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Zhang M, Liu R, Wang Y, Zhu X, Wang Z, Li X, Zheng L. Safety, tolerability, and pharmacokinetic of HY0721 in Chinese healthy subjects: A first-in-human randomized, double-blind, placebo-controlled dose escalation phase I study. Eur J Pharm Sci 2024; 200:106832. [PMID: 38878907 DOI: 10.1016/j.ejps.2024.106832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/15/2024] [Accepted: 06/12/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND HY0721 is a novel inhibitor of sulfonylurea receptor 1-transient receptor potential melastatin 4 (SUR1-TRPM4) for the treatment of acute ischemic stroke. This study aimed to evaluate the safety, tolerability, and pharmacokinetic (PK) profiles of single and multiple intravenous administration of HY0721 in Chinese healthy subjects. METHODS The study enrolled 48 and 30 healthy volunteers in the single-ascending dose (SAD) cohort (20, 60, 120, 240, and 320 mg) and multiple-ascending dose (MAD) cohort (60, 120, and 160 mg/bid), respectively, to receive the corresponding dosage of HY0721 or placebo. Safety monitoring included but was not limited to recording adverse events (AEs), vital signs, electrocardiograms, and laboratory tests. The blood samples were collected from subjects to determine the concentrations of HY0721 for PK evaluation. RESULTS The administration of HY0721 showed good safety and tolerability up to 320 mg in the SAD study and up to 160 mg twice daily in the MAD study. The most common AE was injection site reaction, and no AE led to discontinuation of administration or subject dropout. The exposures of HY0721 increased greater than dose proportional manner at the dosages of 20 to 320 mg in the SAD study. A linear PK profile was observed following multiple doses ranging from 60 to 160 mg twice daily, with no evidence of accumulation. Additionally, the human effective dose of HY0721 was estimated to be 120 mg. CONCLUSION This study demonstrated the intravenous administration of HY0721 is safe and well-tolerated in Chinese healthy subjects and provided 60 to 160 mg b.i.d. as the recommended dosing range for further clinical trials. TRIAL REGISTRATION ChinaDrugTrials.Org.cn; No. CTR20202604, 18 December 2020.
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Affiliation(s)
- Mengyu Zhang
- Department of Neurology, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; Clinical Trial Center, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China
| | - Runhan Liu
- Department of Neurology, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; Clinical Trial Center, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China
| | - Ying Wang
- Department of Neurology, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; Clinical Trial Center, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China
| | - Xiaohong Zhu
- Department of Neurology, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; Clinical Trial Center, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China
| | - Zhenlei Wang
- Department of Neurology, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; Clinical Trial Center, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China
| | - Xiaoyu Li
- Department of Neurology, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; Clinical Trial Center, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China
| | - Li Zheng
- Department of Neurology, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; Clinical Trial Center, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China; NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital of Sichuan University, No.5 Telecom Road, Wuhou District, Chengdu 610041, Sichuan Province, China.
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Comparison of Equiosmolar Doses of 7.5% Hypertonic Saline and 20% Mannitol on Cerebral Oxygenation Status and Release of Brain Injury Markers During Supratentorial Craniotomy: A Randomized Controlled Trial. J Neurosurg Anesthesiol 2023; 35:56-64. [PMID: 34267156 DOI: 10.1097/ana.0000000000000791] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hyperosmolar therapy is the mainstay of treatment to reduce brain bulk and optimize surgical exposure during craniotomy. This study investigated the effect of equiosmolar doses of 7.5% hypertonic saline (HTS) and 20% mannitol on intraoperative cerebral oxygenation and metabolic status, systemic hemodynamics, brain relaxation, markers of cerebral injury, and perioperative craniotomy outcomes. METHODS A total of 51 patients undergoing elective supratentorial craniotomy were randomly assigned to receive 7.5% HTS (2 mL/kg) or 20% mannitol (4.6 mL/kg) at scalp incision. Intraoperative arterial and jugular bulb blood samples were collected at predefined time intervals for assessment of various indices of cerebral oxygenation; multiple hemodynamic variables were concomitantly recorded. S100B protein and neuron-specific enolase levels were determined at baseline, and at 6 and 12 hours after surgery for assessment of neuronal injury. Brain relaxation and perioperative outcomes were also assessed. RESULTS Demographic and intraoperative data, brain relaxation score, and perioperative outcomes were comparable between groups. Jugular bulb oxygen saturation and partial pressure of oxygen, arterial-jugular oxygen and carbon dioxide differences, and brain oxygen extraction ratio were favorably affected by 7.5% HTS up to 240 minutes postinfusion ( P <0.05), whereas mannitol was associated with only a short-lived (up to 15 min) improvement of these indices ( P <0.05). The changes in cerebral oxygenation corresponded to transient expansion of intravascular volume and improvements of cardiovascular performance. Increases in S100B and neuron-specific enolase levels at 6 and 12 hours after surgery ( P <0.0001) were comparable between groups. CONCLUSIONS The conclusion is that 7.5% HTS has a more beneficial effect on cerebral oxygenation than an equiosmolar dose of 20% mannitol during supratentorial craniotomy, yet no clear-cut clinical superiority of either solution could be demonstrated.
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Chen X, Józsa TI, Payne SJ. Computational modelling of cerebral oedema and osmotherapy following ischaemic stroke. Comput Biol Med 2022; 151:106226. [PMID: 36343409 DOI: 10.1016/j.compbiomed.2022.106226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/11/2022] [Accepted: 10/15/2022] [Indexed: 12/27/2022]
Abstract
In ischaemic stroke, a large reduction in blood supply can lead to the breakdown of the blood brain barrier and to cerebral oedema after reperfusion therapy. Cerebral oedema is marked by elevated intracranial pressure (ICP), tissue herniation and reduced cerebral perfusion pressure. In clinical settings, osmotherapy has been a common practice to decrease ICP. However, there are no guidelines on the choice of administration protocol parameters such as injection doses, infusion time and retention time. Most importantly, the effects of osmotherapy have been proven controversial since the infusion of osmotic agents can lead to a range of side effects. Here, a new Finite Element model of brain oedema and osmotherapy is thus proposed to predict treatment outcome. The model consists of three components that simulate blood perfusion, oedema, and osmotherapy, respectively. In the perfusion model (comprising arteriolar, venous, and capillary blood compartments), an anatomically accurate brain geometry is used to identify regions with a perfusion reduction and potential oedema occurrence in stroke. The oedema model is then used to predict ICP using a porous circulation model with four fluid compartments (arteriolar blood, venular blood, capillary blood, and interstitial fluid). In the osmotherapy model, the osmotic pressure is varied and the changes in ICP during different osmotherapy episodes are quantified. The simulation results of the model show excellent agreement with available clinical data and the model is employed to study osmotherapy under various parameters. Consequently, it is demonstrated how therapeutic strategies can be proposed for patients with different pathological parameters based on simulations.
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Affiliation(s)
- Xi Chen
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Parks Road, Oxford, OX1 3PJ, United Kingdom
| | - Tamás I Józsa
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Parks Road, Oxford, OX1 3PJ, United Kingdom; Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, location VUmc, Amsterdam Neuroscience, De Boelelaan 1117, 1118, 1081 HV Amsterdam, the Netherlands
| | - Stephen J Payne
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Parks Road, Oxford, OX1 3PJ, United Kingdom; Institute of Applied Mechanics, National Taiwan University, Roosevelt Road, Da'an Dist., Taipei City, 106, Taiwan.
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Liu J, Chu C, Zhang J, Bie C, Chen L, Aafreen S, Xu J, Kamson DO, van Zijl PCM, Walczak P, Janowski M, Liu G. Label-Free Assessment of Mannitol Accumulation Following Osmotic Blood-Brain Barrier Opening Using Chemical Exchange Saturation Transfer Magnetic Resonance Imaging. Pharmaceutics 2022; 14:pharmaceutics14112529. [PMID: 36432721 PMCID: PMC9695341 DOI: 10.3390/pharmaceutics14112529] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/02/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Mannitol is a hyperosmolar agent for reducing intracranial pressure and inducing osmotic blood-brain barrier opening (OBBBO). There is a great clinical need for a non-invasive method to optimize the safety of mannitol dosing. The aim of this study was to develop a label-free Chemical Exchange Saturation Transfer (CEST)-based MRI approach for detecting intracranial accumulation of mannitol following OBBBO. METHODS In vitro MRI was conducted to measure the CEST properties of D-mannitol of different concentrations and pH. In vivo MRI and MRS measurements were conducted on Sprague-Dawley rats using a Biospec 11.7T horizontal MRI scanner. Rats were catheterized at the internal carotid artery (ICA) and randomly grouped to receive either 1 mL or 3 mL D-mannitol. CEST MR images were acquired before and at 20 min after the infusion. RESULTS In vitro MRI showed that mannitol has a strong, broad CEST contrast at around 0.8 ppm with a mM CEST MRI detectability. In vivo studies showed that CEST MRI could effectively detect mannitol in the brain. The low dose mannitol treatment led to OBBBO but no significant mannitol accumulation, whereas the high dose regimen resulted in both OBBBO and mannitol accumulation. The CEST MRI findings were consistent with 1H-MRS and Gd-enhanced MRI assessments. CONCLUSION We demonstrated that CEST MRI can be used for non-invasive, label-free detection of mannitol accumulation in the brain following BBBO treatment. This method may be useful as a rapid imaging tool to optimize the dosing of mannitol-based OBBBO and improve its safety and efficacy.
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Affiliation(s)
- Jing Liu
- Department of Radiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510230, China
- Russell H. Morgan Department of Radiology and Radiological Sciences, Division of MR Research, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD 21205, USA
| | - Chengyan Chu
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD 21201, USA
| | - Jia Zhang
- Russell H. Morgan Department of Radiology and Radiological Sciences, Division of MR Research, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD 21205, USA
| | - Chongxue Bie
- Russell H. Morgan Department of Radiology and Radiological Sciences, Division of MR Research, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD 21205, USA
| | - Lin Chen
- Russell H. Morgan Department of Radiology and Radiological Sciences, Division of MR Research, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD 21205, USA
| | - Safiya Aafreen
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Jiadi Xu
- Russell H. Morgan Department of Radiology and Radiological Sciences, Division of MR Research, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD 21205, USA
| | - David O. Kamson
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21218, USA
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Peter C. M. van Zijl
- Russell H. Morgan Department of Radiology and Radiological Sciences, Division of MR Research, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD 21205, USA
| | - Piotr Walczak
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD 21201, USA
| | - Miroslaw Janowski
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD 21201, USA
| | - Guanshu Liu
- Russell H. Morgan Department of Radiology and Radiological Sciences, Division of MR Research, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD 21205, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21218, USA
- Correspondence: ; Tel.: +1-443-923-9500; Fax: +1-410-614-3147
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Alanazi AH, Adil MS, Lin X, Chastain DB, Henao-Martínez AF, Franco-Paredes C, Somanath PR. Elevated Intracranial Pressure in Cryptococcal Meningoencephalitis: Examining Old, New, and Promising Drug Therapies. Pathogens 2022; 11:783. [PMID: 35890028 PMCID: PMC9321092 DOI: 10.3390/pathogens11070783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/02/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
Despite the availability of effective antifungal therapy, cryptococcal meningoencephalitis (CM) remains associated with elevated mortality. The spectrum of symptoms associated with the central nervous system (CNS) cryptococcosis is directly caused by the high fungal burden in the subarachnoid space and the peri-endothelial space of the CNS vasculature, which results in intracranial hypertension (ICH). Management of intracranial pressure (ICP) through aggressive drainage of cerebrospinal fluid by lumbar puncture is associated with increased survival. Unfortunately, these procedures are invasive and require specialized skills and supplies that are not readily available in resource-limited settings that carry the highest burden of CM. The institution of pharmacologic therapies to reduce the production or increase the resorption of cerebrospinal fluid would likely improve clinical outcomes associated with ICH in patients with CM. Here, we discuss the potential role of multiple pharmacologic drug classes such as diuretics, corticosteroids, and antiepileptic agents used to decrease ICP in various neurological conditions as potential future therapies for CM.
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Affiliation(s)
- Abdulaziz H. Alanazi
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA 30902, USA; (A.H.A.); (M.S.A.)
- Research Department, Charlie Norwood VA Medical Center, Augusta, GA 30912, USA
| | - Mir S. Adil
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA 30902, USA; (A.H.A.); (M.S.A.)
- Research Department, Charlie Norwood VA Medical Center, Augusta, GA 30912, USA
| | - Xiaorong Lin
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA;
| | - Daniel B. Chastain
- Department of Clinical and Administrative Pharmacy, UGA College of Pharmacy, SWGA Clinical Campus, Phoebe Putney Memorial Hospital, Albany, GA 31701, USA;
| | - Andrés F. Henao-Martínez
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; (A.F.H.-M.); (C.F.-P.)
| | - Carlos Franco-Paredes
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; (A.F.H.-M.); (C.F.-P.)
- Hospital Infantil de México, Federico Gómez, Ciudad de México 06720, Mexico
| | - Payaningal R. Somanath
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA 30902, USA; (A.H.A.); (M.S.A.)
- Research Department, Charlie Norwood VA Medical Center, Augusta, GA 30912, USA
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Zeng M, Zhou H, He Y, Du H, Yin J, Hou Y, Zhu J, Zhang Y, Shao C, Yang J, Wan H. Danhong injection enhances the therapeutic effect of mannitol on hemispheric ischemic stroke by ameliorating blood-brain barrier disruption. Biomed Pharmacother 2021; 142:112048. [PMID: 34435588 DOI: 10.1016/j.biopha.2021.112048] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 01/01/2023] Open
Abstract
Mannitol, a representative of hyperosmolar therapy, is indispensable for the treatment of malignant cerebral infarction, but its therapeutic effect is limited by its exacerbation of blood-brain barrier (BBB) disruption. This study was to explore whether Danhong injection (DHI), a standardized product extracted from Salvia miltiorrhiza Bunge and Carthamus tinctorius L., inhibits the destructive effect of mannitol on BBB and thus enhancing the treatment of hemispheric ischemic stroke. SD rats were subjected to pMCAO followed by intravenous bolus injections of mannitol with/without DHI intervention. Neurological deficit score, brain edema, infarct volume at 24 h after MCAO and histopathology, microvascular ultrastructure, immunohistochemistry and immunofluorescence staining of endothelial cell junctions, energy metabolism in the ischemic penumbra were assessed. Intravenous mannitol after MCAO resulted in a decrease in 24 h mortality and cerebral edema, whereas no significant benefit on neurological deficits, infarct volume and microvascular ultrastructure. Moreover, mannitol led to the loss of endothelial integrity, manifested by the decreased expression of occludin, junctional adhesion molecule-1 (JAM-1) and zonula occluden-1 (ZO-1) and the discontinuity of occludin staining around the periphery of endothelial cells. Meanwhile, after mannitol treatment, energy-dependent vimentin and F-actin, ATP content, and ATP5D expression were down-regulated, while MMP2 and MMP9 expression increased in the ischemic penumbra. All the insults after mannitol treatment were attenuated by addition of intravenous DHI. The results suggest DHI as a potential remedy to attenuate mannitol-related BBB disruption, and the potential of DHI to upregulate energy metabolism and inhibit the activity of MMPs is likely attributable to its effects observed.
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Affiliation(s)
- Miaolin Zeng
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Huifen Zhou
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yu He
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Haixia Du
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Junjun Yin
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yongchun Hou
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Jiaqi Zhu
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yangyang Zhang
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Chongyu Shao
- Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Jiehong Yang
- Zhejiang Chinese Medical University, Hangzhou 310053, China.
| | - Haitong Wan
- Zhejiang Chinese Medical University, Hangzhou 310053, China.
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Wiórek A, Jaworski T, Krzych ŁJ. Hyperosmolar Treatment for Patients at Risk for Increased Intracranial Pressure: A Single-Center Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4573. [PMID: 32630399 PMCID: PMC7345768 DOI: 10.3390/ijerph17124573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/16/2020] [Accepted: 06/23/2020] [Indexed: 12/16/2022]
Abstract
Treatment with osmoactive agents such as mannitol or hypertonic saline (HTS) solutions is widely used to manage or prevent the increase of intracranial pressure (ICP) in central nervous system (CNS) disorders. We sought to evaluate the variability and mean plasma concentrations of the water and electrolyte balance parameters in critically ill patients treated with osmotic therapy and their influence on mortality. This cohort study covered patients hospitalized in an intensive care unit (ICU) from January 2017 to June 2019 with presumed increased ICP or considered to be at risk of it, treated with 15% mannitol (G1, n = 27), a combination of 15% mannitol and 10% hypertonic saline (HTS) (G2, n = 33) or 10% HTS only (G3, n = 13). Coefficients of variation (Cv) and arithmetic means (mean) were calculated for the parameters reflecting the water and electrolyte balance, i.e., sodium (NaCv/NaMean), chloride (ClCv/ClMean) and osmolality (mOsmCv/mOsmMean). In-hospital mortality was also analyzed. The study group comprised 73 individuals (36 men, 49%). Mortality was 67% (n = 49). Median NaCv (G1: p = 0.002, G3: p = 0.03), ClCv (G1: p = 0.02, G3: p = 0.04) and mOsmCv (G1: p = 0.001, G3: p = 0.02) were higher in deceased patients. NaMean (p = 0.004), ClMean (p = 0.04), mOsmMean (p = 0.003) were higher in deceased patients in G3. In G1: NaCv (AUC = 0.929, p < 0.0001), ClCv (AUC = 0.817, p = 0.0005), mOsmCv (AUC = 0.937, p < 0.0001) and in G3: NaMean (AUC = 0.976, p < 0.001), mOsmCv (AUC = 0.881, p = 0.002), mOsmMean (AUC = 1.00, p < 0.001) were the best predictors of mortality. The overall mortality prediction for combined G1+G2+G3 was very good, with AUC = 0.886 (p = 0.0002). The mortality of critically ill patients treated with osmotic agents is high. Electrolyte disequilibrium is the independent predictor of mortality regardless of the treatment method used. Variations of plasma sodium, chloride and osmolality are the most deleterious factors regardless of the absolute values of these parameters.
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Affiliation(s)
- Agnieszka Wiórek
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 14 Medyków Street, 40–752 Katowice, Poland;
| | | | - Łukasz J. Krzych
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 14 Medyków Street, 40–752 Katowice, Poland;
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8
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Ong C, Hutch M, Barra M, Kim A, Zafar S, Smirnakis S. Effects of Osmotic Therapy on Pupil Reactivity: Quantification Using Pupillometry in Critically Ill Neurologic Patients. Neurocrit Care 2020; 30:307-315. [PMID: 30298336 DOI: 10.1007/s12028-018-0620-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Osmotic therapy is a critical component of medical management for cerebral edema. While up to 90% of neurointensivists report using these treatments, few quantitative clinical measurements guide optimal timing, dose, or administration frequency. Its use is frequently triggered by a qualitative assessment of neurologic deterioration and/or pupil size, and anecdotally appears to improve pupil asymmetry suggestive of uncal herniation. However, subjective pupil assessment has poor reliability, making it difficult to detect or track subtle changes. We hypothesized that osmotic therapy reproducibly improves quantitative pupil metrics. METHODS We included patients at two centers who had recorded quantitative pupil measurements within 2 h before and after either 20% mannitol or 23.4% hypertonic saline in the neurosciences intensive care unit. The primary outcome was the Neurologic Pupil Index (NPi), a composite metric ranging from 0 to 5 in which > 3 is considered normal. Secondary outcomes included pupil size, percent change, constriction and dilation velocity, and latency. Results were analyzed with Wilcoxon signed-rank tests, Chi-square and multi-level linear regression to control for other edema-reducing interventions. RESULTS Out of 72 admissions (403 paired pupil observations), NPi significantly differed within 2 h of osmotic therapy when controlling for other commonly used interventions in our whole cohort (β = 0.08, p = 0.0168). The effect was most pronounced (β = 0.57) in patients with abnormal NPi prior to intervention (p = 0.0235). CONCLUSIONS Pupil reactivity significantly improves after osmotic therapy in a heterogenous critically ill population when controlling for various other interventions. Future work is necessary to determine dose-dependent effects and clinical utility.
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Affiliation(s)
- C Ong
- Boston University School of Medicine, Boston, USA.
- Brigham and Women's Hospital, Boston, USA.
- Harvard Medical School, Boston, USA.
| | - M Hutch
- Boston University School of Medicine, Boston, USA
| | - M Barra
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - A Kim
- Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - S Zafar
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - S Smirnakis
- Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
- Jamaica Plain VA Hospital, Boston, USA
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9
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Huang K, Zhou L, Alanis K, Hou J, Baker LA. Imaging effects of hyperosmolality on individual tricellular junctions. Chem Sci 2019; 11:1307-1315. [PMID: 33209250 PMCID: PMC7643560 DOI: 10.1039/c9sc05114g] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/10/2019] [Indexed: 01/26/2023] Open
Abstract
A nanoscale electrochemical imaging method was used to reveal heterogeneity present in conductance at epithelial cell junctions under hyperosmotic stress.
The use of hyperosmolar agents (osmotherapy) has been a major treatment for intracranial hypertension, which occurs frequently in brain diseases or trauma. However, side-effects of osmotherapy on the brain, especially on the blood–brain barrier (BBB) are still not fully understood. Hyperosmolar conditions, termed hyperosmolality here, are known to transiently disrupt the tight junctions (TJs) at the endothelium of the BBB resulting in loss of BBB function. Present techniques for evaluation of BBB transport typically reveal aggregated responses from the entirety of BBB transport components, with little or no opportunity to evaluate heterogeneity present in the system. In this study, we utilized potentiometric-scanning ion conductance microscopy (P-SICM) to acquire nanometer-scale conductance maps of Madin–Darby Canine Kidney strain II (MDCKII) cells under hyperosmolality, from which two types of TJs, bicellular tight junctions (bTJs) and tricellular tight junctions (tTJs), can be visualized and differentiated. We discovered that hyperosmolality leads to increased conductance at tTJs without significant alteration in conductance at bTJs. To quantify this effect, an automated computer vision algorithm was designed to extract and calculate conductance components at both tTJs and bTJs. Additionally, lowering Ca2+ concentration in the bath facilitates tTJ disruption under hyperosmolality. Strengthening tTJ structure by overexpressing immunoglobulin-like domain-containing receptor 1 (ILDR1) protein abrogates the effect of hyperosmolality. We posit that osmotic stress physically disrupts tTJ structure, as evidenced by super-resolution microscopy. Findings from this study not only provide a high-resolution view of TJ structure and function, but also can inform current osmotherapy and drug delivery strategies for brain diseases.
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Affiliation(s)
- Kaixiang Huang
- Department of Chemistry , Indiana University , 800 E. Kirkwood Avenue , Bloomington , Indiana 47405 , USA .
| | - Lushan Zhou
- Department of Chemistry , Indiana University , 800 E. Kirkwood Avenue , Bloomington , Indiana 47405 , USA .
| | - Kristen Alanis
- Department of Chemistry , Indiana University , 800 E. Kirkwood Avenue , Bloomington , Indiana 47405 , USA .
| | - Jianghui Hou
- Renal Division , Washington University Medical School , 660 S. Euclid Avenue , St. Louis , Missouri 63110 , USA
| | - Lane A Baker
- Department of Chemistry , Indiana University , 800 E. Kirkwood Avenue , Bloomington , Indiana 47405 , USA .
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Ma P, Zha S, Shen X, Zhao Y, Li L, Yang L, Lei M, Liu W. NFAT5 mediates hypertonic stress-induced atherosclerosis via activating NLRP3 inflammasome in endothelium. Cell Commun Signal 2019; 17:102. [PMID: 31429763 PMCID: PMC6701070 DOI: 10.1186/s12964-019-0406-7] [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] [Received: 03/28/2019] [Accepted: 07/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND How high-salt intake leads to the occurrence of many cardiovascular diseases such as atherosclerosis is a fundamental question in pathology. Here we postulated that high-salt-induced NFAT5 controls the inflammasome activation by directly regulating NLRP3, which mediates the expression of inflammatory- and adhesion-related genes in vascular endothelium, resulting in the formation of atherosclerosis. METHODS Atherosclerosis-prone apolipoprotein E-deficient (ApoE-/-) mice which accumulate cholesterol ester-enriched particles in the blood due to poor lipoprotein clearance capacity were used as the atherosclerosis model in vivo. Cultured endothelial cells (ECs) and monocytes under high-salt condition were used to explore the atheroprone role of the activation of NFAT5-NLRP3 inflammasome in vascular endothelium in vitro. Bioinformatic analysis and chromatin immunoprecipitation assay were used to identify the DNA binding sites of NFAT5 on promoters of NLRP3 and IL-1β. RESULTS We first observe that high-salt intake promotes atherosclerosis formation in the aortas of ApoE-/- mice, through inducing the expression of NFAT5, NLRP3, and IL-1β in endothelium. Overexpression of NFAT5 activates NLRP3-inflammasome and increases the secretion of IL-1β in ECs partly via ROS. Chromatin immunoprecipitation assay demonstrates that NFAT5 directly binds to the promoter regions of NLRP3 and IL-1β in endothelial cells subjected to the high-salt environment. CONCLUSIONS Our study identifies NFAT5 as a new and essential transcription factor that is required for the early activation of NLRP3-inflammasome-mediated endothelium innate immunity, contributing to the formation of atherosclerosis under hypertonic stress induction.
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Affiliation(s)
- Pingping Ma
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Shenfang Zha
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Xinkun Shen
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Yulan Zhao
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Li Li
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Li Yang
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China
| | - Mingxing Lei
- Integrative Stem Cell Center, China Medical University Hospital, China Medical University, Taichung, 40402, Taiwan. .,Institute of New Drug Development, College of Biopharmaceutical and Food Sciences, China Medical University, Taichung, 40402, Taiwan.
| | - Wanqian Liu
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, Bioengineering College, Chongqing University, Chongqing, 400044, China.
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Mousa SA, Ramadan TH, Kassem M. Brain relaxation and electrolyte balance during resection of posterior fossa tumors under sitting position: Mannitol versus placebo. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Sherif Abdo Mousa
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine , Mansoura University , Egypt
| | - Tarek Habeeb Ramadan
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine , Mansoura University , Egypt
| | - Mohamed Kassem
- Neurosurgery Department, Faculty of Medicine , Mansoura University , Egypt
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Mannitol Improves Intraoperative Brain Relaxation in Patients With a Midline Shift Undergoing Supratentorial Tumor Surgery: A Randomized Controlled Trial. J Neurosurg Anesthesiol 2019; 32:307-314. [DOI: 10.1097/ana.0000000000000585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Predicting cerebral edema in ischemic stroke patients. Neurol Sci 2019; 40:745-752. [PMID: 30659418 DOI: 10.1007/s10072-019-3717-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/10/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To produce a scoring system for predicting the development of edema in ischemic stroke patients without edema on admission. METHODS This retrospective study included 572 ischemic stroke patients (73.3 ± 13.0 years, 300 male) without signs of cerebral edema on the first CT scan, which was performed on admission. Another scan was normally performed 3 days later, and subsequently whenever needed. Edema was defined as cerebral hypodensity with compression of lateral ventricles. The main clinical, laboratory, and instrumental variables obtained during the first 24 h were related to the appearance of edema on the CT scans performed after the first one. RESULTS Cerebral edema occurred in 158 patients (27.6%) after a median time of 4 days. The variables independently associated with edema development were (odds ratio, 95% CI) the following: (1) total anterior circulation syndrome (4.20, 2.55-6.93; P < 0.0001), (2) hyperdense appearance of middle cerebral artery (4.12, 2.03-8.36; P = 0.0001), (3) closed eyes (2.53, 1.39-4.60; P = 0.002), (4) vomiting (3.53, 1.45-8.60; P = 0.006), (5) lacunar cerebral syndrome (0.36, 0.17-0.77; P = 0.008); and (6) white matter lesions (0.53, 0.33-0.86; P = 0.01). Counting one positive point for the first four variables and one negative point for the last two variables, a scoring system (E-score) was built. Cerebral edema could be predicted when the score was ≥ 1 (positive predictive value 61.6%, specificity 85.3%, sensitivity 62.0%). The area under the receiver operating characteristic curve was 0.78. CONCLUSIONS In ischemic stroke patients, six variables obtained during the first 24 h of hospitalization were predictive of subsequent cerebral edema development.
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Utagawa A. Fluid Management for Neurocritical Care. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Wall J, Enblad P. Neurointensive care of patients with cerebral venous sinus thrombosis and intracerebral haemorrhage. J Clin Neurosci 2018; 58:83-88. [PMID: 30340972 DOI: 10.1016/j.jocn.2018.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 09/25/2018] [Accepted: 10/03/2018] [Indexed: 11/19/2022]
Abstract
The aim was to review the neurointensive care (NIC) of cerebral venous sinus thrombosis patients with haemorrhage during a 15-year period. This is a severe condition with substantial mortality caused by increased intracranial pressure (ICP) and studies are lacking describing the complex picture of the NIC, which offers a large treatment arsenal for intracranial hypertension. Patients treated 2000-2015 were investigated. Data regarding patient characteristics, symptoms, imaging, ICP-treatment, NIC-treatment intensity, and outcome were collected and analysed. Twenty-four patients (13 women) were studied, mean age 46 (range 16-75). Twenty patients were in Glasgow coma scale motor score 6 (obeys), 2 in score 5 (localizes) and 2 in score 2 (extension) on admission. Mean haemorrhage volume was 17 ml (range 1-70). Twenty patients (83%) received unfractionated heparin and 3 (13%) low molecular weight heparin. Haemorrhagic progression occurred in 10 patients (42%). In 9 patients (38%), 4-6 of the treatment options mechanical ventilation, hyperventilation, ICP-monitoring, cerebrospinal fluid-drainage, osmotherapy, barbiturates or surgery were used. In 3 patients mechanical ventilation only was used (hyperventilation in 1). Twelve patients were not managed with any of those treatment options. At follow up, 15/24 patients (62%) had favourable outcome (4 missing). The study shows that many patients needed multiple actions to treat intracranial preassure but more than 60% achieved favourable clinical outcome. Preferably, patients with cerebral venous sinus thrombosis and haemorrhage who are awake should have fast access to NIC because it appears difficult to predict who will deteriorate and promptly need NIC treatment.
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Affiliation(s)
- Jacob Wall
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden.
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Bosma EK, van Noorden CJF, Schlingemann RO, Klaassen I. The role of plasmalemma vesicle-associated protein in pathological breakdown of blood-brain and blood-retinal barriers: potential novel therapeutic target for cerebral edema and diabetic macular edema. Fluids Barriers CNS 2018; 15:24. [PMID: 30231925 PMCID: PMC6146740 DOI: 10.1186/s12987-018-0109-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 08/10/2018] [Indexed: 12/14/2022] Open
Abstract
Breakdown of the blood–brain barrier (BBB) or inner blood–retinal barrier (BRB), induced by pathologically elevated levels of vascular endothelial growth factor (VEGF) or other mediators, can lead to vasogenic edema and significant clinical problems such as neuronal morbidity and mortality, or vision loss. Restoration of the barrier function with corticosteroids in the brain, or by blocking VEGF in the eye are currently the predominant treatment options for brain edema and diabetic macular edema, respectively. However, corticosteroids have side effects, and VEGF has important neuroprotective, vascular protective and wound healing functions, implying that long-term anti-VEGF therapy may also induce adverse effects. We postulate that targeting downstream effector proteins of VEGF and other mediators that are directly involved in the regulation of BBB and BRB integrity provide more attractive and safer treatment options for vasogenic cerebral edema and diabetic macular edema. The endothelial cell-specific protein plasmalemma vesicle-associated protein (PLVAP), a protein associated with trans-endothelial transport, emerges as candidate for this approach. PLVAP is expressed in a subset of endothelial cells throughout the body where it forms the diaphragms of caveolae, fenestrae and trans-endothelial channels. However, PLVAP expression in brain and eye barrier endothelia only occurs in pathological conditions associated with a compromised barrier function such as cancer, ischemic stroke and diabetic retinopathy. Here, we discuss the current understanding of PLVAP as a structural component of endothelial cells and regulator of vascular permeability in health and central nervous system disease. Besides providing a perspective on PLVAP identification, structure and function, and the regulatory processes involved, we also explore its potential as a novel therapeutic target for vasogenic cerebral edema and retinal macular edema.
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Affiliation(s)
- Esmeralda K Bosma
- Ocular Angiogenesis Group, Departments of Ophthalmology and Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Cornelis J F van Noorden
- Ocular Angiogenesis Group, Departments of Ophthalmology and Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Genetic Toxicology and Cancer Biology, National Institute of Biology, Ljubljana, Slovenia
| | - Reinier O Schlingemann
- Ocular Angiogenesis Group, Departments of Ophthalmology and Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital, Fondation Asile des Aveugles, Lausanne, Switzerland
| | - Ingeborg Klaassen
- Ocular Angiogenesis Group, Departments of Ophthalmology and Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands. .,Ocular Angiogenesis Group, Department of Medical Biology, Amsterdam UMC, University of Amsterdam, Meibergdreef 15, Room L3-154, 1105 AZ, Amsterdam, The Netherlands.
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Manrique-Carmona LP, Pérez-Neri I. Pathophysiology and Treatment of Peritumoral Brain Edema: Possible Effect of Lidocaine. NEUROCHEM J+ 2018. [DOI: 10.1134/s1819712418010099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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18
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Shah M, Birnbaum L, Rasmussen J, Sekar P, Moomaw CJ, Osborne J, Vashkevich A, Woo D. Effect of Hyperosmolar Therapy on Outcome Following Spontaneous Intracerebral Hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study. J Stroke Cerebrovasc Dis 2018; 27:1061-1067. [PMID: 29305272 PMCID: PMC5845468 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 11/02/2017] [Accepted: 11/10/2017] [Indexed: 12/29/2022] Open
Abstract
PURPOSE We aimed to identify the effect of hyperosmolar therapy (mannitol and hypertonic saline) on outcomes after intracerebral hemorrhage (ICH) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study. METHODS Comparison of ICH cases treated with hyperosmolar therapy versus untreated cases was performed using a propensity score based on age, initial Glasgow Coma Scale, location of ICH (lobar, deep, brainstem, and cerebellar), log-transformed initial ICH volume, presence of intraventricular hemorrhage, and surgical interventions. ERICH subjects with a pre-ICH modified Rankin Scale (mRS) score of 3 or lower were included. Treated cases were matched 1:1 to untreated cases by the closest propensity score (difference ≤.15), gender, and race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic). The McNemar and the Wilcoxon signed-rank tests were used to compare 3-month mRS outcomes between the 2 groups. Good outcome was defined as a 3-month mRS score of 3 or lower. RESULTS As of December 31, 2013, the ERICH study enrolled 2279 cases, of which 304 hyperosmolar-treated cases were matched to 304 untreated cases. Treated cases had worse outcome at 3 months compared with untreated cases (McNemar, P = .0326), and the mean 3-month mRS score was lower in the untreated group (Wilcoxon, P = .0174). Post hoc analysis revealed more brain edema, herniation, and death at discharge for treated cases. CONCLUSIONS Hyperosmolar therapy was not associated with better 3-month mRS outcomes for ICH cases in the ERICH study. This finding likely resulted from greater hyperosmolar therapy use in patients with edema and herniation rather than those agents leading to worse outcomes. Further studies should be performed to determine if hyperosmolar agents are effective in preventing poor outcomes.
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Affiliation(s)
- Manan Shah
- Department of Neurology, UT Health Houston, Houston, Texas
| | - Lee Birnbaum
- Department of Neurology, UT Health San Antonio, San Antonio, Texas.
| | | | - Padmini Sekar
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Charles J Moomaw
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jennifer Osborne
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anastasia Vashkevich
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Sorby-Adams AJ, Marcoionni AM, Dempsey ER, Woenig JA, Turner RJ. The Role of Neurogenic Inflammation in Blood-Brain Barrier Disruption and Development of Cerebral Oedema Following Acute Central Nervous System (CNS) Injury. Int J Mol Sci 2017; 18:E1788. [PMID: 28817088 PMCID: PMC5578176 DOI: 10.3390/ijms18081788] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/07/2017] [Accepted: 08/15/2017] [Indexed: 12/13/2022] Open
Abstract
Acute central nervous system (CNS) injury, encompassing traumatic brain injury (TBI) and stroke, accounts for a significant burden of morbidity and mortality worldwide, largely attributable to the development of cerebral oedema and elevated intracranial pressure (ICP). Despite this, clinical treatments are limited and new therapies are urgently required to improve patient outcomes and survival. Originally characterised in peripheral tissues, such as the skin and lungs as a neurally-elicited inflammatory process that contributes to increased microvascular permeability and tissue swelling, neurogenic inflammation has now been described in acute injury to the brain where it may play a key role in the secondary injury cascades that evolve following both TBI and stroke. In particular, release of the neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) appear to be critically involved. In particular, increased SP expression is observed in perivascular tissue following acute CNS injury, with the magnitude of SP release being related to both the frequency and degree of the insult. SP release is associated with profound blood-brain barrier disruption and the subsequent development of vasogenic oedema, as well as neuronal injury and poor functional outcomes. Inhibition of SP through use of a neurokinin 1 (NK1) antagonist is highly beneficial following both TBI and ischaemic stroke in pre-clinical models. The role of CGRP is more unclear, especially with respect to TBI, with both elevations and reductions in CGRP levels reported following trauma. However, a beneficial role has been delineated in stroke, given its potent vasodilatory effects. Thus, modulating neuropeptides represents a novel therapeutic target in the treatment of cerebral oedema following acute CNS injury.
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Affiliation(s)
- Annabel J Sorby-Adams
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Amanda M Marcoionni
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Eden R Dempsey
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Joshua A Woenig
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Renée J Turner
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
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Grände PO. Critical Evaluation of the Lund Concept for Treatment of Severe Traumatic Head Injury, 25 Years after Its Introduction. Front Neurol 2017; 8:315. [PMID: 28725211 PMCID: PMC5495987 DOI: 10.3389/fneur.2017.00315] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/16/2017] [Indexed: 12/24/2022] Open
Abstract
When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles-i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain Trauma Foundation guidelines and European guidelines) were mainly based on meta-analytic approaches from clinical outcome studies and to some extent from systematic reviews. When introduced, they differed extensively from the LC. We still lack any large randomized outcome study comparing the whole concept of BTF guidelines with other guidelines including the LC. From that point of view, there is limited clinical evidence favoring any of the s-TBI guidelines used today. In principle, the LC has not been changed since its introduction. Some components of the alternative guidelines have approached those in the LC. In this review, I discuss some important principles of brain hemodynamics that have been lodestars during formulation of the LC. Aspects of ventilation, nutrition, and temperature control are also discussed. I critically evaluate the most important components of the LC 25 years after its introduction, based on hemodynamic principles and on the results of own an others experimental and human studies that have been published since then.
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Affiliation(s)
- Per-Olof Grände
- Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
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Angeli S, Stylianopoulos T. Experimental measurements and mathematical modeling towards quantification of brain swelling stress. J Biomech 2017; 56:42-47. [PMID: 28285745 DOI: 10.1016/j.jbiomech.2017.02.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 02/13/2017] [Accepted: 02/26/2017] [Indexed: 11/25/2022]
Abstract
Traumatic brain injury results in brain tissue swelling which can be a life threatening condition due to skull confinement. While previous efforts successfully measured the exhibited volume change in brain tissue swelling, no data exist to provide information about the exhibited stresses. In this study, confined compression mechanical testing was employed to measure swelling stress in murine brain tissue samples by varying the ionic concentration of the bathing solutions. Subsequently, computer simulations of the experimental protocol were employed to confirm a triphasic mathematical model describing the effect and provide insights into the experimental data. We measured the swelling stress to be in the range of 1.2-6.7kPa (9.0-50.2mmHg) depending on the ionic strength of the bathing solution, while a good correspondence was demonstrated among the experimentally measured and simulated responses. Furthermore, the mathematical model featured the osmotic pressure as the primary contributor to the swelling stress, while a parametric analysis showed that the densities of the intracellular fixed charges and of the non-permeable solutes significantly affect the swelling stress.
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Affiliation(s)
- Stelios Angeli
- Cancer Biophysics Laboratory, Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia 1678, Cyprus
| | - Triantafyllos Stylianopoulos
- Cancer Biophysics Laboratory, Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia 1678, Cyprus.
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Conti B, Villacin MK, Simmons JW. Trauma Anesthesia for Traumatic Brain Injury. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0141-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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The Evolution of the Clinical Use of Osmotic Therapy in the Treatment of Cerebral Edema. ACTA NEUROCHIRURGICA SUPPLEMENT 2016; 121:3-6. [DOI: 10.1007/978-3-319-18497-5_1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Impact of Elevation of Temporal Lobe During Middle Fossa Acoustic Neuroma Surgery on Contralateral Speech Discrimination. Otol Neurotol 2015; 36:1720-4. [PMID: 26536414 DOI: 10.1097/mao.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM For middle fossa acoustic neuroma approach, retractors are needed to elevate the temporal lobe to be able to access the internal auditory meatus. The temporal lobe hosts the primary and secondary auditory fields. The question arises regarding whether this elevation affects the functionality of the auditory cortex. MATERIAL AND METHODS In patients, who underwent acoustic neuroma surgery, contralateral speech discrimination was tested pre- and postsurgery using different speech discrimination tests. Results of patients with a middle fossa approach were compared with patients with a translabyrinthine approach. RESULTS No major differences between the translabyrinthine and the middle fossa approach could be detected. CONCLUSION Elevation of the temporal lobe during middle fossa approach for acoustic neuroma surgery does not lead to short-term impaired contralateral speech discrimination compared with translabyrinthine approach.
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Shevtsov MA, Nikolaev BP, Yakovleva LY, Dobrodumov AV, Zhakhov AV, Mikhrina AL, Pitkin E, Parr MA, Rolich VI, Simbircev AS, Ischenko AM. Recombinant interleukin-1 receptor antagonist conjugated to superparamagnetic iron oxide nanoparticles for theranostic targeting of experimental glioblastoma. Neoplasia 2015; 17:32-42. [PMID: 25622897 PMCID: PMC4309733 DOI: 10.1016/j.neo.2014.11.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 10/28/2014] [Accepted: 11/03/2014] [Indexed: 12/20/2022] Open
Abstract
Cerebral edema commonly accompanies brain tumors and contributes to neurologic symptoms. The role of the interleukin-1 receptor antagonist conjugated to superparamagnetic iron oxide nanoparticles (SPION-IL-1Ra) was assessed to analyze its anti-edemal effect and its possible application as a negative contrast enhancing agent for magnetic resonance imaging (MRI). Rats with intracranial C6 glioma were intravenously administered at various concentrations of IL-1Ra or SPION-IL-1Ra. Brain peritumoral edema following treatment with receptor antagonist was assessed with high-field MRI. IL-1Ra administered at later stages of tumor progression significantly reduced peritumoral edema (as measured by MRI) and prolonged two-fold the life span of comorbid animals in a dose-dependent manner in comparison to control and corticosteroid-treated animals (P < .001). Synthesized SPION-IL-1Ra conjugates had the properties of negative contrast agent with high coefficients of relaxation efficiency. In vitro studies of SPION-IL-1Ra nanoparticles demonstrated high intracellular incorporation and absence of toxic influence on C6 cells and lymphocyte viability and proliferation. Retention of the nanoparticles in the tumor resulted in enhanced hypotensive T2-weighted images of glioma, proving the application of the conjugates as negative magnetic resonance contrast agents. Moreover, nanoparticles reduced the peritumoral edema confirming the therapeutic potency of synthesized conjugates. SPION-IL-1Ra nanoparticles have an anti-edemal effect when administered through a clinically relevant route in animals with glioma. The SPION-IL-1Ra could be a candidate for theranostic approach in neuro-oncology both for diagnosis of brain tumors and management of peritumoral edema.
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Affiliation(s)
- Maxim A Shevtsov
- Institute of Cytology of the Russian Academy of Sciences (RAS), St. Petersburg, Russia; A.L. Polenov Russian Research Scientific Institute of Neurosurgery, St. Petersburg, Russia.
| | - Boris P Nikolaev
- Research Institute of Highly Pure Biopreparations, St. Petersburg, Russia
| | | | - Anatolii V Dobrodumov
- Institute of Macromolecular Compounds of the Russian Academy of Sciences (RAS), St. Petersburg, Russia
| | | | - Anastasiy L Mikhrina
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry of the Russian Academy of Sciences (RAS), St. Petersburg, Russia
| | - Emil Pitkin
- Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Marina A Parr
- V.F. Fock Institute of Physics, St. Petersburg State University, St. Petersburg, Russia
| | - Valerii I Rolich
- V.F. Fock Institute of Physics, St. Petersburg State University, St. Petersburg, Russia
| | - Andrei S Simbircev
- Research Institute of Highly Pure Biopreparations, St. Petersburg, Russia
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Li Y, Li Z, Li M, Yang Y, Wang B, Gao L, Zhang X, Cheng H, Fang W, Zhao B, Wang B, Gao G, Li L. Efficacy and Safety of Continuous Micro-Pump Infusion of 3% Hypertonic Saline combined with Furosemide to Control Elevated Intracranial Pressure. Med Sci Monit 2015; 21:1752-8. [PMID: 26082293 PMCID: PMC4484608 DOI: 10.12659/msm.892924] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background Elevated intracranial pressure is one of the most common problems in patients with diverse intracranial disorders, leading to increased morbidity and mortality. Effective management for increased intracranial pressure is based mainly on surgical and medical techniques with hyperosmolar therapy as one of the core medical treatments. The study aimed to explore the effects of continuous micro-pump infusions of 3% hypertonic saline combined with furosemide on intracranial pressure control. Material/Methods We analyzed data on 56 eligible participants with intracranial pressure >20 mmHg from March 2013 to July 2014. The target was to increase and maintain plasma sodium to a level between 145 and 155 mmol/L and osmolarity to a level of 310 to 320 mOsmol/kg. Results Plasma sodium levels significantly increased from 138±5 mmol/L at admission to 151±3 mmol/L at 24 h (P<0.01). Osmolarity increased from 282±11 mOsmol/kg at baseline to 311±8 mOsmol/kg at 24 h (P<0.01). Intracranial pressure significantly decreased from 32±7 mmHg to 15±6 mmHg at 24 h (P<0.01). There was a significant improvement in CPP (P<0.01). Moreover, central venous pressure, mean arterial pressure, and Glasgow Coma Scale slightly increased. However, these changes were not statistically significant. Conclusions Continuous infusion of 3% hypertonic saline + furosemide is effective and safe for intracranial pressure control.
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Affiliation(s)
- Yuqian Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Zhihong Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Min Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Yanlong Yang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Bao Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Li Gao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Xingye Zhang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Hongyu Cheng
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Wei Fang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Bo Zhao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Boliang Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Guodong Gao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
| | - Lihong Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China (mainland)
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Weiser G, Mendlovic J, Dagan D, Albukrek D, Shpriz M, Merin O. Case report: a brain abscess in a disaster zone- beyond the call of duty. DISASTER AND MILITARY MEDICINE 2015; 1:13. [PMID: 28265428 PMCID: PMC5329920 DOI: 10.1186/s40696-015-0003-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 03/20/2015] [Indexed: 11/10/2022]
Abstract
We present a case of a child with a suspected brain abscess treated by a military field hospital in post-typhoon Philippines. We review our intervention and decision process both at the field hospital and following his transfer to a referral center. These interventions were critical for his successful outcome.
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Affiliation(s)
- Giora Weiser
- Medical Corps, Israel Defense Forces, Tel Hashomer, Israel.,Shaare Zedek Medical Center, 12 Shmuel Bait street, Jerusalem, 93722 Israel
| | - Joseph Mendlovic
- Medical Corps, Israel Defense Forces, Tel Hashomer, Israel.,Israel Ministry of Health, Jerusalem, Israel
| | - David Dagan
- Medical Corps, Israel Defense Forces, Tel Hashomer, Israel
| | - Dov Albukrek
- Medical Corps, Israel Defense Forces, Tel Hashomer, Israel.,Reuth Rehabilitation Center, Tel Aviv, Israel
| | - Manor Shpriz
- Medical Corps, Israel Defense Forces, Tel Hashomer, Israel
| | - Ofer Merin
- Medical Corps, Israel Defense Forces, Tel Hashomer, Israel.,Shaare Zedek Medical Center, 12 Shmuel Bait street, Jerusalem, 93722 Israel
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Maciel CB, Sheth KN. Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions. Curr Atheroscler Rep 2015; 17:40. [DOI: 10.1007/s11883-015-0519-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Bober BG, Love JM, Horton SM, Sitnova M, Shahamatdar S, Kannan A, Shah SB. Actin-myosin network influences morphological response of neuronal cells to altered osmolarity. Cytoskeleton (Hoboken) 2015; 72:193-206. [DOI: 10.1002/cm.21219] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 03/11/2015] [Accepted: 03/17/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Brian G. Bober
- Department of Bioengineering; University of California, San Diego; La Jolla California
| | - James M. Love
- Fischell Department of Bioengineering; University of Maryland; College Park Maryland
| | - Steven M. Horton
- Department of Orthopaedic Surgery; University of California, San Diego; La Jolla California
| | - Mariya Sitnova
- Fischell Department of Bioengineering; University of Maryland; College Park Maryland
| | - Sina Shahamatdar
- Fischell Department of Bioengineering; University of Maryland; College Park Maryland
| | - Ajay Kannan
- Fischell Department of Bioengineering; University of Maryland; College Park Maryland
| | - Sameer B. Shah
- Department of Bioengineering; University of California, San Diego; La Jolla California
- Fischell Department of Bioengineering; University of Maryland; College Park Maryland
- Department of Orthopaedic Surgery; University of California, San Diego; La Jolla California
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Abstract
PURPOSE OF REVIEW In recent years, we have begun to better understand how to monitor the injured brain, look for less common complications and importantly, reduce unnecessary and potentially harmful intervention. However, the lack of consensus regarding triggers for intervention, best neuromonitoring techniques and standardization of therapeutic approach is in need of more careful study. This review covers the most recent evidence within this exciting and dynamic field. RECENT FINDINGS The role of intracranial pressure monitoring has been challenged; however, it still remains a cornerstone in the management of the severely brain-injured patient and should be used to compliment other techniques, such as clinical examination and serial imaging.The use of multimodal monitoring continues to be refined and it may be possible to use them to guide novel brain resuscitation techniques, such as the use of exogenous lactate supplementation in the future. SUMMARY Neurocritical care management of traumatic brain injury continues to evolve. However, it is important not to use a 'one-treatment-fits-all' approach, and perhaps look to use targeted therapies to individualize treatment.
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Schwarzmaier SM, Gallozzi M, Plesnila N. Identification of the Vascular Source of Vasogenic Brain Edema following Traumatic Brain Injury Using In Vivo 2-Photon Microscopy in Mice. J Neurotrauma 2015; 32:990-1000. [PMID: 25585052 DOI: 10.1089/neu.2014.3775] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Vasogenic brain edema due to vascular leakage is one of the most important factors determining the clinical outcome of patients following acute brain injury. To date, performing a detailed in vivo quantification of vascular leakage has not been possible. Here, we used in vivo 2-photon microscopy (2-PM) to determine the spatial (3D) and temporal development of vasogenic brain edema following traumatic brain injury (TBI) in mice; in addition, we identified the vessel types involved in vascular leakage. Thirteen male Tie2-GFP mice (6-8 weeks old) were subjected to controlled cortical impact (CCI) or a sham operation; subsequently, a cranial window was prepared adjacent to the injury site, and tetramethylrhodamine-dextran (TMRM, 40 mg/kg, MW 40,000) was injected intravenously to visualize blood plasma leakage. Parenchymal fluorescence intensity was monitored in three regions for 2-4 h post-CCI, reaching from the surface of the brain to a depth of 300 μm, and TMRM leakage was measured as an increase in TMRM fluorescence intensity outside the vessel lumen and in the parenchyma. In the CCI group, vascular leakage was detected in all investigated regions as early as 2.5 h post-injury. This leakage increased over time and was more pronounced proximal to the primary contusion. Both arterioles and venules contributed similarly to brain edema formation and their contribution was independent of vessel size; however, capillaries were the major contributor to leakage. In summary, using 2-PM to perform in vivo 3D deep-brain imaging, we found that TBI induces vascular leakage from capillaries, venules, and arterioles. Thus, all three vessel types are involved in trauma-induced brain edema and should be considered when developing novel therapies for preventing vasogenic brain edema.
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Affiliation(s)
- Susanne M Schwarzmaier
- 1 Department of Neurodegeneration, Royal College of Surgeons in Ireland (RCSI) , Dublin, Ireland .,2 Department of Anesthesiology, University of Munich Medical Center , Germany .,3 Institute for Stroke and Dementia Research (ISD), University of Munich Medical Center , Germany
| | - Micaela Gallozzi
- 1 Department of Neurodegeneration, Royal College of Surgeons in Ireland (RCSI) , Dublin, Ireland
| | - Nikolaus Plesnila
- 1 Department of Neurodegeneration, Royal College of Surgeons in Ireland (RCSI) , Dublin, Ireland .,3 Institute for Stroke and Dementia Research (ISD), University of Munich Medical Center , Germany .,4 Munich Cluster of Symptoms Neurology (Synergy) , Munich, Germany
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Abstract
OPINION STATEMENT Recent years have seen the development of novel neuroimaging techniques whose roles in the management of acute stroke are sometimes confusing and controversial. This may be attributable in part to a focus on establishing simplified algorithms and terminology that omit consideration of the basic pathophysiology of cerebral ischemia and, consequently, of the full potential for optimizing patients' care based upon their individual imaging findings. This review begins by discussing cerebral hemodynamic physiology and of the effects of hemodynamic disturbances upon the brain. Particular attention will be paid to the hemodynamic measurements and markers of tissue injury that are provided by common clinical imaging techniques, with the goal of enabling greater confidence and flexibility in understanding the potential uses of these techniques in various clinical roles, which will be discussed in the remainder of the review.
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Affiliation(s)
- William A Copen
- Massachusetts General Hospital, Division of Neuroradiology, GRB-273A, 55 Fruit Street, Boston, MA, 02114, USA,
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Goriely A, Geers MGD, Holzapfel GA, Jayamohan J, Jérusalem A, Sivaloganathan S, Squier W, van Dommelen JAW, Waters S, Kuhl E. Mechanics of the brain: perspectives, challenges, and opportunities. Biomech Model Mechanobiol 2015; 14:931-65. [PMID: 25716305 PMCID: PMC4562999 DOI: 10.1007/s10237-015-0662-4] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 02/14/2015] [Indexed: 12/24/2022]
Abstract
The human brain is the continuous subject of extensive investigation aimed at understanding its behavior and function. Despite a clear evidence that mechanical factors play an important role in regulating brain activity, current research efforts focus mainly on the biochemical or electrophysiological activity of the brain. Here, we show that classical mechanical concepts including deformations, stretch, strain, strain rate, pressure, and stress play a crucial role in modulating both brain form and brain function. This opinion piece synthesizes expertise in applied mathematics, solid and fluid mechanics, biomechanics, experimentation, material sciences, neuropathology, and neurosurgery to address today’s open questions at the forefront of neuromechanics. We critically review the current literature and discuss challenges related to neurodevelopment, cerebral edema, lissencephaly, polymicrogyria, hydrocephaly, craniectomy, spinal cord injury, tumor growth, traumatic brain injury, and shaken baby syndrome. The multi-disciplinary analysis of these various phenomena and pathologies presents new opportunities and suggests that mechanical modeling is a central tool to bridge the scales by synthesizing information from the molecular via the cellular and tissue all the way to the organ level.
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Affiliation(s)
- Alain Goriely
- Mathematical Institute, University of Oxford, Oxford, OX2 6GG, UK,
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Severe traumatic brain injury management and clinical outcome using the Lund concept. Neuroscience 2014; 283:245-55. [DOI: 10.1016/j.neuroscience.2014.06.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 02/04/2023]
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Randomized Controlled Trial Comparing Cerebral Perfusion Pressure–Targeted Therapy Versus Intracranial Pressure–Targeted Therapy for Raised Intracranial Pressure due to Acute CNS Infections in Children*. Crit Care Med 2014; 42:1775-87. [DOI: 10.1097/ccm.0000000000000298] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Wang Y, Wang E, Pan L, Dai J, Zhang N, Wang X, Liu X, Mei G, Sheng X. A new strategy of CyberKnife treatment system based radiosurgery followed by early use of adjuvant bevacizumab treatment for brain metastasis with extensive cerebral edema. J Neurooncol 2014; 119:369-76. [DOI: 10.1007/s11060-014-1488-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 05/19/2014] [Indexed: 10/25/2022]
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Secretion of von Willebrand factor by endothelial cells links sodium to hypercoagulability and thrombosis. Proc Natl Acad Sci U S A 2014; 111:6485-90. [PMID: 24733925 DOI: 10.1073/pnas.1404809111] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hypercoagulability increases risk of thrombi that cause cardiovascular events. Here we identify plasma sodium concentration as a factor that modulates blood coagulability by affecting the production of von Willebrand factor (vWF), a key initiator of the clotting cascade. We find that elevation of salt over a range from the lower end of what is normal in blood to the level of severe hypernatremia reversibly increases vWF mRNA in endothelial cells in culture and the rate of vWF secretion from them. The high NaCl increases expression of tonicity-regulated transcription factor NFAT5 and its binding to promoter of vWF gene, suggesting involvement of hypertonic signaling in vWF up-regulation. To elevate NaCl in vivo, we modeled mild dehydration, subjecting mice to water restriction (WR) by feeding them with gel food containing 30% water. Such WR elevates blood sodium from 145.1 ± 0.5 to 150.2 ± 1.3 mmol/L and activates hypertonic signaling, evidenced from increased expression of NFAT5 in tissues. WR increases vWF mRNA in liver and lung and raises vWF protein in blood. Immunostaining of liver revealed increased production of vWF protein by endothelium and increased number of microthrombi inside capillaries. WR also increases blood level of D-dimer, indicative of ongoing coagulation and thrombolysis. Multivariate regression analysis of clinical data from the Atherosclerosis Risk in Communities Study demonstrated that serum sodium significantly contributes to prediction of plasma vWF and risk of stroke. The results indicate that elevation of extracellular sodium within the physiological range raises vWF sufficiently to increase coagulability and risk of thrombosis.
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Chowdhury T, Kowalski S, Arabi Y, Dash HH. Specific intensive care management of patients with traumatic brain injury: Present and future. Saudi J Anaesth 2014; 8:268-75. [PMID: 24843345 PMCID: PMC4024689 DOI: 10.4103/1658-354x.130746] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Traumatic brain injury (TBI) is a major global problem and affects approximately 10 million peoples annually; therefore has a substantial impact on the health-care system throughout the world. In this article, we have summarized various aspects of specific intensive care management in patients with TBI including the emerging evidence mainly after the Brain Trauma Foundation (BTF) 2007 and also highlighted the scope of the future therapies. This review has involved the relevant clinical trials and reviews (from 1 January 2007 to 31 March 2013), which specifically discussed about the topic. Though, BTF guideline based management strategies could provide standardized protocols for the management of patients with TBI and have some promising effects on mortality and morbidity; there is still need of inclusion of many suggestions based on various published after 2007. The main focus of majority of these trials remained to prevent or to treat the secondary brain injury. The future therapy will be directed to treat injured neurons and may benefit the outcome. There is also urgent need to develop some good prognostic indicators as well.
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Affiliation(s)
- Tumul Chowdhury
- Department of Anesthesiology and Perioperative Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Canada
| | - Stephen Kowalski
- Department of Anesthesiology and Perioperative Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Canada
| | - Yaseen Arabi
- Department of Intensive Care, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia
| | - Hari Hara Dash
- Department of Anesthesia and Perioperative Medicine, Fortis Memorial Research Institute, Gurgaon, Haryana, India
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Glimåker M, Johansson B, Halldorsdottir H, Wanecek M, Elmi-Terander A, Ghatan PH, Lindquist L, Bellander BM. Neuro-intensive treatment targeting intracranial hypertension improves outcome in severe bacterial meningitis: an intervention-control study. PLoS One 2014; 9:e91976. [PMID: 24667767 PMCID: PMC3965390 DOI: 10.1371/journal.pone.0091976] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 02/16/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of early intracranial pressure (ICP)-targeted treatment, compared to standard intensive care, in adults with community acquired acute bacterial meningitis (ABM) and severely impaired consciousness. DESIGN A prospectively designed intervention-control comparison study of adult cases from September 2004 to January 2012. PATIENTS Included patients were confirmed ABM-cases, aged 16-75 years, with severely impaired mental status on admission. Fifty-two patients, given ICP-targeted treatment at the neuro-intensive care unit, and 53 control cases, treated with conventional intensive care, were included. All the patients received intensive care with mechanical ventilation, sedation, antibiotics and corticosteroids according to current guidelines. Additional ICP-treatment in the intervention group included cerebrospinal fluid drainage using external ventricular catheters (n = 48), osmotherapy (n = 21), hyperventilation (n = 13), external cooling (n = 9), gram-doses of methylprednisolone (n = 3) and deep barbiturate sedation (n = 2) aiming at ICP <20 mmHg and a cerebral perfusion pressure of >50 mmHg. MEASUREMENTS The primary endpoint was mortality at two months and secondary endpoint was Glasgow outcome score and hearing ability at follow-up at 2-6 months. OUTCOMES The mortality was significantly lower in the intervention group compared to controls, 5/52 (10%) versus 16/53 (30%; relative risk reduction 68%; p<0.05). Furthermore, only 17 patients (32%) in the control group fully recovered compared to 28 (54%) in the intervention group (relative risk reduction 40%; p<0.05). CONCLUSIONS Early neuro-intensive care using ICP-targeted therapy, mainly cerebrospinal fluid drainage, reduces mortality and improves the overall outcome in adult patients with ABM and severely impaired mental status on admission.
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Affiliation(s)
- Martin Glimåker
- Unit for Infectious Diseases, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Bibi Johansson
- Unit for Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | | | - Michael Wanecek
- Department of Anesthesiology, Karolinska University Hospital, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Per Hamid Ghatan
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Lars Lindquist
- Unit for Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Bo Michael Bellander
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW To discuss trends in the use of osmotic therapy. RECENT FINDINGS Use of osmotic therapy has evolved from bolus administration of mannitol to routine use of hypertonic saline as a bolus as well as in continuous infusions to creating a sustained hyperosmolar state.In a survey of neurointensivists 55% favored hypertonic saline over mannitol. Retrospective studies suggest better intracranial pressure (ICP) control with hypertonic saline. Whereas a prospective study in adults with head injury compared alternating doses of mannitol and hypertonic saline and found no difference in change in ICP control or outcome, two meta-analyses, which did not include this study, favored hypertonic saline for ICP control (although the absolute difference of 2 mmHg is of little clinical value) with no difference in outcome.Hypertonic saline has also been administered by infusions to creating a sustained stable hyperosmolar state. Two studies, using historical controls, suggested benefit of hypertonic saline infusions. In a prospective, randomized study, in children with severe head injury Lactated Ringer's solution was compared to hypertonic saline. Although ICP control was similar, the hypertonic saline group required fewer other interventions. SUMMARY The existing data do not support favoring boluses of hypertonic saline over mannitol in terms of ICP control, let alone outcome. The rationale for continuous infusions to create a sustained hyperosmolar state is open to discussion and use of this approach should be curtailed pending further research.
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