glucose(+17%). NMR of microdialysates demonstrated that the exogenous 13C-labelled succinate was metabolised intracellularly via the tricarboxylic acid cycle. By targeting LPR using a tiered clinical algorithm incorporating intracranial pressure, brain tissue oxygenation and microdialysis parameters, we identified MD in TBI patients requiring neurointensive care. In these, focal succinate administration improved energy metabolism, evidenced by reduction in LPR. Succinate merits further investigation for TBI therapy.
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Affiliation(s)
- Abdelhakim Khellaf
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Nuria Marco Garcia
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Tamara Tajsic
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Aftab Alam
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Matthew G Stovell
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - Monica J Killen
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Duncan J Howe
- Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Ibrahim Jalloh
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Michael P Murphy
- Medical Research Council Mitochondrial Biology Unit, University of Cambridge, Cambridge, UK
| | - T Adrian Carpenter
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - David K Menon
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Keri Lh Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Eric P Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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15
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Stangler LA, Kouzani A, Bennet KE, Dumee L, Berk M, Worrell GA, Steele S, Burns TC, Howe CL. Microdialysis and microperfusion electrodes in neurologic disease monitoring. Fluids Barriers CNS 2021; 18:52. [PMID: 34852829 PMCID: PMC8638547 DOI: 10.1186/s12987-021-00292-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Contemporary biomarker collection techniques in blood and cerebrospinal fluid have to date offered only modest clinical insights into neurologic diseases such as epilepsy and glioma. Conversely, the collection of human electroencephalography (EEG) data has long been the standard of care in these patients, enabling individualized insights for therapy and revealing fundamental principles of human neurophysiology. Increasing interest exists in simultaneously measuring neurochemical biomarkers and electrophysiological data to enhance our understanding of human disease mechanisms. This review compares microdialysis, microperfusion, and implanted EEG probe architectures and performance parameters. Invasive consequences of probe implantation are also investigated along with the functional impact of biofouling. Finally, previously developed microdialysis electrodes and microperfusion electrodes are reviewed in preclinical and clinical settings. Critically, current and precedent microdialysis and microperfusion probes lack the ability to collect neurochemical data that is spatially and temporally coincident with EEG data derived from depth electrodes. This ultimately limits diagnostic and therapeutic progress in epilepsy and glioma research. However, this gap also provides a unique opportunity to create a dual-sensing technology that will provide unprecedented insights into the pathogenic mechanisms of human neurologic disease.
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Affiliation(s)
- Luke A Stangler
- School of Engineering, Deakin University, 3216, Geelong, Victoria, Australia
- Division of Engineering, Mayo Clinic, 55905, Rochester, MN, USA
| | - Abbas Kouzani
- School of Engineering, Deakin University, 3216, Geelong, Victoria, Australia
| | - Kevin E Bennet
- School of Engineering, Deakin University, 3216, Geelong, Victoria, Australia
- Division of Engineering, Mayo Clinic, 55905, Rochester, MN, USA
| | - Ludovic Dumee
- School of Engineering, Deakin University, 3216, Geelong, Victoria, Australia
| | - Michael Berk
- School of Medicine, Deakin University, 3216, Geelong, Victoria, Australia
| | | | - Steven Steele
- Division of Engineering, Mayo Clinic, 55905, Rochester, MN, USA
| | - Terence C Burns
- Department of Neurosurgery, Mayo Clinic, 55905, Rochester, MN, USA
| | - Charles L Howe
- Department of Neurology, Mayo Clinic, 55905, Rochester, MN, USA.
- Division of Experimental Neurology, Mayo Clinic, 55905, Rochester, MN, USA.
- Center for MS and Autoimmune Neurology, Mayo Clinic, 55905, Rochester, MN, USA.
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16
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Andreazzoli M, Barravecchia I, De Cesari C, Angeloni D, Demontis GC. Inducible Pluripotent Stem Cells to Model and Treat Inherited Degenerative Diseases of the Outer Retina: 3D-Organoids Limitations and Bioengineering Solutions. Cells 2021; 10:cells10092489. [PMID: 34572137 PMCID: PMC8471616 DOI: 10.3390/cells10092489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/12/2021] [Accepted: 09/15/2021] [Indexed: 12/12/2022] Open
Abstract
Inherited retinal degenerations (IRD) affecting either photoreceptors or pigment epithelial cells cause progressive visual loss and severe disability, up to complete blindness. Retinal organoids (ROs) technologies opened up the development of human inducible pluripotent stem cells (hiPSC) for disease modeling and replacement therapies. However, hiPSC-derived ROs applications to IRD presently display limited maturation and functionality, with most photoreceptors lacking well-developed outer segments (OS) and light responsiveness comparable to their adult retinal counterparts. In this review, we address for the first time the microenvironment where OS mature, i.e., the subretinal space (SRS), and discuss SRS role in photoreceptors metabolic reprogramming required for OS generation. We also address bioengineering issues to improve culture systems proficiency to promote OS maturation in hiPSC-derived ROs. This issue is crucial, as satisfying the demanding metabolic needs of photoreceptors may unleash hiPSC-derived ROs full potential for disease modeling, drug development, and replacement therapies.
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Affiliation(s)
| | - Ivana Barravecchia
- Department of Pharmacy, University of Pisa, 56126 Pisa, Italy;
- Institute of Life Sciences, Scuola Superiore Sant’Anna, 56124 Pisa, Italy;
| | | | - Debora Angeloni
- Institute of Life Sciences, Scuola Superiore Sant’Anna, 56124 Pisa, Italy;
| | - Gian Carlo Demontis
- Department of Pharmacy, University of Pisa, 56126 Pisa, Italy;
- Correspondence: (M.A.); (G.C.D.)
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17
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Forsse A, Nielsen TH, Mølstrøm S, Hjelmborg J, Nielsen KS, Nygaard KH, Yilmaz S, Nordström CH, Poulsen FR. A Prospective Observational Feasibility Study of Jugular Bulb Microdialysis in Subarachnoid Hemorrhage. Neurocrit Care 2021; 33:241-255. [PMID: 31845174 DOI: 10.1007/s12028-019-00888-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Cerebral metabolic perturbations are common in aneurysmal subarachnoid hemorrhage (aSAH). Monitoring cerebral metabolism with intracerebral microdialysis (CMD) allows early detection of secondary injury and may guide decisions on neurocritical care interventions, affecting outcome. However, CMD is a regional measuring technique that is influenced by proximity to focal lesions. Continuous microdialysis of the cerebral venous drainage may provide information on global cerebral metabolism relevant for the care of aSAH patients. This observational study aimed to explore the feasibility of jugular bulb microdialysis (JBMD) in aSAH and describe the output characteristics in relation to conventional multimodal monitoring. METHODS Patients with severe aSAH were included at admission or after in-house deterioration when local clinical guidelines prompted extended multimodal monitoring. Non-dominant frontal CMD, intracranial pressure (ICP), partial brain tissue oxygenation pressure (PbtO2), and cerebral perfusion pressure (CPP) were recorded every hour. The dominant jugular vein was accessed by retrograde insertion of a microdialysis catheter with the tip placed in the jugular bulb under ultrasound guidance. Glucose, lactate, pyruvate, lactate/pyruvate ratio, glycerol, and glutamate were studied for correlation to intracranial measurements. Modified Rankin scale was assessed at 6 months. RESULTS Twelve adult aSAH patients were monitored during a mean 4.2 ± 2.6 days yielding 22,041 data points for analysis. No complications related to JBMD were observed. Moderate or strong significant monotonic CMD-to-JBMD correlations were observed most often for glucose (7 patients), followed by lactate (5 patients), and pyruvate, glycerol, and glutamate (3 patients). Moderate correlation for lactate/pyruvate ratio was only seen in one patient. Analysis of critical periods defined by ICP > 20, CPP < 65, or PbtO2 < 15 revealed a tendency toward stronger CMD-to-JBMD associations in patients with many or long critical periods. Possible time lags between CMD and JBMD measurements were only identified in 6 out of 60 patient variables. With the exception of pyruvate, a dichotomized outcome was associated with similar metabolite patterns in JBMD and CMD. A nonsignificant tendency toward greater differences between outcome groups was seen in JBMD. CONCLUSIONS Continuous microdialysis monitoring of the cerebral drainage in the jugular bulb is feasible and safe. JBMD-to-CMD correlation is influenced by the type of metabolite measured, with glucose and lactate displaying the strongest associations. JBMD lactate correlated more often than CMD lactate to CPP, implying utility for detection of global cerebral metabolic perturbations. Studies comparing JBMD to other global measures of cerebral metabolism, e.g., PET CT or Xenon CT, are warranted.
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Affiliation(s)
- Axel Forsse
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark. .,BRIDGE - Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark.,BRIDGE - Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Jacob Hjelmborg
- Department of Biostatistics and Epidemiology, University of Southern Denmark, Odense, Denmark
| | - Kasper Stokbro Nielsen
- Department of Oral and Maxillofacial Surgery, Odense University Hospital, Odense, Denmark
| | - Kevin Hebøll Nygaard
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark.,BRIDGE - Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sibel Yilmaz
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark
| | - Carl-Henrik Nordström
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark.,BRIDGE - Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Frantz Rom Poulsen
- Department of Neurosurgery, Odense University Hospital, Sønder Boulevard 29, 5000, Odense, Denmark.,BRIDGE - Brain Research - Inter-Disciplinary Guided Excellence, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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18
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Mölström S, Nielsen TH, Nordström CH, Forsse A, Möller S, Venö S, Mamaev D, Tencer T, Schmidt H, Toft P. Bedside microdialysis for detection of early brain injury after out-of-hospital cardiac arrest. Sci Rep 2021; 11:15871. [PMID: 34354178 PMCID: PMC8342553 DOI: 10.1038/s41598-021-95405-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022] Open
Abstract
Bedside detection and early treatment of lasting cerebral ischemia may improve outcome after out-of-hospital cardiac arrest (OHCA). This feasibility study explores the possibilities to use microdialysis (MD) for continuous monitoring of cerebral energy metabolism by analyzing the draining cerebral venous blood. Eighteen comatose patients were continuously monitored with jugular bulb and radial artery (reference) MD following resuscitation. Median time from cardiac arrest to MD was 300 min (IQR 230–390) with median monitoring time 60 h (IQR 40–81). The lactate/pyruvate ratio in cerebral venous blood was increased during the first 20 h after OHCA, and significant differences in time-averaged mean MD metabolites between jugular venous and artery measurements, were documented (p < 0.02). In patients with unfavorable outcome (72%), cerebral venous lactate and pyruvate levels remained elevated during the study period. In conclusion, the study indicates that jugular bulb microdialysis (JBM) is feasible and safe. Biochemical signs of lasting ischemia and mitochondrial dysfunction are frequent and associated with unfavorable outcome. The technique may be used in comatose OHCA patients to monitor biochemical variables reflecting ongoing brain damage and support individualized treatment early after resuscitation.
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Affiliation(s)
- Simon Mölström
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.
| | | | - Carl H Nordström
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Axel Forsse
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sören Venö
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Dmitry Mamaev
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Tomas Tencer
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
| | - Palle Toft
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark
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Bouras T, Gatzonis SS, Georgakoulias N, Karatza M, Siatouni A, Stranjalis G, Boviatsis E, Vasileiou S, Sakas DE. Neuro-inflammatory Sequelae of Minimal Trauma in the Non-traumatized Human Brain: A Microdialysis Study. J Neurotrauma 2021; 38:1137-1150. [PMID: 22098490 DOI: 10.1089/neu.2011.1790] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Cytokine measurement directly from the brain parenchyma by means of microdialysis has documented the activation of certain procedures in vivo, after brain trauma in humans. However, the intercalation of the micro-catheter insertion with the phenomena triggered by the head trauma renders the assessment of the findings problematic. The present study attempts to elucidate the pure effect of minimal trauma, represented by the insertion of the micro-catheter, on the non-traumatized human brain. Microdialysis catheters were implanted in 12 patients with drug-resistant epilepsy, and subjected to invasive electroencephalography with intracranial electrodes. Samples were collected during the first 5 days of monitoring. The dialysate was analyzed using bead flow cytometry, and the concentrations of interleukin (IL)-1, IL-6, IL-8, IL-10, IL-12, and tumor necrosis factor-α (TNF-α) were measured. The levels of IL-1 and IL-8 were found to be raised until 48 h post-implantation, and thereafter they reached a plateau of presumably baseline values. The temporal profile of the IL-6 variation was different, with the increase being much more prolonged, as its concentration had not returned to baseline levels at the fifth day post-insertion. TNF-α was found to be significantly raised only 2 h after implantation. IL-10 and IL-12 did not have any significant response to micro-trauma. These findings imply that the reaction of the neuro-inflammatory mechanisms of the brain exist even after minimal trauma, and is unexpectedly intense for IL-6. Questions may arise regarding the objectivity of findings attributed by some studies to inflammatory perturbation after head injury.
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Affiliation(s)
- Triantafyllos Bouras
- Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Athens, Greece
| | | | | | - Marilena Karatza
- Laboratory of Biochemistry, Evaggelismos Hospital, University of Athens, Athens, Greece
| | - Anna Siatouni
- Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Athens, Greece
| | - George Stranjalis
- Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Athens, Greece
| | - Efstathios Boviatsis
- Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Athens, Greece
| | - Spyridoula Vasileiou
- Laboratory of Biochemistry, Evaggelismos Hospital, University of Athens, Athens, Greece
| | - Damianos E Sakas
- Department of Neurosurgery, Evaggelismos Hospital, University of Athens, Athens, Greece
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The Importance of Probe Location for the Interpretation of Cerebral Microdialysis Data in Subarachnoid Hemorrhage Patients. Neurocrit Care 2021; 32:135-144. [PMID: 31037640 PMCID: PMC7012974 DOI: 10.1007/s12028-019-00713-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background There is no uniform definition for cerebral microdialysis (CMD) probe location with respect to focal brain lesions, and the impact of CMD-probe location on measured molecule concentrations is unclear. Methods We retrospectively analyzed data of 51 consecutive subarachnoid hemorrhage patients with CMD-monitoring between 2010 and 2016 included in a prospective observational cohort study. Microdialysis probe location was assessed on all brain computed tomography (CT) scans performed during CMD-monitoring and defined as perilesional in the presence of a focal hypodense or hyperdense lesion within a 1-cm radius of the gold tip of the CMD-probe, or otherwise as normal-appearing brain tissue. Results Probe location was detected in normal-appearing brain tissue on 53/143 (37%) and in perilesional location on 90/143 (63%) CT scans. In the perilesional area, CMD-glucose levels were lower (p = 0.003), whereas CMD-lactate (p = 0.002), CMD-lactate-to-pyruvate-ratio (LPR; p < 0.001), CMD-glutamate (p = 0.002), and CMD-glycerol levels (p < 0.001) were higher. Neuroglucopenia (CMD-glucose < 0.7 mmol/l, p = 0.002), metabolic distress (p = 0.002), and mitochondrial dysfunction (p = 0.005) were more common in perilesional compared to normal-appearing brain tissue. Development of new lesions in the proximity of the CMD-probe (n = 13) was associated with a decrease in CMD-glucose levels, evidence of neuroglucopenia, metabolic distress, as well as increasing CMD-glutamate and CMD-glycerol levels. Neuroglucopenia was associated with poor outcome independent of probe location, whereas elevated CMD-lactate, CMD-LPR, CMD-glutamate, and CMD-glycerol levels were only predictive of poor outcome in normal-appearing brain tissue. Conclusions Focal brain lesions significantly impact on concentrations of brain metabolites assessed by CMD. With the exception of CMD-glucose, the prognostic value of CMD-derived parameters seems to be higher when assessed in normal-appearing brain tissue. CMD was sensitive to detect the development of new focal lesions in vicinity to the neuromonitoring probe. Probe location should be described in the research reporting brain metabolic changes measured by CMD and integrated in statistical models. Electronic supplementary material The online version of this article (10.1007/s12028-019-00713-8) contains supplementary material, which is available to authorized users.
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Wettervik TS, Engquist H, Howells T, Lenell S, Rostami E, Hillered L, Enblad P, Lewén A. Arterial Oxygenation in Traumatic Brain Injury-Relation to Cerebral Energy Metabolism, Autoregulation, and Clinical Outcome. J Intensive Care Med 2020; 36:1075-1083. [PMID: 32715850 PMCID: PMC8343201 DOI: 10.1177/0885066620944097] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Ischemic and hypoxic secondary brain insults are common and detrimental in traumatic brain injury (TBI). Treatment aims to maintain an adequate cerebral blood flow with sufficient arterial oxygen content. It has been suggested that arterial hyperoxia may be beneficial to the injured brain to compensate for cerebral ischemia, overcome diffusion barriers, and improve mitochondrial function. In this study, we investigated the relation between arterial oxygen levels and cerebral energy metabolism, pressure autoregulation, and clinical outcome. Methods: This retrospective study was based on 115 patients with severe TBI treated in the neurointensive care unit, Uppsala university hospital, Sweden, 2008 to 2018. Data from cerebral microdialysis (MD), arterial blood gases, hemodynamics, and intracranial pressure were analyzed the first 10 days post-injury. The first day post-injury was studied in particular. Results: Arterial oxygen levels were higher and with greater variability on the first day post-injury, whereas it was more stable the following 9 days. Normal-to-high mean pO2 was significantly associated with better pressure autoregulation/lower pressure reactivity index (P = .02) and lower cerebral MD-lactate (P = .04) on day 1. Patients with limited cerebral energy metabolic substrate supply (MD-pyruvate below 120 µM) and metabolic disturbances with MD-lactate-/pyruvate ratio (LPR) above 25 had significantly lower arterial oxygen levels than those with limited MD-pyruvate supply and normal MD-LPR (P = .001) this day. Arterial oxygenation was not associated with clinical outcome. Conclusions: Maintaining a pO2 above 12 kPa and higher may improve oxidative cerebral energy metabolism and pressure autoregulation, particularly in cases of limited energy substrate supply in the early phase of TBI. Evaluating the cerebral energy metabolic profile could yield a better patient selection for hyperoxic treatment in future trials.
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Affiliation(s)
| | - Henrik Engquist
- Department of Surgical Sciences/Anesthesia and Intensive Care, 8097Uppsala University, Uppsala, Sweden
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
| | - Samuel Lenell
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
| | - Elham Rostami
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
| | - Lars Hillered
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
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22
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Tobieson L, Rossitti S, Zsigmond P, Hillman J, Marklund N. Persistent Metabolic Disturbance in the Perihemorrhagic Zone Despite a Normalized Cerebral Blood Flow Following Surgery for Intracerebral Hemorrhage. Neurosurgery 2020; 84:1269-1279. [PMID: 29788388 PMCID: PMC6520101 DOI: 10.1093/neuros/nyy179] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 04/07/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND We hypothesized that reduced cerebral blood flow (CBF) and/or energy metabolic disturbances exist in the tissue surrounding a surgically evacuated intracerebral hemorrhage (ICH). If present, such CBF and/or metabolic impairments may contribute to ongoing tissue injury and the modest clinical efficacy of ICH surgery. OBJECTIVE To conduct an observational study of CBF and the energy metabolic state in the perihemorrhagic zone (PHZ) tissue and in seemingly normal cortex (SNX) by microdialysis (MD) following surgical ICH evacuation. METHODS We evaluated 12 patients (median age 64; range 26-71 yr) for changes in CBF and energy metabolism following surgical ICH evacuation using Xenon-enhanced computed tomography (n = 10) or computed tomography perfusion (n = 2) for CBF and dual MD catheters, placed in the PHZ and the SNX at ICH surgery. RESULTS CBF was evaluated at a mean of 21 and 58 h postsurgery. In the hemisphere ipsilateral to the ICH, CBF improved between the investigations (36.6 ± 20 vs 40.6 ± 20 mL/100 g/min; P < .05). In total, 1026 MD samples were analyzed for energy metabolic alterations including glucose and the lactate/pyruvate ratio (LPR). The LPR was persistently elevated in the PHZ compared to the SNX region (P < .05). LPR elevations in the PHZ were predominately type II (pyruvate normal-high; indicating mitochondrial dysfunction) as opposed to type I (pyruvate low; indicating ischemia) at 4 to 48 h (70% vs 30%) and at 49 to 84 h (79% vs 21%; P < .05) postsurgery. CONCLUSION Despite normalization of CBF following ICH evacuation, an energy metabolic disturbance suggestive of mitochondrial dysfunction persists in the perihemorrhagic zone.
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Affiliation(s)
- Lovisa Tobieson
- Department of Neurosurgery, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Sandro Rossitti
- Department of Neurosurgery, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Peter Zsigmond
- Department of Neurosurgery, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Jan Hillman
- Department of Neurosurgery, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences, Neurosurgery, Lund University, Skåne University Hospital, Lund, Sweden
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High Arterial Glucose is Associated with Poor Pressure Autoregulation, High Cerebral Lactate/Pyruvate Ratio and Poor Outcome Following Traumatic Brain Injury. Neurocrit Care 2020; 31:526-533. [PMID: 31123993 PMCID: PMC6872512 DOI: 10.1007/s12028-019-00743-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Arterial hyperglycemia is associated with poor outcome in traumatic brain injury (TBI), but the pathophysiology is not completely understood. Previous preclinical and clinical studies have indicated that arterial glucose worsens pressure autoregulation. The aim of this study was to evaluate the relationship of arterial glucose to both pressure reactivity and cerebral energy metabolism. Method This retrospective study was based on 120 patients with severe TBI treated at the Uppsala University hospital, Sweden, 2008–2018. Data from cerebral microdialysis (glucose, pyruvate, and lactate), arterial glucose, and pressure reactivity index (PRx55-15) were analyzed the first 3 days post-injury. Results High arterial glucose was associated with poor outcome/Glasgow Outcome Scale-Extended at 6-month follow-up (r = − 0.201, p value = 0.004) and showed a positive correlation with both PRx55-15 (r = 0.308, p = 0.001) and cerebral lactate/pyruvate ratio (LPR) days 1–3 (r = 0. 244, p = 0.014). Cerebral lactate-to-pyruvate ratio and PRx55-15 had a positive association day 2 (r = 0.219, p = 0.048). Multivariate linear regression analysis showed that high arterial glucose predicted poor pressure autoregulation on days 1 and 2. Conclusions High arterial glucose was associated with poor outcome, poor pressure autoregulation, and cerebral energy metabolic disturbances. The latter two suggest a pathophysiological mechanism for the negative effect of arterial hyperglycemia, although further studies are needed to elucidate if the correlations are causal or confounded by other factors.
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Jakobsen RP, Nielsen TH, Mølstrøm S, Nordström CH, Granfeldt A, Toft P. Moderately prolonged permissive hypotension results in reversible metabolic perturbation evaluated by intracerebral microdialysis - an experimental animal study. Intensive Care Med Exp 2019; 7:67. [PMID: 31802303 PMCID: PMC6892994 DOI: 10.1186/s40635-019-0282-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/13/2019] [Indexed: 12/28/2022] Open
Abstract
Background Damage control resuscitation (DCR) and damage control surgery (DCS) is the main strategy in patients with uncontrollable hemorrhagic shock. One aspect of DCR is permissive hypotension. However, the duration of hypotension that can be tolerated without affecting the brain is unknown. In the present study we investigate the effect of 60 min severe hypotension on the brain’s energy metabolism and seek to verify earlier findings that venous cerebral blood can be used as a marker of global cerebral energy state. Material and methods Ten pigs were anaesthetized, and vital parameters recorded. Microdialysis catheters were placed in the left parietal lobe, femoral artery, and superior sagittal sinus for analysis of lactate, pyruvate, glucose, glycerol, and glutamate. Hemorrhagic shock was induced by bleeding the animal until mean arterial pressure (MAP) of 40 mmHg was achieved. After 60 min the pigs were resuscitated with autologous blood and observed for 3 h. Results At baseline the lactate to pyruvate ratios (LP ratio) in the hemisphere, artery, and sagittal sinus were (median (interquartile range)) 13 (8–16), 21 (18–24), and 9 (6–22), respectively. After induction of hemorrhagic shock, the LP ratio from the left hemisphere in 9 pigs increased to levels indicating a reversible perturbation of cerebral energy metabolism 19 (12–30). The same pattern was seen in LP measurements from the femoral artery 28 (20–35) and sagittal sinus 22 (19–26). At the end of the experiment hemisphere, artery and sinus LP ratios were 16 (10–23), 17 (15–25), and 17 (10–27), respectively. Although hemisphere and sinus LP ratios decreased, they did not reach baseline levels (p < 0.05). In one pig hemisphere LP ratio increased to a level indicating irreversible metabolic perturbation (LP ratio > 200). Conclusion During 60 min of severe hypotension intracerebral microdialysis shows signs of perturbations of cerebral energy metabolism, and these changes trend towards baseline values after resuscitation. Sagittal sinus microdialysis values followed hemisphere values but were not distinguishable from systemic arterial values. Venous (jugular bulb) microdialysis might have a place in monitoring conditions where global cerebral ischemia is a risk.
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Affiliation(s)
- Rasmus Peter Jakobsen
- Department of Anesthesia and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, Indgang 8, 20, 201, 5000, Odense C, Denmark.
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Kløvervænget 47, Indgang 44, 1. etage, 5000, Odense C, Denmark
| | - Simon Mølstrøm
- Department of Anesthesia and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, Indgang 8, 20, 201, 5000, Odense C, Denmark
| | - Carl-Henrik Nordström
- Department of Neurosurgery, Odense University Hospital, Kløvervænget 47, Indgang 44, 1. etage, 5000, Odense C, Denmark
| | - Asger Granfeldt
- Department of Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99 G304, 8200, Aarhus, Denmark
| | - Palle Toft
- Department of Anesthesia and Intensive Care, Odense University Hospital, J.B. Winsløws Vej 4, Indgang 8, 20, 201, 5000, Odense C, Denmark
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Munk M, Poulsen FR, Larsen L, Nordström CH, Nielsen TH. Cerebral Metabolic Changes Related to Oxidative Metabolism in a Model of Bacterial Meningitis Induced by Lipopolysaccharide. Neurocrit Care 2019; 29:496-503. [PMID: 29508265 DOI: 10.1007/s12028-018-0509-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Cerebral mitochondrial dysfunction is prominent in the pathophysiology of severe bacterial meningitis. In the present study, we hypothesize that the metabolic changes seen after intracisternal lipopolysaccharide (LPS) injection in a piglet model of meningitis is compatible with mitochondrial dysfunction and resembles the metabolic patterns seen in patients with bacterial meningitis. METHODS Eight pigs received LPS injection in cisterna magna, and four pigs received NaCl in cisterna magna as a control. Biochemical variables related to energy metabolism were monitored by intracerebral microdialysis technique and included interstitial glucose, lactate, pyruvate, glutamate, and glycerol. The intracranial pressure (ICP) and brain tissue oxygen tension (PbtO2) were also monitored along with physiological variables including mean arterial pressure, blood glucose, lactate, and partial pressure of O2 and CO2. Pigs were monitored for 60 min at baseline and 240 min after LPS/NaCl injection. RESULTS After LPS injection, a significant increase in cerebral lactate/pyruvate ratio (LPR) compared to control group was registered (p = 0.01). This increase was due to a significant increased lactate with stable and normal values of pyruvate. No significant change in PbtO2 or ICP was registered. No changes in physiological variables were observed. CONCLUSIONS The metabolic changes after intracisternal LPS injection is compatible with disturbance in the oxidative metabolism and partly due to mitochondrial dysfunction with increasing cerebral LPR due to increased lactate and normal pyruvate, PbtO2, and ICP. The metabolic pattern resembles the one observed in patients with bacterial meningitis. Metabolic monitoring in these patients is feasible to monitor for cerebral metabolic derangements otherwise missed by conventional intensive care monitoring.
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Affiliation(s)
- M Munk
- University of Southern Denmark School of Medicine, Odense, Denmark
| | - F R Poulsen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - L Larsen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - C H Nordström
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - T H Nielsen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark. .,Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R209, Stanford, CA, 94305-5327, USA.
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26
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Baker WB, Balu R, He L, Kavuri VC, Busch DR, Amendolia O, Quattrone F, Frangos S, Maloney-Wilensky E, Abramson K, Mahanna Gabrielli E, Yodh AG, Andrew Kofke W. Continuous non-invasive optical monitoring of cerebral blood flow and oxidative metabolism after acute brain injury. J Cereb Blood Flow Metab 2019; 39:1469-1485. [PMID: 31088234 PMCID: PMC6681541 DOI: 10.1177/0271678x19846657] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Rapid detection of ischemic conditions at the bedside can improve treatment of acute brain injury. In this observational study of 11 critically ill brain-injured adults, we employed a monitoring approach that interleaves time-resolved near-infrared spectroscopy (TR-NIRS) measurements of cerebral oxygen saturation and oxygen extraction fraction (OEF) with diffuse correlation spectroscopy (DCS) measurement of cerebral blood flow (CBF). Using this approach, we demonstrate the clinical promise of non-invasive, continuous optical monitoring of changes in CBF and cerebral metabolic rate of oxygen (CMRO2). In addition, the optical CBF and CMRO2 measures were compared to invasive brain tissue oxygen tension (PbtO2), thermal diffusion flowmetry CBF, and cerebral microdialysis measures obtained concurrently. The optical CBF and CMRO2 information successfully distinguished between ischemic, hypermetabolic, and hyperemic conditions that arose spontaneously during patient care. Moreover, CBF monitoring during pressor-induced changes of mean arterial blood pressure enabled assessment of cerebral autoregulation. In total, the findings suggest that this hybrid non-invasive neurometabolic optical monitor (NNOM) can facilitate clinical detection of adverse physiological changes in brain injured patients that are otherwise difficult to measure with conventional bedside monitoring techniques.
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Affiliation(s)
- Wesley B Baker
- 1 Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA.,2 Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ramani Balu
- 3 Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lian He
- 4 Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Venkaiah C Kavuri
- 4 Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - David R Busch
- 4 Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA.,5 Department of Anesthesiology & Pain Management and Neurology & Neurotherapeutics, University of Texas Southwestern, Dallas, TX, USA
| | - Olivia Amendolia
- 6 Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Francis Quattrone
- 6 Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Suzanne Frangos
- 6 Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Kenneth Abramson
- 4 Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Arjun G Yodh
- 4 Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - W Andrew Kofke
- 1 Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
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27
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Dyhrfort P, Shen Q, Clausen F, Thulin M, Enblad P, Kamali-Moghaddam M, Lewén A, Hillered L. Monitoring of Protein Biomarkers of Inflammation in Human Traumatic Brain Injury Using Microdialysis and Proximity Extension Assay Technology in Neurointensive Care. J Neurotrauma 2019; 36:2872-2885. [PMID: 31017044 PMCID: PMC6761596 DOI: 10.1089/neu.2018.6320] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Traumatic brain injury (TBI) is followed by secondary injury mechanisms strongly involving neuroinflammation. To monitor the complex inflammatory cascade in human TBI, we used cerebral microdialysis (MD) and multiplex proximity extension assay (PEA) technology and simultaneously measured levels of 92 protein biomarkers of inflammation in MD samples every three hours for five days in 10 patients with severe TBI under neurointensive care. One μL MD samples were incubated with paired oligonucleotide-conjugated antibodies binding to each protein, allowing quantification by real-time quantitative polymerase chain reaction. Sixty-nine proteins were suitable for statistical analysis. We found five different patterns with either early (<48 h; e.g., CCL20, IL6, LIF, CCL3), mid (48–96 h; e.g., CCL19, CXCL5, CXCL10, MMP1), late (>96 h; e.g., CD40, MCP2, MCP3), biphasic peaks (e.g., CXCL1, CXCL5, IL8) or stable (e.g., CCL4, DNER, VEGFA)/low trends. High protein levels were observed for e.g., CXCL1, CXCL10, MCP1, MCP2, IL8, while e.g., CCL28 and MCP4 were detected at low levels. Several proteins (CCL8, -19, -20, -23, CXCL1, -5, -6, -9, -11, CST5, DNER, Flt3L, and SIRT2) have not been studied previously in human TBI. Cross-correlation analysis revealed that LIF and CXCL5 may play a central role in the inflammatory cascade. This study provides a unique data set with individual temporal trends for potential inflammatory biomarkers in patients with TBI. We conclude that the combination of MD and PEA is a powerful tool to map the complex inflammatory cascade in the injured human brain. The technique offers new possibilities of protein profiling of complex secondary injury pathways.
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Affiliation(s)
- Philip Dyhrfort
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Qiujin Shen
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Fredrik Clausen
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Måns Thulin
- Department of Statistics Uppsala University, Uppsala, Sweden.,School of Mathematics and Maxwell Institute for Mathematical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Masood Kamali-Moghaddam
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Lars Hillered
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Mölström S, Nielsen TH, Nordström CH, Hassager C, Møller JE, Kjærgaard J, Möller S, Schmidt H, Toft P. Design paper of the "Blood pressure targets in post-resuscitation care and bedside monitoring of cerebral energy state: a randomized clinical trial". Trials 2019; 20:344. [PMID: 31182135 PMCID: PMC6558732 DOI: 10.1186/s13063-019-3397-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 05/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neurological injuries remain the leading cause of death in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). Adequate blood pressure is of paramount importance to optimize cerebral perfusion and to minimize secondary brain injury. Markers measuring global cerebral ischemia caused by cardiac arrest and consecutive resuscitation and reflecting the metabolic variations after successful resuscitation are needed to assist a more individualized post-resuscitation care. Currently, no technique is available for bedside evaluation of global cerebral energy state, and until now blood pressure targets have been based on limited clinical evidence. Recent experimental and clinical studies indicate that it might be possible to evaluate cerebral oxidative metabolism from measuring the lactate-to-pyruvate (LP) ratio of the draining venous blood. In this study, jugular bulb microdialysis and immediate bedside biochemical analysis are introduced as new diagnostic tools to evaluate the effect of higher mean arterial blood pressure on global cerebral metabolism and the degree of cellular damage after OHCA. METHODS/DESIGN This is a single-center, randomized, double-blinded, superiority trial. Sixty unconscious patients with sustained return of spontaneous circulation after OHCA will be randomly assigned in a one-to-one fashion to low (63 mm Hg) or high (77 mm Hg) mean arterial blood pressure target. The primary end-point will be a difference in mean LP ratio within 48 h between blood pressure groups. Secondary end-points are (1) association between LP ratio and all-cause intensive care unit (ICU) mortality and (2) association between LP ratio and survival to hospital discharge with poor neurological function. DISCUSSION Markers measuring cerebral ischemia caused by cardiac arrest and consecutive resuscitation and reflecting the metabolic changes after successful resuscitation are urgently needed to enable a more personalized post-resuscitation care and prognostication. Jugular bulb microdialysis may provide a reliable global estimate of cerebral metabolic state and can be implemented as an entirely new and less invasive diagnostic tool for ICU patients after OHCA and has implications for early prognosis and treatment. TRIAL REGISTRATION ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03095742 ). Registered March 30, 2017.
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Affiliation(s)
- Simon Mölström
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, Denmark.
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, J. B. Winsløws Vej 4, Odense, 5000, Denmark
| | - Carl H Nordström
- Department of Neurosurgery, Odense University Hospital, J. B. Winsløws Vej 4, Odense, 5000, Denmark
| | - Christian Hassager
- The Heart Centre, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen, 2100, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, Odense, 5000, Denmark
| | - Jesper Kjærgaard
- The Heart Centre, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen, 2100, Denmark
| | - Sören Möller
- OPEN - Odense Patient data Explorative Network, University of Southern Denmark, Odense University Hospital and Department of Clinical Research, J. B. Winsløws Vej 9, Odense, 5000, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, Denmark
| | - Palle Toft
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, Denmark
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Cerebral metabolism is not affected by moderate hyperventilation in patients with traumatic brain injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:45. [PMID: 30760295 PMCID: PMC6375161 DOI: 10.1186/s13054-018-2304-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 12/26/2018] [Indexed: 12/22/2022]
Abstract
Background Hyperventilation-induced hypocapnia (HV) reduces elevated intracranial pressure (ICP), a dangerous and potentially fatal complication of traumatic brain injury (TBI). HV decreases the arteriolar diameter of intracranial vessels, raising the risk of cerebral ischemia. The aim of this study was to characterize the effects of moderate short-term HV in patients with severe TBI by using concomitant monitoring of cerebral metabolism, brain tissue oxygen tension (PbrO2), and cerebral hemodynamics with transcranial color-coded duplex sonography (TCCD). Methods This prospective trial was conducted between May 2014 and May 2017 in the surgical intensive care unit (ICU) at the University Hospital of Zurich. Patients with nonpenetrating TBI older than 18 years of age with a Glasgow Coma Scale (GCS) score < 9 at presentation and with ICP monitoring, PbrO2, and/or microdialysis (MD) probes during ICU admission within 36 h after injury were included in our study. Data collection and TCCD measurements were performed at baseline (A), at the beginning of moderate HV (C), after 50 min of moderate HV (D), and after return to baseline (E). Moderate HV was defined as arterial partial pressure of carbon dioxide 4–4.7 kPa. Repeated measures analysis of variance was used to compare variables at the different time points, followed by post hoc analysis with Bonferroni adjustment as appropriate. Results Eleven patients (64% males, mean age 36 ± 14 years) with an initial median GCS score of 7 (IQR 3–8) were enrolled. During HV, ICP and mean flow velocity (CBFV) in the middle cerebral artery decreased significantly. Glucose, lactate, and pyruvate in the brain extracellular fluid did not change significantly, whereas PbrO2 showed a statistically significant reduction but remained within the normal range. Conclusion Moderate short-term hyperventilation has a potent effect on the cerebral blood flow, as shown by TCCD, with a concomitant ICP reduction. Under the specific conditions of this study, this degree of hyperventilation did not induce pathological alterations of brain metabolites and oxygenation. Trial registration NCT03822026. Registered on 30 January 2019.
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30
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Geyer ED, Shetty PA, Suozzi CJ, Allen DZ, Benavidez PP, Liu J, Hollis CN, Gerhardt GA, Quintero JE, Burmeister JJ, Whitaker EE. Adaptation of Microelectrode Array Technology for the Study of Anesthesia-induced Neurotoxicity in the Intact Piglet Brain. J Vis Exp 2018. [PMID: 29806825 PMCID: PMC6101183 DOI: 10.3791/57391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Every year, millions of children undergo anesthesia for a multitude of procedures. However, studies in both animals and humans have called into question the safety of anesthesia in children, implicating anesthetics as potentially toxic to the brain in development. To date, no studies have successfully elucidated the mechanism(s) by which anesthesia may be neurotoxic. Animal studies allow investigation of such mechanisms, and neonatal piglets represent an excellent model to study these effects due to their striking developmental similarities to the human brain. This protocol adapts the use of enzyme-based microelectrode array (MEA) technology as a novel way to study the mechanism(s) of anesthesia-induced neurotoxicity (AIN). MEAs enable real-time monitoring of in vivo neurotransmitter activity and offer exceptional temporal and spatial resolution. It is hypothesized that anesthetic neurotoxicity is caused in part by glutamate dysregulation and MEAs offer a method to measure glutamate. The novel implementation of MEA technology in a piglet model presents a unique opportunity for the study of AIN.
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Affiliation(s)
- Emily D Geyer
- Department of Anesthesiology, Ohio State University College of Medicine
| | - Prithvi A Shetty
- Department of Anesthesiology, Ohio State University College of Medicine
| | | | - David Z Allen
- Department of Anesthesiology, Ohio State University College of Medicine; Medical Student Research Program, Ohio State University College of Medicine
| | - Pamela P Benavidez
- Department of Anesthesiology, Ohio State University College of Medicine; Medical Student Research Program, Ohio State University College of Medicine
| | - Joseph Liu
- Department of Anesthesiology, Ohio State University College of Medicine; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital
| | - Charles N Hollis
- Department of Anesthesiology, Ohio State University College of Medicine
| | - Greg A Gerhardt
- Department of Neuroscience, University of Kentucky Medical Center
| | - Jorge E Quintero
- Department of Neuroscience, University of Kentucky Medical Center
| | | | - Emmett E Whitaker
- Department of Anesthesiology, Ohio State University College of Medicine; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital;
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Abstract
Lactate in the brain has long been associated with ischaemia; however, more recent evidence shows that it can be found there under physiological conditions. In the brain, lactate is formed predominantly in astrocytes from glucose or glycogen in response to neuronal activity signals. Thus, neurons and astrocytes show tight metabolic coupling. Lactate is transferred from astrocytes to neurons to match the neuronal energetic needs, and to provide signals that modulate neuronal functions, including excitability, plasticity and memory consolidation. In addition, lactate affects several homeostatic functions. Overall, lactate ensures adequate energy supply, modulates neuronal excitability levels and regulates adaptive functions in order to set the 'homeostatic tone' of the nervous system.
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Kofler M, Schiefecker AJ, Beer R, Gaasch M, Rhomberg P, Stover J, Pfausler B, Thomé C, Schmutzhard E, Helbok R. Enteral nutrition increases interstitial brain glucose levels in poor-grade subarachnoid hemorrhage patients. J Cereb Blood Flow Metab 2018; 38:518-527. [PMID: 28322077 PMCID: PMC5851142 DOI: 10.1177/0271678x17700434] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Low brain tissue glucose levels after acute brain injury are associated with poor outcome. Whether enteral nutrition (EN) reliably increases cerebral glucose levels remains unclear. In this retrospective analysis of prospectively collected observational data, we investigate the effect of EN on brain metabolism in 17 poor-grade subarachnoid hemorrhage (SAH) patients undergoing cerebral microdialysis (CMD) monitoring. CMD-values were obtained hourly. A nutritional intervention was defined as the clinical routine administration of EN without supplemental parenteral nutrition. Sixty-three interventions were analyzed. The mean amount of EN per intervention was 472.4 ± 10.7 kcal. CMD-glucose levels significantly increased from 1.59 ± 0.13 mmol/l at baseline to a maximum of 2.03 ± 0.2 mmol/l after 5 h (p < 0.001), independently of insulin-treatment, baseline serum glucose, baseline brain metabolic distress (CMD-lactate-to-pyruvate-ratio (LPR) > 40) and the microdialysis probe location. The increase in CMD-glucose was directly dependent on the magnitude of increase of serum glucose levels (p = 0.007). No change in CMD-lactate, CMD-pyruvate, CMD-LPR, or CMD-glutamate (p > 0.4) was observed. Routine EN also increased CMD-glucose even if baseline concentrations were critically low ( < 0.7 mmol/l, neuroglucopenia; p < 0.001). These results may have treatment implications regarding glucose management of poor-grade aneurysmal SAH patients.
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Affiliation(s)
- Mario Kofler
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois J Schiefecker
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Maxime Gaasch
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul Rhomberg
- 2 Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - John Stover
- 3 Fresenius Kabi, Bad Homburg vor der Höhe, Germany
| | - Bettina Pfausler
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- 4 Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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33
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Stovell MG, Yan JL, Sleigh A, Mada MO, Carpenter TA, Hutchinson PJA, Carpenter KLH. Assessing Metabolism and Injury in Acute Human Traumatic Brain Injury with Magnetic Resonance Spectroscopy: Current and Future Applications. Front Neurol 2017; 8:426. [PMID: 28955291 PMCID: PMC5600917 DOI: 10.3389/fneur.2017.00426] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/07/2017] [Indexed: 11/25/2022] Open
Abstract
Traumatic brain injury (TBI) triggers a series of complex pathophysiological processes. These include abnormalities in brain energy metabolism; consequent to reduced tissue pO2 arising from ischemia or abnormal tissue oxygen diffusion, or due to a failure of mitochondrial function. In vivo magnetic resonance spectroscopy (MRS) allows non-invasive interrogation of brain tissue metabolism in patients with acute brain injury. Nuclei with “spin,” e.g., 1H, 31P, and 13C, are detectable using MRS and are found in metabolites at various stages of energy metabolism, possessing unique signatures due to their chemical shift or spin–spin interactions (J-coupling). The most commonly used clinical MRS technique, 1H MRS, uses the great abundance of hydrogen atoms within molecules in brain tissue. Spectra acquired with longer echo-times include N-acetylaspartate (NAA), creatine, and choline. NAA, a marker of neuronal mitochondrial activity related to adenosine triphosphate (ATP), is reported to be lower in patients with TBI than healthy controls, and the ratio of NAA/creatine at early time points may correlate with clinical outcome. 1H MRS acquired with shorter echo times produces a more complex spectrum, allowing detection of a wider range of metabolites.31 P MRS detects high-energy phosphate species, which are the end products of cellular respiration: ATP and phosphocreatine (PCr). ATP is the principal form of chemical energy in living organisms, and PCr is regarded as a readily mobilized reserve for its replenishment during periods of high utilization. The ratios of high-energy phosphates are thought to represent a balance between energy generation, reserve and use in the brain. In addition, the chemical shift difference between inorganic phosphate and PCr enables calculation of intracellular pH.13 C MRS detects the 13C isotope of carbon in brain metabolites. As the natural abundance of 13C is low (1.1%), 13C MRS is typically performed following administration of 13C-enriched substrates, which permits tracking of the metabolic fate of the infused 13C in the brain over time, and calculation of metabolic rates in a range of biochemical pathways, including glycolysis, the tricarboxylic acid cycle, and glutamate–glutamine cycling. The advent of new hyperpolarization techniques to transiently boost signal in 13C-enriched MRS in vivo studies shows promise in this field, and further developments are expected.
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Affiliation(s)
- Matthew G Stovell
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jiun-Lin Yan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Department of Neurosurgery, Keelung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Alison Sleigh
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,National Institute for Health Research/Wellcome Trust Clinical Research Facility, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Marius O Mada
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - T Adrian Carpenter
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter J A Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Keri L H Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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34
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Nyholm L, Howells T, Lewén A, Hillered L, Enblad P. The influence of hyperthermia on intracranial pressure, cerebral oximetry and cerebral metabolism in traumatic brain injury. Ups J Med Sci 2017; 122:177-184. [PMID: 28463046 PMCID: PMC5649323 DOI: 10.1080/03009734.2017.1319440] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 04/07/2017] [Accepted: 04/11/2017] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Hyperthermia is a common secondary insult in traumatic brain injury (TBI). The aim was to evaluate the relationship between hyperthermia and intracranial pressure (ICP), and if intracranial compliance and cerebral blood flow (CBF) pressure autoregulation affected that relationship. The relationships between hyperthermia and cerebral oximetry (BtipO2) and cerebral metabolism were also studied. METHODS A computerized multimodality monitoring system was used for data collection at the neurointensive care unit. Demographic and monitoring data (temperature, ICP, blood pressure, microdialysis, BtipO2) were analyzed from 87 consecutive TBI patients. ICP amplitude was used as measure of compliance, and CBF pressure autoregulation status was calculated using collected blood pressure and ICP values. Mixed models and comparison between groups were used. RESULTS The influence of hyperthermia on intracranial dynamics (ICP, brain energy metabolism, and BtipO2) was small, but individual differences were seen. Linear mixed models showed that hyperthermia raises ICP slightly more when temperature increases in the groups with low compliance and impaired CBF pressure autoregulation. There was also a tendency (not statistically significant) for increased BtipO2, and for increased pyruvate and lactate, with higher temperature, while the lactate/pyruvate ratio and glucose were stable. CONCLUSIONS The major finding was that the effects of hyperthermia on intracranial dynamics (ICP, brain energy metabolism, and BtipO2) were not extensive in general, but there were exceptional cases. Hyperthermia treatment has many side effects, so it is desirable to identify cases in which hyperthermia is dangerous. Information from multimodality monitoring may be used to guide treatment in individual patients.
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Affiliation(s)
- Lena Nyholm
- Department of Neuroscience/Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
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35
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Sánchez-Guerrero A, Mur-Bonet G, Vidal-Jorge M, Gándara-Sabatini D, Chocrón I, Cordero E, Poca MA, Mullen K, Sahuquillo J. Reappraisal of the reference levels for energy metabolites in the extracellular fluid of the human brain. J Cereb Blood Flow Metab 2017; 37:2742-2755. [PMID: 27742889 PMCID: PMC5536785 DOI: 10.1177/0271678x16674222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/21/2016] [Accepted: 09/15/2016] [Indexed: 11/16/2022]
Abstract
Cerebral microdialysis is widely used in neurocritical care units. The goal of this study was to establish the reference interval for the interstitial fluid concentrations of energy metabolites and glycerol by using the extrapolation to zero-flow methodology in anesthetized patients and by constant perfusion at 0.3 µL/min in awake patients. A CMA-71 probe was implanted during surgery in normal white matter of patients with posterior fossa or supratentorial lesions, and the perfusion flow rate was randomized to 0.1, 0.3, 0.6, 1.2, and 2.4 µL/min. Within 24 h of surgery, perfusion was restarted at a constant 0.3 µL/min in fully awake patients. The actual interstitial fluid metabolite concentrations were calculated using the zero-flow methodology. In vitro experiments were also conducted to evaluate the reproducibility of the in vivo methodology. Nineteen patients (seven males) with a median age of 44 years (range: 21-69) were included in the in vivo study. The median (lower-upper) reference interval values were 1.57 (1.15-4.13 mmol/L) for glucose, 2.01 (1.30-5.31 mmol/L) for lactate, 80.0 (54.4-197.0 µmol/L) for pyruvate, and 49.9 (23.6-227.3 µmol/L) for glycerol. The reference intervals reported raises the need to reconsider traditional definitions of brain metabolic disturbances and emphasize the importance of using different thresholds for awake patients and patients under anesthesia.
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Affiliation(s)
- Angela Sánchez-Guerrero
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gemma Mur-Bonet
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marian Vidal-Jorge
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Ivette Chocrón
- Department of Anesthesiology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Esteban Cordero
- Department of Neurosurgery, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Maria-Antonia Poca
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neurosurgery, Vall d’Hebron University Hospital, Barcelona, Spain
| | | | - Juan Sahuquillo
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neurosurgery, Vall d’Hebron University Hospital, Barcelona, Spain
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36
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Jalloh I, Helmy A, Howe DJ, Shannon RJ, Grice P, Mason A, Gallagher CN, Stovell MG, van der Heide S, Murphy MP, Pickard JD, Menon DK, Carpenter TA, Hutchinson PJ, Carpenter KLH. Focally perfused succinate potentiates brain metabolism in head injury patients. J Cereb Blood Flow Metab 2017; 37:2626-2638. [PMID: 27798266 PMCID: PMC5482384 DOI: 10.1177/0271678x16672665] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Following traumatic brain injury, complex cerebral energy perturbations occur. Correlating with unfavourable outcome, high brain extracellular lactate/pyruvate ratio suggests hypoxic metabolism and/or mitochondrial dysfunction. We investigated whether focal administration of succinate, a tricarboxylic acid cycle intermediate interacting directly with the mitochondrial electron transport chain, could improve cerebral metabolism. Microdialysis perfused disodium 2,3-13C2 succinate (12 mmol/L) for 24 h into nine sedated traumatic brain injury patients' brains, with simultaneous microdialysate collection for ISCUS analysis of energy metabolism biomarkers (nine patients) and nuclear magnetic resonance of 13C-labelled metabolites (six patients). Metabolites 2,3-13C2 malate and 2,3-13C2 glutamine indicated tricarboxylic acid cycle metabolism, and 2,3-13C2 lactate suggested tricarboxylic acid cycle spinout of pyruvate (by malic enzyme or phosphoenolpyruvate carboxykinase and pyruvate kinase), then lactate dehydrogenase-mediated conversion to lactate. Versus baseline, succinate perfusion significantly decreased lactate/pyruvate ratio (p = 0.015), mean difference -12%, due to increased pyruvate concentration (+17%); lactate changed little (-3%); concentrations decreased for glutamate (-43%) (p = 0.018) and glucose (-15%) (p = 0.038). Lower lactate/pyruvate ratio suggests better redox status: cytosolic NADH recycled to NAD+ by mitochondrial shuttles (malate-aspartate and/or glycerol 3-phosphate), diminishing lactate dehydrogenase-mediated pyruvate-to-lactate conversion, and lowering glutamate. Glucose decrease suggests improved utilisation. Direct tricarboxylic acid cycle supplementation with 2,3-13C2 succinate improved human traumatic brain injury brain chemistry, indicated by biomarkers and 13C-labelling patterns in metabolites.
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Affiliation(s)
- Ibrahim Jalloh
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
- Ibrahim Jalloh, University of Cambridge, Department of Clinical Neurosciences, Division of Neurosurgery, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Duncan J Howe
- Department of Chemistry, University of Cambridge, UK
| | - Richard J Shannon
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Grice
- Department of Chemistry, University of Cambridge, UK
| | - Andrew Mason
- Department of Chemistry, University of Cambridge, UK
| | - Clare N Gallagher
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Canada
| | - Matthew G Stovell
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Susan van der Heide
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | | | - John D Pickard
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, UK
| | - David K Menon
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
| | - T Adrian Carpenter
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Keri LH Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, UK
- Keri LH Carpenter, University of Cambridge, Department of Clinical Neurosciences, Division of Neurosurgery, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.
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37
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Nordström CH, Koskinen LO, Olivecrona M. Aspects on the Physiological and Biochemical Foundations of Neurocritical Care. Front Neurol 2017; 8:274. [PMID: 28674514 PMCID: PMC5474476 DOI: 10.3389/fneur.2017.00274] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/29/2017] [Indexed: 12/25/2022] Open
Abstract
Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood-brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors.
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Affiliation(s)
| | - Lars-Owe Koskinen
- Department of Clinical Neuroscience, Division of Neurosurgery, Umeå University, Umeå, Sweden
| | - Magnus Olivecrona
- Faculty of Health and Medicine, Department of Anesthesia and Intensive Care, Section for Neurosurgery Örebro University Hospital, Örebro University, Örebro, Sweden
- Department for Medical Sciences, Örebro University, Örebro, Sweden
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38
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Pinczolits A, Zdunczyk A, Dengler NF, Hecht N, Kowoll CM, Dohmen C, Graf R, Winkler MK, Major S, Hartings JA, Dreier JP, Vajkoczy P, Woitzik J. Standard-sampling microdialysis and spreading depolarizations in patients with malignant hemispheric stroke. J Cereb Blood Flow Metab 2017; 37:1896-1905. [PMID: 28350195 PMCID: PMC5435299 DOI: 10.1177/0271678x17699629] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Spreading depolarizations (SD) occur in high frequency in patients with malignant hemispheric stroke (MHS). Experimentally, SDs cause marked increases in glutamate and lactate, whereas glucose decreases. Here, we studied extracellular brain glutamate, glucose, lactate, pyruvate and the lactate/pyruvate ratio in relationship to SDs after MHS. We inserted two microdialysis probes in peri-infarct tissue at 5 and 15 mm to the infarct in close proximity to a subdural electrode strip. During 2356.6 monitoring hours, electrocorticography (ECoG) revealed 697 SDs in 16 of 18 patients. Ninety-nine SDs in electrically active tissue (spreading depressions, SDd) were single (SDds) and 485 clustered (SDdc), whereas 10 SDs with at least one electrode in electrically inactive tissue (isoelectric SDs, SDi) were single (SDis) and 103 clustered (SDic). More SDs and a significant number of clustered SDs occurred during the first 36 h post-surgery when glutamate was significantly elevated (> 100 µM). In a grouped analysis, we observed minor glutamate elevations with more than two SDs per hour. Glucose slightly decreased during SDic at 5 mm from the infarct. Directions of SD-related metabolic changes correspond to the experimental setting but the long sampling time of standard microdialysis precludes a more adequate account of the dynamics revealed by ECoG.
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Affiliation(s)
- Alexandra Pinczolits
- 1 Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany.,2 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Zdunczyk
- 1 Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany.,2 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nora F Dengler
- 1 Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany.,2 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nils Hecht
- 1 Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany.,2 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christina M Kowoll
- 3 Department of Neurology, University of Cologne, Cologne, Germany.,4 Max Planck Institute for Neurological Research, Cologne, Germany
| | - Christian Dohmen
- 3 Department of Neurology, University of Cologne, Cologne, Germany.,4 Max Planck Institute for Neurological Research, Cologne, Germany
| | - Rudolf Graf
- 4 Max Planck Institute for Neurological Research, Cologne, Germany
| | - Maren Kl Winkler
- 2 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,5 Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Major
- 2 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,5 Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jed A Hartings
- 6 Department of Neurosurgery, University of Cincinnati College of Medicine, Mayfield Clinic, Cincinnati, OH, USA
| | - Jens P Dreier
- 2 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,5 Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- 1 Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany.,2 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Woitzik
- 1 Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany.,2 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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39
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In vivo online magnetic resonance quantification of absolute metabolite concentrations in microdialysate. Sci Rep 2016; 6:36080. [PMID: 27811972 PMCID: PMC5095764 DOI: 10.1038/srep36080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 10/11/2016] [Indexed: 12/23/2022] Open
Abstract
In order to study metabolic processes in animal models of diseases and in patients, microdialysis probes have evolved as powerful tools that are minimally invasive. However, analyses of microdialysate, performed remotely, do not provide real-time monitoring of microdialysate composition. Microdialysate solutions can theoretically be analyzed online inside a preclicinal or clinical MRI scanner using MRS techniques. Due to low NMR sensitivity, acquisitions of real-time NMR spectra on very small solution volumes (μL) with low metabolite concentrations (mM range) represent a major issue. To address this challenge we introduce the approach of combining a microdialysis probe with a custom-built magnetic resonance microprobe that allows for online metabolic analysis (1H and 13C) with high sensitivity under continuous flow conditions. This system is mounted inside an MRI scanner and allows performing simultaneously MRI experiments and rapid MRS metabolic analysis of the microdialysate. The feasibility of this approach is demonstrated by analyzing extracellular brain cancer cells (glioma) in vitro and brain metabolites in an animal model in vivo. We expect that our approach is readily translatable into clinical settings and can be used for a better and precise understanding of diseases linked to metabolic dysfunction.
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40
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Dienel GA, Rothman DL, Nordström CH. Microdialysate concentration changes do not provide sufficient information to evaluate metabolic effects of lactate supplementation in brain-injured patients. J Cereb Blood Flow Metab 2016; 36:1844-1864. [PMID: 27604313 PMCID: PMC5094313 DOI: 10.1177/0271678x16666552] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/03/2016] [Indexed: 12/31/2022]
Abstract
Cerebral microdialysis is a widely used clinical tool for monitoring extracellular concentrations of selected metabolites after brain injury and to guide neurocritical care. Extracellular glucose levels and lactate/pyruvate ratios have high diagnostic value because they can detect hypoglycemia and deficits in oxidative metabolism, respectively. In addition, patterns of metabolite concentrations can distinguish between ischemia and mitochondrial dysfunction, and are helpful to choose and evaluate therapy. Increased intracranial pressure can be life-threatening after brain injury, and hypertonic solutions are commonly used for pressure reduction. Recent reports have advocated use of hypertonic sodium lactate, based on claims that it is glucose sparing and provides an oxidative fuel for injured brain. However, changes in extracellular concentrations in microdialysate are not evidence that a rise in extracellular glucose level is beneficial or that lactate is metabolized and improves neuroenergetics. The increase in glucose concentration may reflect inhibition of glycolysis, glycogenolysis, and pentose phosphate shunt pathway fluxes by lactate flooding in patients with mitochondrial dysfunction. In such cases, lactate will not be metabolizable and lactate flooding may be harmful. More rigorous approaches are required to evaluate metabolic and physiological effects of administration of hypertonic sodium lactate to brain-injured patients.
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Affiliation(s)
- Gerald A Dienel
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, USA, and Department of Cell Biology and Physiology, University of New Mexico, Albuquerque, NM, USA
| | - Douglas L Rothman
- Department of Radiology and Biomedical Imaging, Magnetic Resonance Research Center, Yale University School of Medicine, New Haven, CT, USA
| | - Carl-Henrik Nordström
- Department of Neurosurgery, Lund University Hospital, Lund, Sweden, and Department of Neurosurgery, Odense University Hospital, Odense, Denmark
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Abstract
Microdialysis enables the chemistry of the extracellular interstitial space to be monitored. Use of this technique in patients with acute brain injury has increased our understanding of the pathophysiology of several acute neurological disorders. In 2004, a consensus document on the clinical application of cerebral microdialysis was published. Since then, there have been significant advances in the clinical use of microdialysis in neurocritical care. The objective of this review is to report on the International Microdialysis Forum held in Cambridge, UK, in April 2014 and to produce a revised and updated consensus statement about its clinical use including technique, data interpretation, relationship with outcome, role in guiding therapy in neurocritical care and research applications.
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42
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Grejs AM, Gjedsted J, Pedersen M, Birke-Sørensen H, Rauff-Mortensen A, Andersen KK, Kirkegaard H. Cerebral Effects of Targeted Temperature Management Methods Assessed by Diffusion-Weighted Magnetic Resonance Imaging. Ther Hypothermia Temp Manag 2016; 6:198-207. [PMID: 27249179 DOI: 10.1089/ther.2016.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The aim of this randomized porcine study was to compare surface targeted temperature management (TTM) to endovascular TTM evaluated by cerebral diffusion-weighted magnetic resonance imaging (MRI): apparent diffusion coefficient (ADC), and by intracerebral/intramuscular microdialysis. It is well known that alteration in the temperature affects ADC, but the relationship between cerebral ADC values and the cooling method per se has not been established. Eighteen anesthetized 60-kg female swine were hemodynamically and intracerebrally monitored and subsequently subjected to a baseline MRI. The animals were then randomized into three groups: (1) surface cooling (n = 6) at 33.5°C using EMCOOLSpad®, (2) endovascular cooling (n = 6) at 33.5°C using an Icy® cooling catheter with the CoolGard 3000®, or (3) control (n = 6) at 38.5°C using a Bair Hugger™. The swine were treated with TTM for 6 hours followed by a second MRI examination, including ADC. Blood and microdialysate were sampled regularly throughout the experiment, and glucose, lactate, pyruvate, glycerol, and the lactate/pyruvate ratio did not differ among groups, neither intracerebrally nor intramuscularly. Surface cooling yielded a significantly lower median ADC than endovascular cooling: 714 (634; 804) × 10-6 mm2/s versus 866 (828; 927) × 10-6 mm2/s, (p < 0.05). The surface cooling ADC was lowered to a range usually attributed to cytotoxic edema and these low values could not be explained solely by the temperature effect per se. To what extent the ADC is fully reversible at rewarming is unknown and the clinical implications should be further investigated in clinical studies.
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Affiliation(s)
- Anders Morten Grejs
- 1 Research Center for Emergency Medicine, Aarhus University Hospital , Aarhus C, Denmark .,2 Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital , Aarhus N, Denmark .,3 Department of Clinical Medicine, Aarhus University Hospital , Aarhus N, Denmark
| | - Jakob Gjedsted
- 2 Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital , Aarhus N, Denmark
| | - Michael Pedersen
- 3 Department of Clinical Medicine, Aarhus University Hospital , Aarhus N, Denmark
| | - Hanne Birke-Sørensen
- 3 Department of Clinical Medicine, Aarhus University Hospital , Aarhus N, Denmark
| | | | | | - Hans Kirkegaard
- 1 Research Center for Emergency Medicine, Aarhus University Hospital , Aarhus C, Denmark
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Abstract
The challenges posed by acute brain injury (ABI) involve the management of the initial insult in addition to downstream inflammation, edema, and ischemia that can result in secondary brain injury (SBI). SBI is often subclinical, but can be detected through physiologic changes. These changes serve as a surrogate for tissue injury/cell death and are captured by parameters measured by various monitors that measure intracranial pressure (ICP), cerebral blood flow (CBF), brain tissue oxygenation (PbtO2), cerebral metabolism, and electrocortical activity. In the ideal setting, multimodality monitoring (MMM) integrates these neurological monitoring parameters with traditional hemodynamic monitoring and the physical exam, presenting the information needed to clinicians who can intervene before irreversible damage occurs. There are now consensus guidelines on the utilization of MMM, and there continue to be new advances and questions regarding its use. In this review, we examine these recommendations, recent evidence for MMM, and future directions for MMM.
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Affiliation(s)
- David Roh
- Department of Neurology and Neurocritical Care, Columbia University, 177 Fort Washington Ave, New York, NY 10032, USA
| | - Soojin Park
- Department of Neurology and Neurocritical Care, Columbia University, 177 Fort Washington Ave, New York, NY 10032, USA
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44
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Frontera J, Ziai W, O'Phelan K, Leroux PD, Kirkpatrick PJ, Diringer MN, Suarez JI. Regional brain monitoring in the neurocritical care unit. Neurocrit Care 2016; 22:348-59. [PMID: 25832349 DOI: 10.1007/s12028-015-0133-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Regional multimodality monitoring has evolved over the last several years as a tool to understand the mechanisms of brain injury and brain function at the cellular level. Multimodality monitoring offers an important augmentation to the clinical exam and is especially useful in comatose neurocritical care patients. Cerebral microdialysis, brain tissue oxygen monitoring, and cerebral blood flow monitoring all offer insight into permutations in brain chemistry and function that occur in the context of brain injury. These tools may allow for development of individual therapeutic strategies that are mechanistically driven and goal-directed. We present a summary of the discussions that took place during the Second Neurocritical Care Research Conference regarding regional brain monitoring.
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Affiliation(s)
- Jennifer Frontera
- Cerebrovascular Center, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland Clinic Mail Code S80, Cleveland, OH, 44195, USA,
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Bartek J, Thelin EP, Ghatan PH, Glimaker M, Bellander BM. Neuron-Specific Enolase Is Correlated to Compromised Cerebral Metabolism in Patients Suffering from Acute Bacterial Meningitis; An Observational Cohort Study. PLoS One 2016; 11:e0152268. [PMID: 27019200 PMCID: PMC4809596 DOI: 10.1371/journal.pone.0152268] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 03/13/2016] [Indexed: 11/19/2022] Open
Abstract
Introduction Patients suffering from acute bacterial meningitis (ABM) with a decreased level of consciousness have been shown to have an improved clinical outcome if treated with an intracranial pressure (ICP) guided therapy. By using intracranial microdialysis (MD) to monitor cerebral metabolism in combination with serum samples of biomarkers indicating brain tissue injury, S100B and Neuron Specific Enolase (NSE), additional information might be provided. The aim of this study was to evaluate biomarkers in serum and MD parameters in patients with ABM. Methods From a prior study on patients (n = 52) with a confirmed ABM and impaired consciousness (GCS ≤ 9, or GCS = 10 combined with lumbar spinal opening pressure > 400 mmH2O), a subgroup of patients (n = 21) monitored with intracerebral MD and biomarkers was included in the present study. All patients were treated in the NICU with intracranial pressure (ICP) guided therapy. Serum biomarkers were obtained at admission and every 12 hours. The MD parameters glucose, lactate, pyruvate and glycerol were analyzed. Outcome was assessed at 12–55 months after discharge from hospital. Mann-Whitney U-Test and Wilcoxon matched-pairs signed rank test were applied. Results The included patients had a mean GCS of 8 (range, 3–10) on admission and increased ICP (>20 mmHg) was observed in 62% (n = 13/21) of the patients. Patients with a lactate:pyruvate ratio (LPR) >40 (n = 9/21, 43%) had significantly higher peak levels of serum NSE (p = 0.03), with similar, although non-significant observations made in patients with high levels of glycerol (>500 μmol/L, p = 0.11) and those with a metabolic crisis (Glucose <0.8 mmol/L, LPR >25, p = 0.09). No associations between serum S100B and MD parameters were found. Furthermore, median MD glucose levels decreased significantly between day 1 (0–24h) and day 3 (48–72h) after admission to the NICU (p = 0.0001). No correlation between MD parameters or biomarkers and outcome was found. Conclusion In this observational cohort study, we were able to show that cerebral metabolism is frequently affected in patients with ABM. Furthermore, patients with high LPR (LPR>40) had significantly higher levels of NSE, suggesting ongoing deterioration in compromised cerebral tissue. However, the potential clinical impact of MD and biomarker monitoring in ABM patients will need to be further elaborated in larger clinical trials.
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Affiliation(s)
- Jiri Bartek
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Per Hamid Ghatan
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Martin Glimaker
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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46
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Hinzman JM, Wilson JA, Mazzeo AT, Bullock MR, Hartings JA. Excitotoxicity and Metabolic Crisis Are Associated with Spreading Depolarizations in Severe Traumatic Brain Injury Patients. J Neurotrauma 2016; 33:1775-1783. [PMID: 26586606 DOI: 10.1089/neu.2015.4226] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cerebral microdialysis has enabled the clinical characterization of excitotoxicity (glutamate >10 μM) and non-ischemic metabolic crisis (lactate/pyruvate ratio [LPR] >40) as important components of secondary damage in severe traumatic brain injury (TBI). Spreading depolarizations (SD) are pathological waves that occur in many patients in the days following TBI and, in animal models, cause elevations in extracellular glutamate, increased anaerobic metabolism, and energy substrate depletion. Here, we examined the association of SD with changes in cerebral neurochemistry by placing a microdialysis probe alongside a subdural electrode strip in peri-lesional cortex of 16 TBI patients requiring neurosurgery. In 107 h (median; range: 76-117 h) of monitoring, 135 SDs were recorded in six patients. Glutamate (50 μmol/L) and lactate (3.7 mmol/L) were significantly elevated on day 0 in patients with SD compared with subsequent days and with patients without SD, whereas pyruvate was decreased in the latter group on days 0 and 1 (two-way analysis of variance [ANOVA], p values <0.05). In patients with SD, both glutamate and LPR increased in a dose-dependent manner with the number of SDs in the microdialysis sampling period (0, 1, ≥2 SD) [glutamate: 2.1→7.0→52.3 μmol/L; LPR: 27.8→29.9→45.0, p values <0.05]. In these patients, there was a 10% probability of SD occurring when glutamate and LPR were in normal ranges, but a 60% probability when both variables were abnormal (>10 μmol/L and >40 μmol/L, respectively). Taken together with previous studies, these preliminary clinical results suggest SDs are a key pathophysiological process of secondary brain injury associated with non-ischemic glutamate excitotoxicity and severe metabolic crisis in severe TBI patients.
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Affiliation(s)
- Jason M Hinzman
- 1 Department of Neurosurgery, University of Cincinnati (UC) College of Medicine , Cincinnati, Ohio
| | - J Adam Wilson
- 1 Department of Neurosurgery, University of Cincinnati (UC) College of Medicine , Cincinnati, Ohio
| | - Anna Teresa Mazzeo
- 2 Division of Neurosurgery, Virginia Commonwealth University , Richmond, Virginia.,3 Department Anesthesia and Intensive Care, University of Torino , Torino, Italy
| | - M Ross Bullock
- 2 Division of Neurosurgery, Virginia Commonwealth University , Richmond, Virginia.,4 Department of Neurosurgery, University of Miami , Miami, Florida
| | - Jed A Hartings
- 1 Department of Neurosurgery, University of Cincinnati (UC) College of Medicine , Cincinnati, Ohio.,5 Neurotrauma Center, UC Neuroscience Institute , Cincinnati, Ohio.,6 Mayfield Clinic , Cincinnati, Ohio
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47
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Glucose Transporters at the Blood-Brain Barrier: Function, Regulation and Gateways for Drug Delivery. Mol Neurobiol 2016; 54:1046-1077. [PMID: 26801191 DOI: 10.1007/s12035-015-9672-6] [Citation(s) in RCA: 204] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/17/2015] [Indexed: 12/31/2022]
Abstract
Glucose transporters (GLUTs) at the blood-brain barrier maintain the continuous high glucose and energy demands of the brain. They also act as therapeutic targets and provide routes of entry for drug delivery to the brain and central nervous system for treatment of neurological and neurovascular conditions and brain tumours. This article first describes the distribution, function and regulation of glucose transporters at the blood-brain barrier, the major ones being the sodium-independent facilitative transporters GLUT1 and GLUT3. Other GLUTs and sodium-dependent transporters (SGLTs) have also been identified at lower levels and under various physiological conditions. It then considers the effects on glucose transporter expression and distribution of hypoglycemia and hyperglycemia associated with diabetes and oxygen/glucose deprivation associated with cerebral ischemia. A reduction in glucose transporters at the blood-brain barrier that occurs before the onset of the main pathophysiological changes and symptoms of Alzheimer's disease is a potential causative effect in the vascular hypothesis of the disease. Mutations in glucose transporters, notably those identified in GLUT1 deficiency syndrome, and some recreational drug compounds also alter the expression and/or activity of glucose transporters at the blood-brain barrier. Approaches for drug delivery across the blood-brain barrier include the pro-drug strategy whereby drug molecules are conjugated to glucose transporter substrates or encapsulated in nano-enabled delivery systems (e.g. liposomes, micelles, nanoparticles) that are functionalised to target glucose transporters. Finally, the continuous development of blood-brain barrier in vitro models is important for studying glucose transporter function, effects of disease conditions and interactions with drugs and xenobiotics.
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48
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Jakobsen R, Halfeld Nielsen T, Granfeldt A, Toft P, Nordström CH. A technique for continuous bedside monitoring of global cerebral energy state. Intensive Care Med Exp 2016; 4:3. [PMID: 26791144 PMCID: PMC4720625 DOI: 10.1186/s40635-016-0077-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 01/11/2016] [Indexed: 12/14/2022] Open
Abstract
Background Cerebral cytoplasmatic redox state is a sensitive indicator of cerebral oxidative metabolism and is conventionally evaluated from the extracellular lactate/pyruvate (LP) ratio. In the present experimental study of global cerebral ischemia induced by hemorrhagic shock, we investigate whether the LP ratio obtained from microdialysis of cerebral venous blood may be used as a surrogate marker of global cerebral energy state. Methods Six female pigs were anesthetized and vital parameters were recorded. Microdialysis catheters were placed in the left parietal lobe, the superior sagittal sinus, and the femoral artery. Hemorrhagic shock was achieved by bleeding the animals to a mean arterial pressure (MAP) of approximately 40 mmHg and kept at a MAP of about 30–40 mmHg for 90 min. The animals were resuscitated with autologous whole blood followed by 3 h of observation. Results The LP ratio obtained from the intracerebral and intravenous catheters immediately increased during the period of hemorrhagic shock while the LP ratio in the arterial blood remained close to normal levels. At the end of the experiment, median LP ratio (interquartile range) obtained from the intracerebral, intravenous, and intra-arterial microdialysis catheters were 846 (243–1990), 309 (103–488), and 27 (21–31), respectively. There was a significant difference in the LP ratio obtained from the intravenous location and the intra-arterial location (P < 0.001). Conclusions During cerebral ischemia induced by severe hemorrhagic shock, intravascular microdialysis of the draining venous blood will exhibit changes of the LP ratio revealing the deterioration of global cerebral oxidative energy metabolism. In neurocritical care, this technique might be used to give information regarding global cerebral energy metabolism in addition to the regional information obtained from intracerebral microdialysis catheters. The technique might also be used to evaluate cerebral energy state in various critical care conditions when insertion of an intracerebral microdialysis catheter may be contraindicated, e.g., resuscitation after cardiac standstill, open-heart surgery, and multi-trauma.
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Affiliation(s)
- Rasmus Jakobsen
- Department of Anaesthesia and Intensive care, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.
| | - Asger Granfeldt
- Department of Anesthesiology, Regional Hospital of Randers, Skovlyvej 1, 8930, Randers NØ, Denmark.
| | - Palle Toft
- Department of Anaesthesia and Intensive care, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.
| | - Carl-Henrik Nordström
- Department of Neurosurgery, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.
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49
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Poulsen FR, Schulz M, Jacobsen A, Andersen ÅB, Larsen L, Schalén W, Nielsen TH, Nordström CH. Bedside evaluation of cerebral energy metabolism in severe community-acquired bacterial meningitis. Neurocrit Care 2016; 22:221-8. [PMID: 25142826 DOI: 10.1007/s12028-014-0057-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Mortality and morbidity have remained high in bacterial meningitis. Impairment of cerebral energy metabolism probably contributes to unfavorable outcome. Intracerebral microdialysis is routinely used to monitor cerebral energy metabolism, and recent experimental studies indicate that this technique may separate ischemia and non-ischemic mitochondrial dysfunction. The present study is a retrospective interpretation of biochemical data obtained in a series of patients with severe community-acquired meningitis. METHODS Cerebral energy metabolism was monitored in 15 patients with severe community-acquired meningitis utilizing intracerebral microdialysis and bedside biochemical analysis. According to previous studies, cerebral ischemia was defined as lactate/pyruvate (LP) ratio > 30 with intracerebral pyruvate level < 70 µmol L(-1). Non-ischemic mitochondrial dysfunction was defined as LP-ratio > 30 at a normal or increased interstitial concentration of pyruvate (≥ 70 μmol L(-1)). Patients with LP-ratios < 30 were classified as no mitochondrial dysfunction. RESULTS The biochemical pattern was in 8 patients (10 microdialysis catheters) classified as no mitochondrial dysfunction, in 5 patients classified as non-ischemic mitochondrial dysfunction, and in 2 patients (3 catheters) classified as ischemia. CONCLUSIONS In patients with severe community-acquired meningitis, compromised cerebral energy metabolism occurs frequently and was diagnosed in 7 out of 15 cases. A biochemical pattern of non-ischemic mitochondrial dysfunction appears to be a more common underlying condition than cerebral ischemia.
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Affiliation(s)
- Frantz R Poulsen
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
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50
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Quintard H, Patet C, Zerlauth JB, Suys T, Bouzat P, Pellerin L, Meuli R, Magistretti PJ, Oddo M. Improvement of Neuroenergetics by Hypertonic Lactate Therapy in Patients with Traumatic Brain Injury Is Dependent on Baseline Cerebral Lactate/Pyruvate Ratio. J Neurotrauma 2015; 33:681-7. [PMID: 26421521 PMCID: PMC4827289 DOI: 10.1089/neu.2015.4057] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Energy dysfunction is associated with worse prognosis after traumatic brain injury (TBI). Recent data suggest that hypertonic sodium lactate infusion (HL) improves energy metabolism after TBI. Here, we specifically examined whether the efficacy of HL (3h infusion, 30–40 μmol/kg/min) in improving brain energetics (using cerebral microdialysis [CMD] glucose as a main therapeutic end-point) was dependent on baseline cerebral metabolic state (assessed by CMD lactate/pyruvate ratio [LPR]) and cerebral blood flow (CBF, measured with perfusion computed tomography [PCT]). Using a prospective cohort of 24 severe TBI patients, we found CMD glucose increase during HL was significant only in the subgroup of patients with elevated CMD LPR >25 (n = 13; +0.13 [95% confidence interval (CI) 0.08–0.19] mmol/L, p < 0.001; vs. +0.04 [–0.05–0.13] in those with normal LPR, p = 0.33, mixed-effects model). In contrast, CMD glucose increase was independent from baseline CBF (coefficient +0.13 [0.04–0.21] mmol/L when global CBF was <32.5 mL/100 g/min vs. +0.09 [0.04–0.14] mmol/L at normal CBF, both p < 0.005) and systemic glucose. Our data suggest that improvement of brain energetics upon HL seems predominantly dependent on baseline cerebral metabolic state and support the concept that CMD LPR – rather than CBF – could be used as a diagnostic indication for systemic lactate supplementation following TBI.
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Affiliation(s)
- Hervé Quintard
- 1 Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland .,2 Department of Anesthesia and Intensive Care, Nice University Hospital , Nice, France
| | - Camille Patet
- 1 Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland
| | - Jean-Baptiste Zerlauth
- 3 Department of Medical Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland
| | - Tamarah Suys
- 1 Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland
| | - Pierre Bouzat
- 1 Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland .,4 Department of Anesthesia and Intensive Care, Grenoble University Hospital , Grenoble, France
| | - Luc Pellerin
- 5 Institute of Physiology, University of Lausanne , Lausanne, Switzerland
| | - Reto Meuli
- 3 Department of Medical Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland
| | - Pierre J Magistretti
- 6 Division of Biological and Environmental Sciences and Engineering, King Abdullah University of Science and Technology (KAUST) , Thuwal, Kingdom of Saudi Arabia .,7 Centre de Neurosciences Psychiatriques, Department of Psychiatry, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland .,8 Laboratory of Neuroenergetics and Cellular Dynamics, Brain Mind Institute , Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Mauro Oddo
- 1 Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland
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