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Svedung Wettervik T, Hånell A, Ahlgren KM, Hillered L, Lewén A. Preliminary Observations of the Loke Microdialysis in an Experimental Pig Model: Are We Ready for Continuous Monitoring of Brain Energy Metabolism? Neurocrit Care 2024:10.1007/s12028-024-02080-5. [PMID: 39085507 DOI: 10.1007/s12028-024-02080-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/10/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Brain energy metabolism is often disturbed after acute brain injuries. Current neuromonitoring methods with cerebral microdialysis (CMD) are based on intermittent measurements (1-4 times/h), but such a low frequency could miss transient but important events. The solution may be the recently developed Loke microdialysis (MD), which provides high-frequency data of glucose and lactate. Before clinical implementation, the reliability and stability of Loke remain to be determined in vivo. The purpose of this study was to validate Loke MD in relation to the standard intermittent CMD method. METHODS Four pigs aged 2-3 months were included. They received two adjacent CMD catheters, one for standard intermittent assessments and one for continuous (Loke MD) assessments of glucose and lactate. The standard CMD was measured every 15 min. Continuous Loke MD was sampled every 2-3 s and was averaged over corresponding 15-min intervals for the statistical comparisons with standard CMD. Intravenous glucose injections and intracranial hypertension by inflation of an intracranial epidural balloon were performed to induce variations in intracranial pressure, cerebral perfusion pressure, and systemic and cerebral glucose and lactate levels. RESULTS In a linear mixed-effect model of standard CMD glucose (mM), there was a fixed effect value (± standard error [SE]) at 0.94 ± 0.07 (p < 0.001) for Loke MD glucose (mM), with an intercept at - 0.19 ± 0.15 (p = 0.20). The model showed a conditional R2 at 0.81 and a marginal R2 at 0.72. In a linear mixed-effect model of standard CMD lactate (mM), there was a fixed effect value (± SE) at 0.41 ± 0.16 (p = 0.01) for Loke MD lactate (mM), with an intercept at 0.33 ± 0.21 (p = 0.25). The model showed a conditional R2 at 0.47 and marginal R2 at 0.17. CONCLUSIONS The established standard CMD glucose thresholds may be used as for Loke MD with some caution, but this should be avoided for lactate.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Kerstin M Ahlgren
- Department of Surgical Sciences, Uppsala University, 751 85, Uppsala, Sweden
| | - Lars Hillered
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
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Rahmani F, Batson RD, Zimmerman A, Reddigari S, Bigler ED, Lanning SC, Ilasa E, Grafman JH, Lu H, Lin AP, Raji CA. Rate of abnormalities in quantitative MR neuroimaging of persons with chronic traumatic brain injury. BMC Neurol 2024; 24:235. [PMID: 38969967 PMCID: PMC11225195 DOI: 10.1186/s12883-024-03745-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/26/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) can result in lasting brain damage that is often too subtle to detect by qualitative visual inspection on conventional MR imaging. Although a number of FDA-cleared MR neuroimaging tools have demonstrated changes associated with mTBI, they are still under-utilized in clinical practice. METHODS We investigated a group of 65 individuals with predominantly mTBI (60 mTBI, 48 due to motor-vehicle collision, mean age 47 ± 13 years, 27 men and 38 women) with MR neuroimaging performed in a median of 37 months post-injury. We evaluated abnormalities in brain volumetry including analysis of left-right asymmetry by quantitative volumetric analysis, cerebral perfusion by pseudo-continuous arterial spin labeling (PCASL), white matter microstructure by diffusion tensor imaging (DTI), and neurometabolites via magnetic resonance spectroscopy (MRS). RESULTS All participants demonstrated atrophy in at least one lobar structure or increased lateral ventricular volume. The globus pallidi and cerebellar grey matter were most likely to demonstrate atrophy and asymmetry. Perfusion imaging revealed significant reductions of cerebral blood flow in both occipital and right frontoparietal regions. Diffusion abnormalities were relatively less common though a subset analysis of participants with higher resolution DTI demonstrated additional abnormalities. All participants showed abnormal levels on at least one brain metabolite, most commonly in choline and N-acetylaspartate. CONCLUSION We demonstrate the presence of coup-contrecoup perfusion injury patterns, widespread atrophy, regional brain volume asymmetry, and metabolic aberrations as sensitive markers of chronic mTBI sequelae. Our findings expand the historic focus on quantitative imaging of mTBI with DTI by highlighting the complementary importance of volumetry, arterial spin labeling perfusion and magnetic resonance spectroscopy neurometabolite analyses in the evaluation of chronic mTBI.
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Affiliation(s)
- Farzaneh Rahmani
- Department of Radiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Richard D Batson
- Endocrine & Brain Injury Research Alliance, Neurevolution Medicine, PLLC, NUNM Helfgott Research Institute, Portland, Oregon, USA
| | | | | | - Erin D Bigler
- Department of Neurology, Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | | | | | - Jordan H Grafman
- Departments of Physical Medicine & Rehabilitation, Neurology, Cognitive Neurology and Alzheimer's Center, Department of Psychiatry, Feinberg School of Medicine, Department of Psychology, Weinberg College of Arts and Sciences, Northwestern University, Chicago, IL, USA
| | - Hanzhang Lu
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexander P Lin
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Cyrus A Raji
- Department of Radiology, Washington University School of Medicine, Saint Louis, MO, USA.
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA.
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3
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Shahim P, Pham DL, van der Merwe AJ, Moore B, Chou Y, Lippa SM, Kenney K, Diaz‐Arrastia R, Chan L. Serum NfL and GFAP as biomarkers of progressive neurodegeneration in TBI. Alzheimers Dement 2024; 20:4663-4676. [PMID: 38805359 PMCID: PMC11247683 DOI: 10.1002/alz.13898] [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: 11/29/2023] [Revised: 04/01/2024] [Accepted: 04/12/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND We examined spatial patterns of brain atrophy after mild, moderate, and severe traumatic brain injury (TBI), the relationship between progression of brain atrophy with initial traumatic axonal injury (TAI), cognitive outcome, and with serum biomarkers of brain injury. METHODS A total of 143 patients with TBI and 43 controls were studied cross-sectionally and longitudinally up to 5 years with multiple assessments, which included brain magnetic resonance imaging, cognitive testing, and serum biomarkers. RESULTS TBI patients showed progressive volume loss regardless of injury severity over several years, and TAI was independently associated with accelerated brain atrophy. Cognitive performance improved over time. Higher baseline serum neurofilament light (NfL) and glial fibrillary acidic protein (GFAP) were associated with greater rate of brain atrophy over 5 years. DISCUSSSION Spatial patterns of atrophy differ by injury severity and TAI is associated with the progression of brain atrophy. Serum NfL and GFAP show promise as non-invasive prognostic biomarkers of progressive neurodegeneration in TBI. HIGHLIGHTS In this longitudinal study of patient with mild, moderate, and severe traumatic brain injury (TBI) who were assessed with paired magnetic resonance imaging (MRI), blood biomarkers, and cognitive assessments, we found that brain atrophy after TBI is progressive and continues for many years even after a mild head trauma without signs of brain injury on conventional MRI. We found that spatial pattern of brain atrophy differs between mild, moderate, and severe TBI, where in patients with mild TBI , atrophy is mainly seen in the gray matter, while in those with moderate to severe brain injury atrophy is predominantly seen in the subcortical gray matter and whiter matter. Cognitive performance improves over time after a TBI. Serum measures of neurofilament light or glial fibrillary acidic protein are associated with progression of brain atrophy after TBI.
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Affiliation(s)
- Pashtun Shahim
- Rehabilitation Medicine DepartmentNational Institutes of Health (NIH) Clinical CenterBethesdaMarylandUSA
- National Institutes of Neurological Disorders and Stroke, NIHBethesdaMarylandUSA
- Department of NeurologyMedStar Georgetown University Hospital, Pasquerilla Healthcare CenterWashingtonDistrict of ColumbiaUSA
- The Military Traumatic Brain Injury Initiative (MTBI2)BethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Dzung L. Pham
- The Military Traumatic Brain Injury Initiative (MTBI2)BethesdaMarylandUSA
- Uniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Andre J. van der Merwe
- Rehabilitation Medicine DepartmentNational Institutes of Health (NIH) Clinical CenterBethesdaMarylandUSA
- The Military Traumatic Brain Injury Initiative (MTBI2)BethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Brian Moore
- Rehabilitation Medicine DepartmentNational Institutes of Health (NIH) Clinical CenterBethesdaMarylandUSA
- The Military Traumatic Brain Injury Initiative (MTBI2)BethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Yi‐Yu Chou
- The Military Traumatic Brain Injury Initiative (MTBI2)BethesdaMarylandUSA
- The Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Sara M. Lippa
- Uniformed Services University of the Health SciencesBethesdaMarylandUSA
- National Intrepid Center of Excellence, Walter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Kimbra Kenney
- Uniformed Services University of the Health SciencesBethesdaMarylandUSA
- National Intrepid Center of Excellence, Walter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Ramon Diaz‐Arrastia
- Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Leighton Chan
- Rehabilitation Medicine DepartmentNational Institutes of Health (NIH) Clinical CenterBethesdaMarylandUSA
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Kang J, Shah I, Shahrestani S, Nguyen CQ, Chen PM, Lopez AM, Chen JW. Friedman's Gradient-Boosting Algorithm Predicts Lactate-Pyruvate Ratio Trends in Cases of Intracerebral Hemorrhages. World Neurosurg 2024; 187:e620-e628. [PMID: 38679378 DOI: 10.1016/j.wneu.2024.04.136] [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: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE The local effects of an intracerebral hemorrhage (ICH) on surrounding brain tissue can be detected bedside using multimodal brain monitoring techniques. The aim of this study is to design a gradient boosting regression model using the R package boostmtree with the ability to predict lactate-pyruvate ratio measurements in ICH. METHODS We performed a retrospective analysis of 6 spontaneous ICH and 6 traumatic ICH patients who underwent surgical removal of the clot with microdialysis catheters placed in the perihematomal zone. Predictors of glucose, lactate, pyruvate, age, sex, diagnosis, and operation status were used to design our model. RESULTS In a holdout analysis, the model forecasted lactate-pyruvate ratio trends in a representative in-sample testing set. We anticipate that boostmtree could be applied to designs of similar regression models to analyze trends in other multimodal monitoring features across other types of acute brain injury. CONCLUSIONS The model successfully predicted hourly lactate-pyruvate ratios in spontaneous ICH and traumatic ICH cases after the hemorrhage evacuation and displayed significantly better performance than linear models. Our results suggest that boostmtree may be a powerful tool in developing more advanced mathematical models to assess other multimodal monitoring parameters for cases in which the perihematomal environment is monitored.
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Affiliation(s)
- Jaeyoung Kang
- Department of Cell Biology, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurological Surgery, University of California Irvine, Orange, California, USA
| | - Ishan Shah
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA; Keck School of Medicine of USC, Los Angeles, California, USA.
| | - Shane Shahrestani
- Keck School of Medicine of USC, Los Angeles, California, USA; Department of Neurological Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christopher Q Nguyen
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
| | - Patrick M Chen
- Department of Neurology, University of California Irvine, Orange, California, USA
| | - Alexander M Lopez
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
| | - Jefferson W Chen
- Department of Neurological Surgery, University of California Irvine, Orange, California, USA
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Gong L, Liang J, Xie L, Zhang Z, Mei Z, Zhang W. Metabolic Reprogramming in Gliocyte Post-cerebral Ischemia/ Reperfusion: From Pathophysiology to Therapeutic Potential. Curr Neuropharmacol 2024; 22:1672-1696. [PMID: 38362904 PMCID: PMC11284719 DOI: 10.2174/1570159x22666240131121032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/08/2023] [Accepted: 12/13/2023] [Indexed: 02/17/2024] Open
Abstract
Ischemic stroke is a leading cause of disability and death worldwide. However, the clinical efficacy of recanalization therapy as a preferred option is significantly hindered by reperfusion injury. The transformation between different phenotypes of gliocytes is closely associated with cerebral ischemia/ reperfusion injury (CI/RI). Moreover, gliocyte polarization induces metabolic reprogramming, which refers to the shift in gliocyte phenotype and the overall transformation of the metabolic network to compensate for energy demand and building block requirements during CI/RI caused by hypoxia, energy deficiency, and oxidative stress. Within microglia, the pro-inflammatory phenotype exhibits upregulated glycolysis, pentose phosphate pathway, fatty acid synthesis, and glutamine synthesis, whereas the anti-inflammatory phenotype demonstrates enhanced mitochondrial oxidative phosphorylation and fatty acid oxidation. Reactive astrocytes display increased glycolysis but impaired glycogenolysis and reduced glutamate uptake after CI/RI. There is mounting evidence suggesting that manipulation of energy metabolism homeostasis can induce microglial cells and astrocytes to switch from neurotoxic to neuroprotective phenotypes. A comprehensive understanding of underlying mechanisms and manipulation strategies targeting metabolic pathways could potentially enable gliocytes to be reprogrammed toward beneficial functions while opening new therapeutic avenues for CI/RI treatment. This review provides an overview of current insights into metabolic reprogramming mechanisms in microglia and astrocytes within the pathophysiological context of CI/RI, along with potential pharmacological targets. Herein, we emphasize the potential of metabolic reprogramming of gliocytes as a therapeutic target for CI/RI and aim to offer a novel perspective in the treatment of CI/RI.
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Affiliation(s)
- Lipeng Gong
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan 410208, China
| | - Junjie Liang
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan 410208, China
| | - Letian Xie
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan 410208, China
| | - Zhanwei Zhang
- Department of Neurosurgery, First Affiliated Hospital of Hunan University of Traditional Chinese Medicine, Changsha, Hunan 410007, China
| | - Zhigang Mei
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, College of Integrated Traditional Chinese Medicine and Western Medicine, Hunan University of Chinese Medicine, Changsha, Hunan 410208, China
- Third-Grade Pharmacological Laboratory on Chinese Medicine Approved by State Administration of Traditional Chinese Medicine, College of Medicine and Health Sciences, China Three Gorges University, Yichang, Hubei 443002, China
| | - Wenli Zhang
- School of Pharmacy, Hunan University of Chinese Medicine, Changsha, Hunan 410208, China
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Riviere-Cazaux C, Rajani K, Rahman M, Oh J, Brown DA, White JF, Himes BT, Jusue-Torres I, Rodriguez M, Warrington AE, Kizilbash SH, Elmquist WF, Burns TC. Methodological and analytical considerations for intra-operative microdialysis. Fluids Barriers CNS 2023; 20:94. [PMID: 38115038 PMCID: PMC10729367 DOI: 10.1186/s12987-023-00497-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Microdialysis is a technique that can be utilized to sample the interstitial fluid of the central nervous system (CNS), including in primary malignant brain tumors known as gliomas. Gliomas are mainly accessible at the time of surgery, but have rarely been analyzed via interstitial fluid collected via microdialysis. To that end, we obtained an investigational device exemption for high molecular weight catheters (HMW, 100 kDa) and a variable flow rate pump to perform microdialysis at flow rates amenable to an intra-operative setting. We herein report on the lessons and insights obtained during our intra-operative HMW microdialysis trial, both in regard to methodological and analytical considerations. METHODS Intra-operative HMW microdialysis was performed during 15 clinically indicated glioma resections in fourteen patients, across three radiographically diverse regions in each patient. Microdialysates were analyzed via targeted and untargeted metabolomics via ultra-performance liquid chromatography tandem mass spectrometry. RESULTS Use of albumin and lactate-containing perfusates impacted subsets of metabolites evaluated via global metabolomics. Additionally, focal delivery of lactate via a lactate-containing perfusate, induced local metabolic changes, suggesting the potential for intra-operative pharmacodynamic studies via reverse microdialysis of candidate drugs. Multiple peri-operatively administered drugs, including levetiracetam, cefazolin, caffeine, mannitol and acetaminophen, could be detected from one microdialysate aliquot representing 10 min worth of intra-operative sampling. Moreover, clinical, radiographic, and methodological considerations for performing intra-operative microdialysis are discussed. CONCLUSIONS Intra-operative HMW microdialysis can feasibly be utilized to sample the live human CNS microenvironment, including both metabolites and drugs, within one surgery. Certain variables, such as perfusate type, must be considered during and after analysis. Trial registration NCT04047264.
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Affiliation(s)
- Cecile Riviere-Cazaux
- Department of Neurological Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Karishma Rajani
- Department of Neurological Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Masum Rahman
- Department of Neurological Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Juhee Oh
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Desmond A Brown
- Neurosurgical Oncology Unit, Surgical Neurology Branch, National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Jaclyn F White
- Department of Neurological Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Benjamin T Himes
- Department of Neurological Surgery, Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ignacio Jusue-Torres
- Department of Neurological Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | | | - Arthur E Warrington
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - William F Elmquist
- Brain Barriers Research Center, Department of Pharmaceutics, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Terry C Burns
- Department of Neurological Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
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7
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Benson EJ, Aronowitz DI, Forti RM, Lafontant A, Ranieri NR, Starr JP, Melchior RW, Lewis A, Jahnavi J, Breimann J, Yun B, Laurent GH, Lynch JM, White BR, Gaynor JW, Licht DJ, Yodh AG, Kilbaugh TJ, Mavroudis CD, Baker WB, Ko TS. Diffuse Optical Monitoring of Cerebral Hemodynamics and Oxygen Metabolism during and after Cardiopulmonary Bypass: Hematocrit Correction and Neurological Vulnerability. Metabolites 2023; 13:1153. [PMID: 37999249 PMCID: PMC10672802 DOI: 10.3390/metabo13111153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
Cardiopulmonary bypass (CPB) provides cerebral oxygenation and blood flow (CBF) during neonatal congenital heart surgery, but the impacts of CPB on brain oxygen supply and metabolic demands are generally unknown. To elucidate this physiology, we used diffuse correlation spectroscopy and frequency-domain diffuse optical spectroscopy to continuously measure CBF, oxygen extraction fraction (OEF), and oxygen metabolism (CMRO2) in 27 neonatal swine before, during, and up to 24 h after CPB. Concurrently, we sampled cerebral microdialysis biomarkers of metabolic distress (lactate-pyruvate ratio) and injury (glycerol). We applied a novel theoretical approach to correct for hematocrit variation during optical quantification of CBF in vivo. Without correction, a mean (95% CI) +53% (42, 63) increase in hematocrit resulted in a physiologically improbable +58% (27, 90) increase in CMRO2 relative to baseline at CPB initiation; following correction, CMRO2 did not differ from baseline at this timepoint. After CPB initiation, OEF increased but CBF and CMRO2 decreased with CPB time; these temporal trends persisted for 0-8 h following CPB and coincided with a 48% (7, 90) elevation of glycerol. The temporal trends and glycerol elevation resolved by 8-24 h. The hematocrit correction improved quantification of cerebral physiologic trends that precede and coincide with neurological injury following CPB.
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Affiliation(s)
- Emilie J. Benson
- Department of Physics & Astronomy, University of Pennsylvania, Philadelphia, PA 19104, USA; (E.J.B.); (A.G.Y.)
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Danielle I. Aronowitz
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.); (J.W.G.); (C.D.M.)
| | - Rodrigo M. Forti
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Alec Lafontant
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Nicolina R. Ranieri
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Jonathan P. Starr
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (J.P.S.); (T.J.K.)
| | - Richard W. Melchior
- Department of Perfusion Services, Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Alistair Lewis
- Department of Chemistry, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jharna Jahnavi
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Jake Breimann
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Bohyun Yun
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Gerard H. Laurent
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Jennifer M. Lynch
- Division of Cardiothoracic Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Brian R. White
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - J. William Gaynor
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.); (J.W.G.); (C.D.M.)
| | - Daniel J. Licht
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Arjun G. Yodh
- Department of Physics & Astronomy, University of Pennsylvania, Philadelphia, PA 19104, USA; (E.J.B.); (A.G.Y.)
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (J.P.S.); (T.J.K.)
| | - Constantine D. Mavroudis
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (D.I.A.); (J.W.G.); (C.D.M.)
| | - Wesley B. Baker
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (R.M.F.); (A.L.); (N.R.R.); (J.J.); (J.B.); (B.Y.); (G.H.L.); (D.J.L.); (W.B.B.)
| | - Tiffany S. Ko
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (J.P.S.); (T.J.K.)
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Riviere-Cazaux C, Neth BJ, Hoplin MD, Wessel B, Miska J, Kizilbash SH, Burns TC. Glioma Metabolic Feedback In Situ: A First-In-Human Pharmacodynamic Trial of Difluoromethylornithine + AMXT-1501 Through High-Molecular Weight Microdialysis. Neurosurgery 2023; 93:932-938. [PMID: 37246885 PMCID: PMC10637404 DOI: 10.1227/neu.0000000000002511] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND AND OBJECTIVES No new drug has improved survival for glioblastoma since temozolomide in 2005, due in part to the relative inaccessibility of each patient's individualized tumor biology and its response to therapy. We have identified a conserved extracellular metabolic signature of enhancing high-grade gliomas enriched for guanidinoacetate (GAA). GAA is coproduced with ornithine, the precursor to protumorigenic polyamines through ornithine decarboxylase (ODC). AMXT-1501 is a polyamine transporter inhibitor that can overcome tumoral resistance to the ODC inhibitor, difluoromethylornithine (DFMO). We will use DFMO with or without AMXT-1501 to identify candidate pharmacodynamic biomarkers of polyamine depletion in patients with high-grade gliomas in situ . We aim to determine (1) how blocking polyamine production affects intratumoral extracellular guanidinoacetate abundance and (2) the impact of polyamine depletion on the global extracellular metabolome within live human gliomas in situ. METHODS DFMO, with or without AMXT-1501, will be administered postoperatively in 15 patients after clinically indicated subtotal resection for high-grade glioma. High-molecular weight microdialysis catheters implanted into residual tumor and adjacent brain will be used for postoperative monitoring of extracellular GAA and polyamines throughout therapeutic intervention from postoperative day (POD) 1 to POD5. Catheters will be removed on POD5 before discharge. EXPECTED OUTCOMES We anticipate that GAA will be elevated in tumor relative to adjacent brain although it will decrease within 24 hours of ODC inhibition with DFMO. If AMXT-1501 effectively increases the cytotoxic impact of ODC inhibition, we expect an increase in biomarkers of cytotoxicity including glutamate with DFMO + AMXT-1501 treatment when compared with DFMO alone. DISCUSSION Limited mechanistic feedback from individual patients' gliomas hampers clinical translation of novel therapies. This pilot Phase 0 study will provide in situ feedback during DFMO + AMXT-1501 treatment to determine how high-grade gliomas respond to polyamine depletion.
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Affiliation(s)
| | - Bryan J. Neth
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew D. Hoplin
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bambi Wessel
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason Miska
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | | | - Terry C. Burns
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
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9
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Lazaridis C, Foreman B. Management Strategies Based on Multi-Modality Neuromonitoring in Severe Traumatic Brain Injury. Neurotherapeutics 2023; 20:1457-1471. [PMID: 37491682 PMCID: PMC10684466 DOI: 10.1007/s13311-023-01411-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 07/27/2023] Open
Abstract
Secondary brain injury after neurotrauma is comprised of a host of distinct, potentially concurrent and interacting mechanisms that may exacerbate primary brain insult. Multimodality neuromonitoring is a method of measuring multiple aspects of the brain in order to understand the signatures of these different pathomechanisms and to detect, treat, or prevent potentially reversible secondary brain injuries. The most studied invasive parameters include intracranial pressure (ICP), cerebral perfusion pressure (CPP), autoregulatory indices, brain tissue partial oxygen tension, and tissue energy and metabolism measures such as the lactate pyruvate ratio. Understanding the local metabolic state of brain tissue in order to infer pathology and develop appropriate management strategies is an area of active investigation. Several clinical trials are underway to define the role of brain tissue oxygenation monitoring and electrocorticography in conjunction with other multimodal neuromonitoring information, including ICP and CPP monitoring. Identifying an optimal CPP to guide individualized management of blood pressure and ICP has been shown to be feasible, but definitive clinical trial evidence is still needed. Future work is still needed to define and clinically correlate patterns that emerge from integrated measurements of metabolism, pressure, flow, oxygenation, and electrophysiology. Pathophysiologic targets and precise critical care management strategies to address their underlying causes promise to mitigate secondary injuries and hold the potential to improve patient outcome. Advancements in clinical trial design are poised to establish new standards for the use of multimodality neuromonitoring to guide individualized clinical care.
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Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA.
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
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10
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Muñoz-Ballester C, Robel S. Astrocyte-mediated mechanisms contribute to traumatic brain injury pathology. WIREs Mech Dis 2023; 15:e1622. [PMID: 37332001 PMCID: PMC10526985 DOI: 10.1002/wsbm.1622] [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: 03/04/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 06/20/2023]
Abstract
Astrocytes respond to traumatic brain injury (TBI) with changes to their molecular make-up and cell biology, which results in changes in astrocyte function. These changes can be adaptive, initiating repair processes in the brain, or detrimental, causing secondary damage including neuronal death or abnormal neuronal activity. The response of astrocytes to TBI is often-but not always-accompanied by the upregulation of intermediate filaments, including glial fibrillary acidic protein (GFAP) and vimentin. Because GFAP is often upregulated in the context of nervous system disturbance, reactive astrogliosis is sometimes treated as an "all-or-none" process. However, the extent of astrocytes' cellular, molecular, and physiological adjustments is not equal for each TBI type or even for each astrocyte within the same injured brain. Additionally, new research highlights that different neurological injuries and diseases result in entirely distinctive and sometimes divergent astrocyte changes. Thus, extrapolating findings on astrocyte biology from one pathological context to another is problematic. We summarize the current knowledge about astrocyte responses specific to TBI and point out open questions that the field should tackle to better understand how astrocytes shape TBI outcomes. We address the astrocyte response to focal versus diffuse TBI and heterogeneity of reactive astrocytes within the same brain, the role of intermediate filament upregulation, functional changes to astrocyte function including potassium and glutamate homeostasis, blood-brain barrier maintenance and repair, metabolism, and reactive oxygen species detoxification, sex differences, and factors influencing astrocyte proliferation after TBI. This article is categorized under: Neurological Diseases > Molecular and Cellular Physiology.
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Affiliation(s)
- Carmen Muñoz-Ballester
- Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stefanie Robel
- Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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11
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Venturini S, Bhatti F, Timofeev I, Carpenter KLH, Hutchinson PJ, Guilfoyle MR, Helmy A. Microdialysis-Based Classifications of Abnormal Metabolic States after Traumatic Brain Injury: A Systematic Review of the Literature. J Neurotrauma 2023; 40:195-209. [PMID: 36112699 DOI: 10.1089/neu.2021.0502] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
After traumatic brain injury (TBI), cerebral metabolism can become deranged, contributing to secondary injury. Cerebral microdialysis (CMD) allows cerebral metabolism assessment and is often used with other neuro-monitoring modalities. CMD-derived parameters such as the lactate/pyruvate ratio (LPR) show a failure of oxidative energy generation. CMD-based abnormal metabolic states can be described following TBI, informing the etiology of physiological derangements. This systematic review summarizes the published literature on microdialysis-based abnormal metabolic classifications following TBI. Original research studies in which the populations were patients with TBI were included. Studies that described CMD-based classifications of metabolic abnormalities were included in the synthesis of the narrative results. A total of 825 studies underwent two-step screening after duplicates were removed. Fifty-three articles that used CMD in TBI patients were included. Of these, 14 described abnormal metabolic states based on CMD parameters. Classifications were heterogeneous between studies. LPR was the most frequently used parameter in the classifications; high LPR values were described as metabolic crisis. Ischemia was consistently defined as high LPR with low CMD substrate levels (glucose or pyruvate). Mitochondrial dysfunction, describing inability to use energy substrate despite availability, was identified based on raised LPR with near-normal levels of pyruvate. This is the first systematic review summarizing the published literature on microdialysis-based abnormal metabolic states following TBI. Although variability exists among individual classifications, there is broad agreement about broad definitions of metabolic crisis, ischemia, and mitochondrial dysfunction. Identifying the etiology of deranged cerebral metabolism after TBI is important for targeting therapeutic interventions.
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Affiliation(s)
- Sara Venturini
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Faheem Bhatti
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ivan Timofeev
- Division of Neurosurgery, 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
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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12
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Sharma R, Tsikvadze M, Peel J, Howard L, Kapoor N, Freeman WD. Multimodal monitoring: practical recommendations (dos and don'ts) in challenging situations and uncertainty. Front Neurol 2023; 14:1135406. [PMID: 37206910 PMCID: PMC10188941 DOI: 10.3389/fneur.2023.1135406] [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: 12/31/2022] [Accepted: 04/06/2023] [Indexed: 05/21/2023] Open
Abstract
With the advancements in modern medicine, new methods are being developed to monitor patients in the intensive care unit. Different modalities evaluate different aspects of the patient's physiology and clinical status. The complexity of these modalities often restricts their use to the realm of clinical research, thereby limiting their use in the real world. Understanding their salient features and their limitations can aid physicians in interpreting the concomitant information provided by multiple modalities to make informed decisions that may affect clinical care and outcomes. Here, we present a review of the commonly used methods in the neurological intensive care unit with practical recommendations for their use.
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Affiliation(s)
- Rohan Sharma
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
- *Correspondence: Rohan Sharma
| | - Mariam Tsikvadze
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Jeffrey Peel
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Levi Howard
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Nidhi Kapoor
- Department of Neurology, Baptist Medical Center, Jacksonville, FL, United States
| | - William D. Freeman
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
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13
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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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14
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Hwang M, Chattaraj R, Sridharan A, Shin SS, Viaene AN, Haddad S, Khrichenko D, Sehgal C, Lee D, Kilbaugh TJ. Can Ultrasound-Guided Xenon Delivery Provide Neuroprotection in Traumatic Brain Injury? Neurotrauma Rep 2022; 3:97-104. [PMID: 35317306 PMCID: PMC8935480 DOI: 10.1089/neur.2021.0070] [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] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury (TBI) is associated with high mortality and morbidity in children and adults. Unfortunately, there is no effective management for TBI in the acute setting. Rodent studies have shown that xenon, a well-known anesthetic gas, can be neuroprotective when administered post-TBI. Gas inhalation therapy, however, the approach typically used for administering xenon, is expensive, inconvenient, and fraught with systemic side effects. Therapeutic delivery to the brain is minimal, with much of the inhaled gas cleared by the lungs. To bridge major gaps in clinical care and enhance cerebral delivery of xenon, this study introduces a novel xenon delivery technique, utilizing microbubbles, in which a high impulse ultrasound signal is used for targeted cerebral release of xenon. Briefly, an ultrasound pulse is applied along the carotid artery at the level of the neck on intravenous injection of xenon microbubbles (XeMBs) resulting in release of xenon from microbubbles into the brain. This delivery technique employs a hand-held, portable ultrasound system that could be adopted in resource-limited environments. Using a high-fidelity porcine model, this study demonstrates the neuroprotective efficacy of xenon microbubbles in TBI for the first time.
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Affiliation(s)
- Misun Hwang
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rajarshi Chattaraj
- Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Samuel S. Shin
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angela N. Viaene
- Department of Pathology, and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sophie Haddad
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dmitry Khrichenko
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chandra Sehgal
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daeyeon Lee
- Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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15
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Biofluid Biomarkers in Traumatic Brain Injury: A Systematic Scoping Review. Neurocrit Care 2021; 35:559-572. [PMID: 33403583 DOI: 10.1007/s12028-020-01173-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 12/01/2020] [Indexed: 02/05/2023]
Abstract
Emerging evidence suggests that biofluid-based biomarkers have diagnostic and prognostic potential in traumatic brain injuries (TBI). However, owing to the lack of a conceptual framework or comprehensive review, it is difficult to visualize the breadth of materials that might be available. We conducted a systematic scoping review to map and categorize the evidence regarding biofluid-based biochemical markers of TBI. A comprehensive search was undertaken in January 2019. Of 25,354 records identified through the literature search, 1036 original human studies were included. Five hundred forty biofluid biomarkers were extracted from included studies and classified into 19 distinct categories. Three categories of biomarkers including cytokines, coagulation tests, and nerve tissue proteins were investigated more than others and assessed in almost half of the studies (560, 515, and 502 from 1036 studies, respectively). S100 beta as the most common biomarker for TBI was tested in 21.2% of studies (220 articles). Cortisol was the only biomarker measured in blood, cerebrospinal fluid, urine, and saliva. The most common sampling time was at admission and within 24 h of injury. The included studies focused mainly on biomarkers from blood and central nervous system sources, the adult population, and severe and blunt injuries. The most common outcome measures used in studies were changes in biomarker concentration level, Glasgow coma scale, Glasgow outcome scale, brain computed tomography scan, and mortality rate. Biofluid biomarkers could be clinically helpful in the diagnosis and prognosis of TBI. However, there was no single definitive biomarker with accurate characteristics. The present categorization would be a road map to investigate the biomarkers of the brain injury cascade separately and detect the most representative biomarker of each category. Also, this comprehensive categorization could provide a guiding framework to design combined panels of multiple biomarkers.
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16
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Pumiglia L, Williams AM, Kemp MT, Wakam GK, Alam HB, Biesterveld BE. Brain proteomic changes by histone deacetylase inhibition after traumatic brain injury. Trauma Surg Acute Care Open 2021; 6:e000682. [PMID: 33880414 PMCID: PMC7993337 DOI: 10.1136/tsaco-2021-000682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/22/2021] [Accepted: 03/07/2021] [Indexed: 11/04/2022] Open
Abstract
Background Traumatic brain injury (TBI) is a leading cause of morbidity and mortality. There are currently no cytoprotective treatments for TBI. There is growing evidence that the histone deacetylase inhibitor valproic acid (VPA) may be beneficial in the treatment of TBI associated with hemorrhagic shock and in isolation. We sought to further evaluate the mechanistic underpinnings of this demonstrated efficacy via proteomic analysis of injured brain tissue. Methods Swine were subjected to TBI via controlled cortical impact, randomized to treatment with VPA or control and observed for 6 hours. The brains of the pigs were then sectioned, and tissue was prepared and analyzed for proteomic data, including gene ontology (GO), gene-set enrichment analysis and enrichment mapping, and network mapping. Results Proteomic analysis demonstrated differential expression of hundreds of proteins in injured brain tissue after treatment with VPA. GO analysis and network analyses revealed groups of proteins and processes that are known to modulate injury response after TBI and impact cell fate. Processes affected included protein targeting and transport, cation and G-protein signaling, metabolic response, neurotransmitter response and immune function. Discussion This proteomic analysis provides initial mechanistic insight into the observed rescue of injured brain tissue after VPA administration in isolated TBI. Level of evidence Not applicable (animal study).
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Affiliation(s)
| | - Aaron M Williams
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael T Kemp
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Glenn K Wakam
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Hasan B Alam
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Surgery, Northwestern University, Evanston, Illinois, USA
| | - Ben E Biesterveld
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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17
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Musick S, Alberico A. Neurologic Assessment of the Neurocritical Care Patient. Front Neurol 2021; 12:588989. [PMID: 33828517 PMCID: PMC8019734 DOI: 10.3389/fneur.2021.588989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/02/2021] [Indexed: 11/30/2022] Open
Abstract
Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.
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Affiliation(s)
- Shane Musick
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
| | - Anthony Alberico
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
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18
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Sungura R, Onyambu C, Mpolya E, Sauli E, Vianney JM. The extended scope of neuroimaging and prospects in brain atrophy mitigation: A systematic review. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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19
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Tomaiuolo F, Cerasa A, Lerch JP, Bivona U, Carlesimo GA, Ciurli P, Raffa G, Quattropani MC, Germanò A, Caltagirone C, Formisano R, Nigro S. Brain Neurodegeneration in the Chronic Stage of the Survivors from Severe Non-Missile Traumatic Brain Injury: A Voxel-Based Morphometry Within-Group at One versus Nine Years from a Head Injury. J Neurotrauma 2020; 38:283-290. [PMID: 32962533 DOI: 10.1089/neu.2020.7203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The long-term time course of neuropathological changes occurring in survivors from severe traumatic brain injury (TBI) remains uncertain. We investigated the brain morphometry and memory performance modifications within the same group of severe non-missile traumatic brain injury patients (nmTBI) after about ∼one year and at ∼ nine years from injury. Brain magnetic resonance imaging (MRI) measurements were performed with voxel-based morphometry (VBM) to determine specific changes in the gray matter (GM) and white matter (WM) and the overall gray matter volume modifications (GMV) and white matter volume modifications (WMV). Contemporarily, memory-tests were also administered. In comparison with healthy control subjects (HC), those with nmTBI showed a significant change and volume reduction in the GM and WM and also in the GMV and WMV after ∼one year; conversely, ∼nine years after injury, neurodegenerative changes spared the GM and GMV, but a prominent loss was detected in WMV and in WM sites, such as the superior longitudinal fasciculi, the body of the corpus callosum, the optic radiation, and the uncinate fasciculus. Memory performance at ∼one year in comparison with ∼nine years was stable with a subtle but significant trend toward recovery. These data demonstrate that patients with nmTBI undergo neurodegenerative processes during the chronic stage affecting mainly the cerebral WM rather than GM. Despite these anatomical brain parenchyma losses, memory performance tends to be stable or even slightly recovered. These results suggest possible correlations between progressive demyelinization and/or neuropsychiatric changes other than memory performance, and support possible treatments to prevent long-term WM degeneration of the examined nmTBI.
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Affiliation(s)
- Francesco Tomaiuolo
- Department of Clinical and Experimental Medicine and Department BIOMORF, University of Messina, Messina, Italy
| | - Antonio Cerasa
- IRIB, National Research Council, Cosenza, Italy, and S. Anna Institute and Research in Advanced Neurorehabilitation (RAN), Crotone, Italy
| | - Jason P Lerch
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, The University of Oxford, Oxford, United Kingdom
| | | | - Giovanni Augusto Carlesimo
- IRCCS Fondazione 'Santa Lucia', Rome, Italy.,Dipartimento di Medicina dei Sistemi, Università Tor Vergata, Rome, Italy
| | | | - Giovanni Raffa
- Division of Neurosurgery, Department BIOMORF, University of Messina, Messina, Italy
| | - Marina Catena Quattropani
- Department of Clinical and Experimental Medicine and Department BIOMORF, University of Messina, Messina, Italy
| | - Antonino Germanò
- Division of Neurosurgery, Department BIOMORF, University of Messina, Messina, Italy
| | | | | | - Salvatore Nigro
- Institute of Nanotechnology (NANOTEC), National Research Council, Lecce, Italy
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20
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Schwartz L, Peres S, Jolicoeur M, da Veiga Moreira J. Cancer and Alzheimer's disease: intracellular pH scales the metabolic disorders. Biogerontology 2020; 21:683-694. [PMID: 32617766 DOI: 10.1007/s10522-020-09888-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 06/23/2020] [Indexed: 12/14/2022]
Abstract
Alzheimer's disease (AD) and cancer have much in common than previously recognized. These pathologies share common risk factors (inflammation and aging), with similar epidemiological and biochemical features such as impaired mitochondria. Metabolic reprogramming occurs during aging and inflammation. We assume that inflammation is directly responsible of the Warburg effect in cancer cells, with a decreased oxidative phosphorylation and a compensatory highthroughput glycolysis (HTG). Similarly, the Warburg effect in cancer is thought to support an alkaline intracellular pH (pHi), a key component of unrelenting cell growth. In the brain, inflammation results in increased secretion of lactate by astrocytes. The increased uptake of lactic acid by neurons results in the inverse Warburg effect, such as seen in AD. The neuronal activity is dampened by a fall of pHi. Pronounced cytosol acidification results in decreased mitochondrial energy yield as well as apoptotic cell death. The link between AD and cancer is reinforced by the fact that treatment aiming at restoring the mitochondrial activity have been experimentally shown to be effective in both diseases. Low carb diet, lipoic acid, and/or methylene blue could then appear promising in both sets of these clinically diverse diseases.
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Affiliation(s)
| | - Sabine Peres
- LRI, Université Paris-Sud, CNRS, Université Paris-Saclay, 91405, Orsay, France.,MaIAGE, INRA, Université Paris-Saclay, 78350, Jouy-en-Josas, France
| | - Mario Jolicoeur
- Research Laboratory in Applied Metabolic Engineering, Department of Chemical, Engineering, Ecole Polytechnique de Montréal, Montréal, QC, Canada
| | - Jorgelindo da Veiga Moreira
- Research Laboratory in Applied Metabolic Engineering, Department of Chemical, Engineering, Ecole Polytechnique de Montréal, Montréal, QC, Canada.
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Intranasal Insulin Treatment Attenuates Metabolic Distress and Early Brain Injury After Subarachnoid Hemorrhage in Mice. Neurocrit Care 2020; 34:154-166. [PMID: 32495315 DOI: 10.1007/s12028-020-01011-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Intranasal administration of insulin to the brain bypasses the blood brain barrier (BBB) and can increase cerebral glucose uptake and prevent energy failure. Intranasal insulin treatment has shown neuroprotective effects in multiple central nervous system (CNS) lesions, but the effects of intranasal insulin on the metabolic and pathological process of subarachnoid hemorrhage (SAH) are not clear. This study is designed to explore the effects of intranasal insulin treatment on metabolic distress and early brain injury (EBI) after experimental SAH. METHODS SAH model was built by endovascular filament perforation method in adult male C57BL/6J mice, and then, insulin was administrated via intranasal route at 0, 24, and 48 h post-SAH. EBI was assessed according to the neurological performance, BBB damage, brain edema, neuroinflammatory reaction, and neuronal apoptosis at each time point. To evaluate metabolic conditions, microdialysis was used to continuously monitor the real-time levels of glucose, pyruvate, and lactate in interstitial fluid (ISF) in living animals. The mRNA and protein expression of glucose transporter-1 and 3 (GLUT-1 and -3) were also tested by RT-PCR and Western blot in brain after SAH. RESULTS Compared to vehicle, intranasal insulin treatment promoted the relative mRNA and protein levels of GLUT-1 in SAH brain (0.98 ± 0.020 vs 0.33 ± 0.016 at 24 h, 0.91 ± 0.25 vs 0.21 ± 0.013 at 48 h and 0.94 ± 0.025 vs 0.28 ± 0.015 at 72 h in mRNA/0.96 ± 0.023 vs 0.36 ± 0.015 at 24 h, 0.91 ± 0.022 vs 0.22 ± 0.011 at 48 h and 0.95 ± 0.024 vs 0.27 ± 0.014 at 72 h in protein, n = 8/Group, p < 0.001). Similar results were also observed in GLUT-3. Intranasal insulin reduced the lactate/pyruvate ratio (LPR) and increased ISF glucose level. It also improved neurological dysfunction, BBB damage, and brain edema and attenuated the levels of pro-inflammatory cytokines as well as neuronal apoptosis after SAH. CONCLUSIONS The intranasal insulin treatment protects brain from EBI possibly via improving metabolic distress after SAH.
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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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Busl KM, Bleck TP, Varelas PN. Neurocritical Care Outcomes, Research, and Technology: A Review. JAMA Neurol 2020; 76:612-618. [PMID: 30667464 DOI: 10.1001/jamaneurol.2018.4407] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Neurocritical care has grown into an organized specialty that may have consequences for patient care, outcomes, research, and neurointensive care (neuroICU) technology. Observations Neurocritical care improves care and outcomes of the patients who are neurocritically ill, and neuroICUs positively affect the financial state of health care systems. The development of neurocritical care as a recognized subspecialty has fostered multidisciplinary research, neuromonitoring, and neurocritical care information technology, with advances and innovations in practice and progress. Conclusions and Relevance Neurocritical care has become an important part of health systems and an established subspecialty of neurology. Understanding its structure, scope of practice, consequences for care, and research are important.
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Affiliation(s)
- Katharina Maria Busl
- NeuroIntensive Care Unit, University of Florida Health Shands Hospital, Gainesville.,Department of Neurology, Division of Neurocritical Care, College of Medicine, University of Florida, Gainesville
| | - Thomas P Bleck
- Rush University Medical Center, Rush Medical College, Chicago, Illinois
| | - Panayiotis N Varelas
- Neurosciences Critical Care Services, Neuro-Intensive Care Unit, Henry Ford Hospital, Wayne State University, Detroit, Michigan
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Scoppettuolo P, Gaspard N, Depondt C, Legros B, Ligot N, Naeije G. Epileptic activity in neurological deterioration after ischemic stroke, a continuous EEG study. Clin Neurophysiol 2019; 130:2282-2286. [DOI: 10.1016/j.clinph.2019.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 08/23/2019] [Accepted: 09/15/2019] [Indexed: 12/13/2022]
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Zahra K, Gopal N, Freeman WD, Turnbull MT. Using Cerebral Metabolites to Guide Precision Medicine for Subarachnoid Hemorrhage: Lactate and Pyruvate. Metabolites 2019; 9:metabo9110245. [PMID: 31652842 PMCID: PMC6918279 DOI: 10.3390/metabo9110245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/09/2019] [Accepted: 10/22/2019] [Indexed: 12/20/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is one of the deadliest types of strokes with high rates of morbidity and permanent injury. Fluctuations in the levels of cerebral metabolites following SAH can be indicators of brain injury severity. Specifically, the changes in the levels of key metabolites involved in cellular metabolism, lactate and pyruvate, can be used as a biomarker for patient prognosis and tailor treatment to an individual’s needs. Here, clinical research is reviewed on the usefulness of cerebral lactate and pyruvate measurements as a predictive tool for SAH outcomes and their potential to guide a precision medicine approach to treatment.
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Affiliation(s)
- Kaneez Zahra
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.
| | - Neethu Gopal
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.
| | - William D Freeman
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.
- Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.
| | - Marion T Turnbull
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.
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Harris TC, de Rooij R, Kuhl E. The Shrinking Brain: Cerebral Atrophy Following Traumatic Brain Injury. Ann Biomed Eng 2019; 47:1941-1959. [PMID: 30341741 PMCID: PMC6757025 DOI: 10.1007/s10439-018-02148-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/01/2018] [Indexed: 11/29/2022]
Abstract
Cerebral atrophy in response to traumatic brain injury is a well-documented phenomenon in both primary investigations and review articles. Recent atrophy studies focus on exploring the region-specific patterns of cerebral atrophy; yet, there is no study that analyzes and synthesizes the emerging atrophy patterns in a single comprehensive review. Here we attempt to fill this gap in our current knowledge by integrating the current literature into a cohesive theory of preferential brain tissue loss and by identifying common risk factors for accelerated atrophy progression. Our review reveals that observations for mild traumatic brain injury remain inconclusive, whereas observations for moderate-to-severe traumatic brain injury converge towards robust patterns: brain tissue loss is on the order of 5% per year, and occurs in the form of generalized atrophy, across the entire brain, or focal atrophy, in specific brain regions. The most common regions of focal atrophy are the thalamus, hippocampus, and cerebellum in gray matter and the corpus callosum, corona radiata, and brainstem in white matter. We illustrate the differences of generalized and focal gray and white matter atrophy on emerging deformation and stress profiles across the whole brain using computational simulation. The characteristic features of our atrophy simulations-a widening of the cortical sulci, a gradual enlargement of the ventricles, and a pronounced cortical thinning-agree well with clinical observations. Understanding region-specific atrophy patterns in response to traumatic brain injury has significant implications in modeling, simulating, and predicting injury outcomes. Computational modeling of brain atrophy could open new strategies for physicians to make informed decisions for whom, how, and when to administer pharmaceutical treatment to manage the chronic loss of brain structure and function.
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Intracranial Monitoring in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Cole JH, Jolly A, de Simoni S, Bourke N, Patel MC, Scott G, Sharp DJ. Spatial patterns of progressive brain volume loss after moderate-severe traumatic brain injury. Brain 2019; 141:822-836. [PMID: 29309542 PMCID: PMC5837530 DOI: 10.1093/brain/awx354] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 11/08/2017] [Indexed: 12/14/2022] Open
Abstract
Traumatic brain injury leads to significant loss of brain volume, which continues into the chronic stage. This can be sensitively measured using volumetric analysis of MRI. Here we: (i) investigated longitudinal patterns of brain atrophy; (ii) tested whether atrophy is greatest in sulcal cortical regions; and (iii) showed how atrophy could be used to power intervention trials aimed at slowing neurodegeneration. In 61 patients with moderate-severe traumatic brain injury (mean age = 41.55 years ± 12.77) and 32 healthy controls (mean age = 34.22 years ± 10.29), cross-sectional and longitudinal (1-year follow-up) brain structure was assessed using voxel-based morphometry on T1-weighted scans. Longitudinal brain volume changes were characterized using a novel neuroimaging analysis pipeline that generates a Jacobian determinant metric, reflecting spatial warping between baseline and follow-up scans. Jacobian determinant values were summarized regionally and compared with clinical and neuropsychological measures. Patients with traumatic brain injury showed lower grey and white matter volume in multiple brain regions compared to controls at baseline. Atrophy over 1 year was pronounced following traumatic brain injury. Patients with traumatic brain injury lost a mean (± standard deviation) of 1.55% ± 2.19 of grey matter volume per year, 1.49% ± 2.20 of white matter volume or 1.51% ± 1.60 of whole brain volume. Healthy controls lost 0.55% ± 1.13 of grey matter volume and gained 0.26% ± 1.11 of white matter volume; equating to a 0.22% ± 0.83 reduction in whole brain volume. Atrophy was greatest in white matter, where the majority (84%) of regions were affected. This effect was independent of and substantially greater than that of ageing. Increased atrophy was also seen in cortical sulci compared to gyri. There was no relationship between atrophy and time since injury or age at baseline. Atrophy rates were related to memory performance at the end of the follow-up period, as well as to changes in memory performance, prior to multiple comparison correction. In conclusion, traumatic brain injury results in progressive loss of brain tissue volume, which continues for many years post-injury. Atrophy is most prominent in the white matter, but is also more pronounced in cortical sulci compared to gyri. These findings suggest the Jacobian determinant provides a method of quantifying brain atrophy following a traumatic brain injury and is informative in determining the long-term neurodegenerative effects after injury. Power calculations indicate that Jacobian determinant images are an efficient surrogate marker in clinical trials of neuroprotective therapeutics.
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Affiliation(s)
- James H Cole
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Amy Jolly
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Sara de Simoni
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Niall Bourke
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Maneesh C Patel
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - Gregory Scott
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
| | - David J Sharp
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Imperial College London, Division of Brain Sciences, Hammersmith Hospital, London, UK
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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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Sambin S, Gaspard N, Legros B, Depondt C, De Breucker S, Naeije G. Role of Epileptic Activity in Older Adults With Delirium, a Prospective Continuous EEG Study. Front Neurol 2019; 10:263. [PMID: 30941098 PMCID: PMC6434717 DOI: 10.3389/fneur.2019.00263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/27/2019] [Indexed: 12/29/2022] Open
Abstract
Background/Objectives: Delirium occurs in up to 50 % of hospitalized old patients and is associated with increased morbidity and mortality. Acute medical conditions favor delirium, but the pathophysiology is unclear. Preliminary evidence from retrospective and prospective studies suggests that a substantial minority of old patients with unexplained delirium have non-convulsive seizures or status epilepticus (NCSE). Yet, seeking epileptic activity only in unexplained cases of delirium might result in misinterpretation of its actual prevalence. We aimed to systematically investigate the role of epileptic activity in all older patients with delirium regardless of the underlying etiology. Design, Setting: Prospective observational study in a tertiary medical center. Adults >65 years with delirium underwent at least 24 h of continuous electro-encephalographic monitoring (cEEG). Background patterns and ictal and interictal epileptic discharges were identified, as well as clinical and biological characteristics. Participants: Fifty patients were included in the study. Results: NCSE was found in 6 (12%) patients and interictal discharges in 15 (30%). There was no difference in the prevalence of epileptic activity rates between delirium associated with an acute medical condition and delirium of unknown etiology. Conclusion: Epileptic activity may play a substantial role in the pathophysiology of delirium by altering brain functioning and neuronal metabolism. No clinical or biological marker was found to distinguish delirious patients with or without epileptic activity, underlining the importance of cEEG in this context.
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Affiliation(s)
- Sara Sambin
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Nicolas Gaspard
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Benjamin Legros
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Chantal Depondt
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Sandra De Breucker
- Geriatrics Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Gilles Naeije
- Neurology Department, ULB-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Taş YÇ, Solaroğlu İ, Gürsoy-Özdemir Y. Spreading Depolarization Waves in Neurological Diseases: A Short Review about its Pathophysiology and Clinical Relevance. Curr Neuropharmacol 2019; 17:151-164. [PMID: 28925885 PMCID: PMC6343201 DOI: 10.2174/1570159x15666170915160707] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/03/2017] [Accepted: 09/09/2017] [Indexed: 02/05/2023] Open
Abstract
Lesion growth following acutely injured brain tissue after stroke, subarachnoid hemorrhage and traumatic brain injury is an important issue and a new target area for promising therapeutic interventions. Spreading depolarization or peri-lesion depolarization waves were demonstrated as one of the significant contributors of continued lesion growth. In this short review, we discuss the pathophysiology for SD forming events and try to list findings detected in neurological disorders like migraine, stroke, subarachnoid hemorrhage and traumatic brain injury in both human as well as experimental studies. Pharmacological and non-pharmacological treatment strategies are highlighted and future directions and research limitations are discussed.
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Affiliation(s)
| | | | - Yasemin Gürsoy-Özdemir
- Address correspondence to these authors at the Department of Neurosurgery, School of Medicine, Koç University, İstanbul, Turkey; Tel: +90 850 250 8250; E-mails: ,
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Spotlight on Neurotrauma Research in Canada's Leading Academic Centers. J Neurotrauma 2018; 35:1986-2004. [PMID: 30074875 DOI: 10.1089/neu.2018.29017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Harris T, Azar A, Sapir G, Gamliel A, Nardi-Schreiber A, Sosna J, Gomori JM, Katz-Brull R. Real-time ex-vivo measurement of brain metabolism using hyperpolarized [1- 13C]pyruvate. Sci Rep 2018; 8:9564. [PMID: 29934508 PMCID: PMC6014998 DOI: 10.1038/s41598-018-27747-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 06/11/2018] [Indexed: 12/19/2022] Open
Abstract
The ability to directly monitor in vivo brain metabolism in real time in a matter of seconds using the dissolution dynamic nuclear polarization technology holds promise to aid the understanding of brain physiology in health and disease. However, translating the hyperpolarized signal observed in the brain to cerebral metabolic rates is not straightforward, as the observed in vivo signals reflect also the influx of metabolites produced in the body, the cerebral blood volume, and the rate of transport across the blood brain barrier. We introduce a method to study rapid metabolism of hyperpolarized substrates in the viable rat brain slices preparation, an established ex vivo model of the brain. By retrospective evaluation of tissue motion and settling from analysis of the signal of the hyperpolarized [1-13C]pyruvate precursor, the T1s of the metabolites and their rates of production can be determined. The enzymatic rates determined here are in the range of those determined previously with classical biochemical assays and are in agreement with hyperpolarized metabolite relative signal intensities observed in the rodent brain in vivo.
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Affiliation(s)
- Talia Harris
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - Assad Azar
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - Gal Sapir
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - Ayelet Gamliel
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - Atara Nardi-Schreiber
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - Jacob Sosna
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - J Moshe Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, 9112001, Israel
| | - Rachel Katz-Brull
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, 9112001, Israel.
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Harutyunyan G, Harutyunyan G, Mkhoyan G. New Viewpoint in Exaggerated Increase of PtiO 2 With Normobaric Hyperoxygenation and Reasons to Limit Oxygen Use in Neurotrauma Patients. Front Med (Lausanne) 2018; 5:119. [PMID: 29872657 PMCID: PMC5972302 DOI: 10.3389/fmed.2018.00119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 04/10/2018] [Indexed: 01/06/2023] Open
Affiliation(s)
| | | | - Gagik Mkhoyan
- Anesthesiology and Intensive Care, Erebouni Medical Center, Yerevan, Armenia
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Sharma B, Lawrence DW, Hutchison MG. Branched Chain Amino Acids (BCAAs) and Traumatic Brain Injury: A Systematic Review. J Head Trauma Rehabil 2018; 33:33-45. [DOI: 10.1097/htr.0000000000000280] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Cerebrospinal fluid and brain extracellular fluid in severe brain trauma. HANDBOOK OF CLINICAL NEUROLOGY 2018; 146:237-258. [DOI: 10.1016/b978-0-12-804279-3.00014-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Zeiler FA, Thelin EP, Helmy A, Czosnyka M, Hutchinson PJA, Menon DK. A systematic review of cerebral microdialysis and outcomes in TBI: relationships to patient functional outcome, neurophysiologic measures, and tissue outcome. Acta Neurochir (Wien) 2017; 159:2245-2273. [PMID: 28988334 PMCID: PMC5686263 DOI: 10.1007/s00701-017-3338-2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 09/19/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To perform a systematic review on commonly measured cerebral microdialysis (CMD) analytes and their association to: (A) patient functional outcome, (B) neurophysiologic measures, and (C) tissue outcome; after moderate/severe TBI. The aim was to provide a foundation for next-generation CMD studies and build on existing pragmatic expert guidelines for CMD. METHODS We searched MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library (inception to October 2016). Strength of evidence was adjudicated using GRADE. RESULTS (A) Functional Outcome: 55 articles were included, assessing outcome as mortality or Glasgow Outcome Scale (GOS) at 3-6 months post-injury. Overall, there is GRADE C evidence to support an association between CMD glucose, glutamate, glycerol, lactate, and LPR to patient outcome at 3-6 months. (B) Neurophysiologic Measures: 59 articles were included. Overall, there currently exists GRADE C level of evidence supporting an association between elevated CMD measured mean LPR, glutamate and glycerol with elevated ICP and/or decreased CPP. In addition, there currently exists GRADE C evidence to support an association between elevated mean lactate:pyruvate ratio (LPR) and low PbtO2. Remaining CMD measures and physiologic outcomes displayed GRADE D or no evidence to support a relationship. (C) Tissue Outcome: four studies were included. Given the conflicting literature, the only conclusion that can be drawn is acute/subacute phase elevation of CMD measured LPR is associated with frontal lobe atrophy at 6 months. CONCLUSIONS This systematic review replicates previously documented relationships between CMD and various outcome, which have driven clinical application of the technique. Evidence assessments do not address the application of CMD for exploring pathophysiology or titrating therapy in individual patients, and do not account for the modulatory effect of therapy on outcome, triggered at different CMD thresholds in individual centers. Our findings support clinical application of CMD and refinement of existing guidelines.
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Affiliation(s)
- Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9 Canada
- Clinician Investigator Program, University of Manitoba, Winnipeg, Canada
- Department of Anesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Eric Peter Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Department of Clinical Neuroscience, Neurosurgical Research Laboratory, Karolinska University Hospital, Building R2:02, Karolinska Institutet, S-17176 Stockholm, Sweden
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Section of Brain Physics, Division of Neurosurgery, University of Cambridge, Cambridge, CB2 0QQ UK
| | - Peter J. A. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - David K. Menon
- Department of Anesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
- Queens’ College, Cambridge, UK
- National Institute for Health Research, Southampton, UK
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Mannino C, Glenn TC, Hovda DA, Vespa PM, McArthur DL, Van Horn JD, Wright MJ. Acute glucose and lactate metabolism are associated with cognitive recovery following traumatic brain injury. J Neurosci Res 2017; 96:696-701. [PMID: 28609544 DOI: 10.1002/jnr.24097] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/11/2017] [Accepted: 05/12/2017] [Indexed: 11/08/2022]
Abstract
Traumatic brain injury (TBI) is associated with acute cerebral metabolic crisis (ACMC). ACMC-related atrophy appears to be prominent in frontal and temporal lobes following moderate-to-severe TBI. This atrophy is correlated with poorer cognitive outcomes in TBI. The current study investigated ability of acute glucose and lactate metabolism to predict long-term recovery of frontal-temporal cognitive function in participants with moderate-to-severe TBI. Cerebral metabolic rate of glucose and lactate were measured by the Kety-Schmidt method on days 0-7 post-injury. Indices of frontal-temporal cognitive processing were calculated for six months post-injury; 12 months post-injury; and recovery (the difference between the six- and 12-month scores). Glucose and lactate metabolism were included in separate regression models, as they were highly intercorrelated. Also, glucose and lactate values were centered and averaged and included in a final regression model. Models for the prediction frontal-temporal cognition at six and 12 months post-injury were not significant. However, average glucose and lactate metabolism predicted recovery of frontal-temporal cognition, accounting for 23% and 22% of the variance, respectively. Also, maximum glucose metabolism, but not maximum lactate metabolism, was an inverse predictor in the recovery of frontal-temporal cognition, accounting for 23% of the variance. Finally, the average of glucose and lactate metabolism predicted frontal-temporal cognitive recovery, accounting for 22% of the variance. These data indicate that acute glucose and lactate metabolism both support cognitive recovery from TBI. Also, our data suggest that control of endogenous fuels and/or supplementation with exogenous fuels may have therapeutic potential for cognitive recovery from TBI.
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Affiliation(s)
| | - Thomas C Glenn
- University of California, Los Angeles, Department of Neurosurgery
| | - David A Hovda
- University of California, Los Angeles, Department of Neurosurgery
| | - Paul M Vespa
- University of California, Los Angeles, Department of Neurosurgery.,University of California, Los Angeles, Department of Neurology
| | - David L McArthur
- University of California, Los Angeles, Department of Neurosurgery
| | - John D Van Horn
- University of Southern California, Laboratory of Neuro Imaging, Institute for Neuroimaging Informatics, Department of Neurology
| | - Matthew J Wright
- University of California, Los Angeles, Department of Psychiatry and Biobehavioral Sciences.,Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
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Küchler J, Wojak J, Abusamha A, Ditz C, Tronnier VM, Gliemroth J. Analysis of extracellular brain chemistry during percutaneous dilational tracheostomy: A retrospective study of 19 patients. Clin Neurol Neurosurg 2017; 159:1-5. [PMID: 28511149 DOI: 10.1016/j.clineuro.2017.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 04/30/2017] [Accepted: 05/08/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze changes in brain tissue chemistry around percutaneous dilational tracheostomy (PDT) in patients with acute brain injury (ABI) in a retrospective single-center analysis. PATIENTS AND METHODS We included 19 patients who had continuous monitoring of brain tissue chemistry and intracranial pressure (ICP) during a 20h period before and after PDT. Different microdialysis parameters (lactate, pyruvate, lactate pyruvate ratio (LPR), glycerol and glutamate) and values of ICP, cerebral perfusion pressure (CPP) and brain tissue oxygenation (PBrO2) were recorded per hour. Mean values were compared between a 10h period before PDT (prePDT) and after PDT (postPDT). RESULTS Mean values of cerebral lactate, pyruvate, LPR, glycerol and glutamate did not differ significantly between prePDT and postPDT. In addition, the rate of patients, which exceeded the known threshold was similar between prePDT and postPDT. Only one patient showed a strong increase of cerebral glycerol during the postPDT period, but analysis of subcutaneous glycerol could exclude an intracerebral event. ICP, CPP and PBrO2 did not exhibit significant changes. CONCLUSIONS We could exclude the occurrence of cerebral metabolic crisis and the excess release of cerebral glutamate and glycerol in a series of 19 patients. Our results support the safety of PDT in patients with ABI.
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Affiliation(s)
- Jan Küchler
- Department of Neurosurgery, University of Lübeck, Germany.
| | - Jann Wojak
- Department of Neurosurgery, University of Lübeck, Germany
| | | | - Claudia Ditz
- Department of Neurosurgery, University of Lübeck, Germany
| | | | - Jan Gliemroth
- Department of Neurosurgery, University of Lübeck, Germany
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Sahu S, Nag DS, Swain A, Samaddar DP. Biochemical changes in the injured brain. World J Biol Chem 2017; 8:21-31. [PMID: 28289516 PMCID: PMC5329711 DOI: 10.4331/wjbc.v8.i1.21] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/23/2016] [Accepted: 12/13/2016] [Indexed: 02/05/2023] Open
Abstract
Brain metabolism is an energy intensive phenomenon involving a wide spectrum of chemical intermediaries. Various injury states have a detrimental effect on the biochemical processes involved in the homeostatic and electrophysiological properties of the brain. The biochemical markers of brain injury are a recent addition in the armamentarium of neuro-clinicians and are being increasingly used in the routine management of neuro-pathological entities such as traumatic brain injury, stroke, subarachnoid haemorrhage and intracranial space occupying lesions. These markers are increasingly being used in assessing severity as well as in predicting the prognostic course of neuro-pathological lesions. S-100 protein, neuron specific enolase, creatinine phosphokinase isoenzyme BB and myelin basic protein are some of the biochemical markers which have been proven to have prognostic and clinical value in the brain injury. While S-100, glial fibrillary acidic protein and ubiquitin C terminal hydrolase are early biomarkers of neuronal injury and have the potential to aid in clinical decision-making in the initial management of patients presenting with an acute neuronal crisis, the other biomarkers are of value in predicting long-term complications and prognosis in such patients. In recent times cerebral microdialysis has established itself as a novel way of monitoring brain tissue biochemical metabolites such as glucose, lactate, pyruvate, glutamate and glycerol while small non-coding RNAs have presented themselves as potential markers of brain injury for future.
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Abstract
Neurocritical care has two main objectives. Initially, the emphasis is on treatment of patients with acute damage to the central nervous system whether through infection, trauma, or hemorrhagic or ischemic stroke. Thereafter, attention shifts to the identification of secondary processes that may lead to further brain injury, including fever, seizures, and ischemia, among others. Multimodal monitoring is the concept of using various tools and data integration to understand brain physiology and guide therapeutic interventions to prevent secondary brain injury. This chapter will review the use of electroencephalography, intracranial pressure monitoring, brain tissue oxygenation, cerebral microdialysis and neurochemistry, near-infrared spectroscopy, and transcranial Doppler sonography as they relate to neuromonitoring in the critically ill. The concepts and design of each monitor, in addition to the patient population that may most benefit from each modality, will be discussed, along with the various tools that can be used together to guide individualized patient treatment options. Major clinical trials, observational studies, and their effect on clinical outcomes will be reviewed. The future of multimodal monitoring in the field of bioinformatics, clinical research, and device development will conclude the chapter.
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Affiliation(s)
- G Korbakis
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - P M Vespa
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
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Das C, Wang G, Sun Q, Ledden B. Multiplexed and fully automated detection of metabolic biomarkers using microdialysis probe. SENSORS AND ACTUATORS. B, CHEMICAL 2017; 238:633-640. [PMID: 28090149 PMCID: PMC5224532 DOI: 10.1016/j.snb.2016.07.097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
We report here, the design and development of an automated near real-time continuous detection system for lactate, glutamate, pyruvate and glucose using microdialysis probe. The system developed can automatically push perfusate through microdialysis probe (20, 100 and 1000 kDa MWCO cutoff probe) at low to medium flow rate of 0.5-2 μL/min with almost 100% fluid recovery. The microdialysate collected from the probe is analyzed automatically for these four metabolite biomarkers. It operates in a continuous mode with measurements of all four biomarkers once every 20 min. The dynamic range for these different markers covers the entire clinical range of traumatic brain injury. The prototype shows a low variation of ~ 7-10% across the entire clinical range for all the biomarkers with fairly good accuracy of ~95%. The instrument canrun continuously for 24 h without user intervention. With a long tubing of 1 m to and from the microdialysis probe and associated dead volume, the total lag time for actual event at the probe site versusreported concentration is roughly 1 h.
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Abstract
PURPOSE OF REVIEW Alterations of blood glucose levels are secondary insults with detrimental consequences for the injured brain. Here, we review various aspects of brain glucose metabolism and analyze the evidence on glycemic control during acute brain injury. RECENT FINDINGS An essential component in the overall management of acute brain injury, especially during the acute phase, is maintaining adequate and appropriate control of serum glucose. This is one of the few physiological parameters that is modifiable. Hypoglycemia should be rigorously avoided. However, intensive insulin therapy is associated with unacceptable rates of hypoglycemia and metabolic crisis, and does not necessarily provide benefit. Hyperglycemia is harmful to the injured brain as it compromises microcirculatory blood flow, increases blood-brain barrier permeability, and promotes inflammation. In addition, it triggers osmotic diuresis, hypovolemia, and immunosuppression. SUMMARY Glucose is the primary energy substrate for the brain. During injury, the brain increases its needs and is vulnerable to glucose deficit. In these situations, alternative fuel can be lactate, which has potential implications for future research. In this review, various pathophysiological aspects of glucose metabolism during acute brain injury, as well as the risks, causes, and consequences of glucose deficiency or excess, will be discussed.
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McAllister TW. Mild Traumatic Brain Injury. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2016; 14:410-421. [PMID: 31975821 DOI: 10.1176/appi.focus.20160025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Mild traumatic brain injury (MTBI) is a significant public health problem worldwide. Injured individuals have an increased relative risk of developing a variety of neuropsychiatric conditions associated with the profile of brain regions typically affected in TBI. Within a neurobiopsychosocial framework, this article reviews what is known about the neuropsychiatric sequelae of MTBI, with an emphasis on recent advances.
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Affiliation(s)
- Thomas W McAllister
- Dr. McAllister is with the Department of Psychiatry, Indiana University School of Medicine, Indianapolis (e-mail: )
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Wolahan SM, Hirt D, Braas D, Glenn TC. Role of Metabolomics in Traumatic Brain Injury Research. Neurosurg Clin N Am 2016; 27:465-72. [PMID: 27637396 DOI: 10.1016/j.nec.2016.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Metabolomics is an important member of the omics community in that it defines which small molecules may be responsible for disease states. This article reviews the essential principles of metabolomics from specimen preparation, chemical analysis, to advanced statistical methods. Metabolomics in traumatic brain injury has so far been underutilized. Future metabolomics-based studies focused on the diagnoses, prognoses, and treatment effects need to be conducted across all types of traumatic brain injury.
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Affiliation(s)
- Stephanie M Wolahan
- UCLA Brain Injury Research Center, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA; Department of Neurosurgery, David Geffen School of Medicine at UCLA, 300 Stein Plaza, Los Angeles, CA 90095-6901, USA
| | - Daniel Hirt
- UCLA Brain Injury Research Center, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA; Department of Neurosurgery, David Geffen School of Medicine at UCLA, 300 Stein Plaza, Los Angeles, CA 90095-6901, USA
| | - Daniel Braas
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, 570 Westwood Plaza, Los Angeles, CA 90095-1735, USA; UCLA Metabolomics and Proteomics Center, 570 Westwood Plaza, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Thomas C Glenn
- UCLA Brain Injury Research Center, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA; Department of Neurosurgery, David Geffen School of Medicine at UCLA, 300 Stein Plaza, Los Angeles, CA 90095-6901, USA.
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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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Pevzner A, Izadi A, Lee DJ, Shahlaie K, Gurkoff GG. Making Waves in the Brain: What Are Oscillations, and Why Modulating Them Makes Sense for Brain Injury. Front Syst Neurosci 2016; 10:30. [PMID: 27092062 PMCID: PMC4823270 DOI: 10.3389/fnsys.2016.00030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 03/22/2016] [Indexed: 01/19/2023] Open
Abstract
Traumatic brain injury (TBI) can result in persistent cognitive, behavioral and emotional deficits. However, the vast majority of patients are not chronically hospitalized; rather they have to manage their disabilities once they are discharged to home. Promoting recovery to pre-injury level is important from a patient care as well as a societal perspective. Electrical neuromodulation is one approach that has shown promise in alleviating symptoms associated with neurological disorders such as in Parkinson’s disease (PD) and epilepsy. Consistent with this perspective, both animal and clinical studies have revealed that TBI alters physiological oscillatory rhythms. More recently several studies demonstrated that low frequency stimulation improves cognitive outcome in models of TBI. Specifically, stimulation of the septohippocampal circuit in the theta frequency entrained oscillations and improved spatial learning following TBI. In order to evaluate the potential of electrical deep brain stimulation for clinical translation we review the basic neurophysiology of oscillations, their role in cognition and how they are changed post-TBI. Furthermore, we highlight several factors for future pre-clinical and clinical studies to consider, with the hope that it will promote a hypothesis driven approach to subsequent experimental designs and ultimately successful translation to improve outcome in patients with TBI.
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Affiliation(s)
- Aleksandr Pevzner
- Department of Neurological Surgery, University of California-DavisSacramento, CA, USA; Center for Neuroscience, University of California-DavisSacramento, CA, USA
| | - Ali Izadi
- Department of Neurological Surgery, University of California-DavisSacramento, CA, USA; Center for Neuroscience, University of California-DavisSacramento, CA, USA
| | - Darrin J Lee
- Department of Neurological Surgery, University of California-DavisSacramento, CA, USA; Center for Neuroscience, University of California-DavisSacramento, CA, USA
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California-DavisSacramento, CA, USA; Center for Neuroscience, University of California-DavisSacramento, CA, USA
| | - Gene G Gurkoff
- Department of Neurological Surgery, University of California-DavisSacramento, CA, USA; Center for Neuroscience, University of California-DavisSacramento, CA, USA
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Konstantinou N, Pettemeridou E, Seimenis I, Eracleous E, Papacostas SS, Papanicolaou AC, Constantinidou F. Assessing the Relationship between Neurocognitive Performance and Brain Volume in Chronic Moderate-Severe Traumatic Brain Injury. Front Neurol 2016; 7:29. [PMID: 27014183 PMCID: PMC4785138 DOI: 10.3389/fneur.2016.00029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 02/24/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives Characterize the scale and pattern of long-term atrophy in gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF) in chronic moderate–severe traumatic brain injury (TBI) and its relationship to neurocognitive outcomes. Participants The TBI group consisted of 17 males with primary diagnosis of moderate–severe closed head injury. Participants had not received any systematic, post-acute rehabilitation and were recruited on average 8.36 years post-injury. The control group consisted of 15 males matched on age and education. Main measures Neurocognitive battery included widely used tests of verbal memory, visual memory, executive functioning, and attention/organization. GM, WM, and CSF volumes were calculated from segmented T1-weighted anatomical MR images. Voxel-based morphometry was employed to identify brain regions with differences in GM and WM between TBI and control groups. Results Chronic TBI results in significant neurocognitive impairments, and significant loss of GM and WM volume, and significant increase in CSF volume. Brain atrophy is not widespread, but it is rather distributed in a fronto-thalamic network. The extent of volume loss is predictive of performance on the neurocognitive tests. Conclusion Significant brain atrophy and associated neurocognitive impairments during the chronic stages of TBI support the notion that TBI results in a chronic condition with lifelong implications.
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Affiliation(s)
- Nikos Konstantinou
- Center for Applied Neuroscience, University of Cyprus, Nicosia, Cyprus; Department of Psychology, University of Cyprus, Nicosia, Cyprus
| | - Eva Pettemeridou
- Center for Applied Neuroscience, University of Cyprus, Nicosia, Cyprus; Department of Psychology, University of Cyprus, Nicosia, Cyprus
| | - Ioannis Seimenis
- Department of Medical Physics, Medical School, Democritus University of Thrace , Alexandroupolis , Greece
| | - Eleni Eracleous
- Medical Diagnostic Center "Ayios Therissos" , Nicosia , Cyprus
| | - Savvas S Papacostas
- Neurology Clinic B, The Cyprus Institute of Neurology and Genetics, The Cyprus School of Molecular Medicine , Nicosia , Cyprus
| | - Andrew C Papanicolaou
- Division of Clinical Neurosciences, Department of Pediatrics, The Le Bonheur Neuroscience Institute, University of Tennessee Health Science Center, Memphis, TN, USA; Division of Clinical Neurosciences, Department of Neurobiology and Anatomy, The Le Bonheur Neuroscience Institute, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Fofi Constantinidou
- Center for Applied Neuroscience, University of Cyprus, Nicosia, Cyprus; Department of Psychology, University of Cyprus, Nicosia, Cyprus
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Young B, Kalanuria A, Kumar M, Burke K, Balu R, Amendolia O, McNulty K, Marion B, Beckmann B, Ciocco L, Miller K, Schuele D, Maloney-Wilensky E, Frangos S, Wright D. Cerebral Microdialysis. Crit Care Nurs Clin North Am 2016; 28:109-24. [DOI: 10.1016/j.cnc.2015.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kilbaugh TJ, Karlsson M, Duhaime AC, Hansson MJ, Elmer E, Margulies SS. Mitochondrial response in a toddler-aged swine model following diffuse non-impact traumatic brain injury. Mitochondrion 2016; 26:19-25. [PMID: 26549476 PMCID: PMC4752861 DOI: 10.1016/j.mito.2015.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 01/19/2023]
Abstract
Traumatic brain injury (TBI) is an important health problem, and a leading cause of death in children worldwide. Mitochondrial dysfunction is a critical component of the secondary TBI cascades. Mitochondrial response in the pediatric brain has limited investigation, despite evidence that the developing brain's response differs from that of the adult, especially in diffuse non-impact TBI. We performed a detailed evaluation of mitochondrial bioenergetics using high-resolution respirometry in a swine model of diffuse TBI (rapid non-impact rotational injury: RNR), and examined the cortex and hippocampus. A substrate-uncoupler-inhibitor-titration protocol examined the role of the individual complexes as well as the uncoupled maximal respiration. Respiration per mg of tissue was also related to citrate synthase activity (CS) as an attempt to control for variability in mitochondrial content following injury. Diffuse RNR stimulated increased complex II-driven respiration relative to mitochondrial content in the hippocampus compared to shams. LEAK (State 4o) respiration increased in both regions, with decreased respiratory ratios of convergent oxidative phosphorylation through complex I and II, compared to sham animals, indicating uncoupling of oxidative phosphorylation at 24h. The study suggests that proportionately, complex I contribution to convergent mitochondrial respiration was reduced in the hippocampus after RNR, with a simultaneous increase in complex-II driven respiration. Mitochondrial respiration 24h after diffuse TBI varies by location within the brain. We concluded that significant uncoupling of oxidative phosphorylation and alterations in convergent respiration through complex I- and complex II-driven respiration reveals therapeutic opportunities for the injured at-risk pediatric brain.
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Affiliation(s)
- Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA.
| | - Michael Karlsson
- Mitochondrial Medicine, Department of Clinical Sciences, Lund University, BMC A13, SE-221 84 Lund, Sweden.
| | - Ann-Christine Duhaime
- Department of Bioengineering, University of Pennsylvania, 210 South 33rd Street, Philadelphia, PA 19104, USA.
| | - Magnus J Hansson
- Mitochondrial Medicine, Department of Clinical Sciences, Lund University, BMC A13, SE-221 84 Lund, Sweden.
| | - Eskil Elmer
- Mitochondrial Medicine, Department of Clinical Sciences, Lund University, BMC A13, SE-221 84 Lund, Sweden.
| | - Susan S Margulies
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA 02114, USA.
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