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Lee A, Katznelson R, Ouzounian M, Au D, Chung J, Djaiani G, Lindsay T. Adjunctive hyperbaric oxygen therapy for spinal cord ischemia after complex aortic repair. J Vasc Surg 2024; 79:478-484. [PMID: 37925040 DOI: 10.1016/j.jvs.2023.10.055] [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: 06/16/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE Spinal cord ischemia (SCI) with paraplegia or paraparesis is a devastating complication of complex aortic repair (CAR). Treatment includes cerebrospinal fluid drainage, maintenance of hemoglobin concentration (>10 g/L), and elevating mean arterial blood pressure. Animal and human case series have reported improvements in SCI outcomes with hyperbaric oxygen therapy (HBOT). We reviewed our center's experience with HBOT as a rescue treatment for spinal cord ischemia post-CAR in addition to standard treatment. METHODS A retrospective review of the University Health Network's Hyperbaric Medicine Unit treatment database identified HBOT sessions for patients with SCI post-CAR between January 2013 and June 2021. Mean estimates of overall motor function scores were determined for postoperative, pre-HBOT, post-HBOT (within 4 hours of the final HBOT session), and at the final assessment (last available in-hospital evaluation) using a linear mixed model. A subgroup analysis compared the mean estimates of overall motor function scores between improvement and non-improvement groups at given timepoints. Improvement of motor function was defined as either a ≥2 point increase in overall muscle function score in patients with paraparesis or an upward change in motor deficit categorization (para/monoplegia, paraparesis, and no deficit). Subgroup analysis was performed by stratifying by improvement or non-improvement of motor function from pre-HBOT to final evaluation. RESULTS Thirty patients were treated for SCI. Pre-HBOT, the motor deficit categorization was 10 paraplegia, three monoplegia, 16 paraparesis, and one unable to assess. At the final assessment, 14 patients demonstrated variable degrees of motor function improvement; eight patients demonstrated full motor function recovery. Seven of the 10 patients with paraplegia remained paraplegic despite HBOT. The estimated mean of overall muscle function score for pre-HBOT was 16.6 ± 2.9 (95% confidence interval [CI], 10.9-22.3) and for final assessment was 23.4 ± 2.9 (95% CI, 17.7-29.1). The estimated mean difference between pre-HBOT and final assessment overall muscle function score was 6.7 ± 3.1 (95% CI, 0.6-16.1). The estimated mean difference of the overall muscle function score between pre-HBOT and final assessment for the improved group was 16.6 ± 3.5 (95% CI, 7.5-25.7) vs -4.9 ± 4.2 (95% CI, -16.0 to 6.2) for the non-improved group. CONCLUSIONS HBOT, in addition to standard treatment, may potentially improve recovery in spinal cord function following SCI post-CAR. However, the potential benefits of HBOT are not equally distributed among subgroups.
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Affiliation(s)
- Angela Lee
- Division of Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Rita Katznelson
- Hyperbaric Medicine Unit, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Darren Au
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jennifer Chung
- Division of Cardiac Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - George Djaiani
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas Lindsay
- Division of Vascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Effect of Hyperbaric Oxygen Therapy on Sleep Quality, Drug Dosage, and Nerve Function in Patients with Sleep Disorders after Ischemic Cerebral Stroke. Emerg Med Int 2022. [DOI: 10.1155/2022/8307865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective. To explore the effects of hyperbaric oxygen therapy (HOT) on sleep quality, drug dosage, and nerve function in patients with sleep disorders after ischemic cerebral stroke (ICS). Methods. A total of 120 patients with acute ICS and sleep disorders who came to our hospital for treatment from January 2019 to October 2021 were selected and divided into control and observation groups according to the random numbering method, with 60 cases in each group. Both groups were treated with sertraline and eszopiclone for treating insomnia. The control group was given routine treatment for ICS, and the observation group was additionally treated with HOT in addition to the control group. The sleep quality, the use of sleep medication, the neurological function score, and the levels of serum tumor necrosis factor-α (TNF-α), endothelin (ET), and neuropeptide Y (NPY) before and after treatment were compared between the two groups. Results. The levels of TNF-α, ET and NPY were not significantly different between the two groups of patients before treatment (
), and all of the above indicators decreased significantly in both groups after treatment, with the observation group being lower than the control group (
). There was no significant difference in the sleep quality scores of PSQI, ESS, and SBQ between the two groups before treatment (
), and the above indicators decreased significantly in both groups after treatment, with the observation group being lower than the control group (
). There was no significant difference in the dose of sleep medication used in the first day of treatment between the two groups (
), and the amount of sleep medication used in the observation group was significantly less than that in the control group after 14 d of treatment (
). There was no significant difference in the NIHSS scores between the two groups before treatment (
), and the scores of both groups decreased after treatment, and the scores of the observation group were significantly lower than those of the control group (
). Conclusion. Compared with routine treatment, the addition of HOT to treat patients with sleep disorders after ICS can significantly improve their sleep quality, reduce dosage of sleep drugs, reduce inflammatory level of brain tissue and nerve function damage, and improve their prognosis. Trial Registration. This study was registered in the EA2019056
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3
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Siwicka-Gieroba D, Robba C, Gołacki J, Badenes R, Dabrowski W. Cerebral Oxygen Delivery and Consumption in Brain-Injured Patients. J Pers Med 2022; 12:1763. [PMID: 36573716 PMCID: PMC9698645 DOI: 10.3390/jpm12111763] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/30/2022] Open
Abstract
Organism survival depends on oxygen delivery and utilization to maintain the balance of energy and toxic oxidants production. This regulation is crucial to the brain, especially after acute injuries. Secondary insults after brain damage may include impaired cerebral metabolism, ischemia, intracranial hypertension and oxygen concentration disturbances such as hypoxia or hyperoxia. Recent data highlight the important role of clinical protocols in improving oxygen delivery and resulting in lower mortality in brain-injured patients. Clinical protocols guide the rules for oxygen supplementation based on physiological processes such as elevation of oxygen supply (by mean arterial pressure (MAP) and intracranial pressure (ICP) modulation, cerebral vasoreactivity, oxygen capacity) and reduction of oxygen demand (by pharmacological sedation and coma or hypothermia). The aim of this review is to discuss oxygen metabolism in the brain under different conditions.
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Affiliation(s)
- Dorota Siwicka-Gieroba
- Department of Anaesthesiology and Intensive Care, Medical University in Lublin, 20-954 Lublin, Poland
| | - Chiara Robba
- Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
| | - Jakub Gołacki
- Department of Anaesthesiology and Intensive Care, Medical University in Lublin, 20-954 Lublin, Poland
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Wojciech Dabrowski
- Department of Anaesthesiology and Intensive Care, Medical University in Lublin, 20-954 Lublin, Poland
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4
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Marcinkowska AB, Mankowska ND, Kot J, Winklewski PJ. Impact of Hyperbaric Oxygen Therapy on Cognitive Functions: a Systematic Review. Neuropsychol Rev 2022; 32:99-126. [PMID: 33847854 PMCID: PMC8888529 DOI: 10.1007/s11065-021-09500-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 03/07/2021] [Indexed: 12/13/2022]
Abstract
Hyperbaric oxygen therapy (HBOT) is a modality of treatment in which patients inhale 100% oxygen inside a hyperbaric chamber pressurised to greater than 1 atmosphere. The aim of this review is to discuss neuropsychological findings in various neurological disorders treated with HBOT and to open new perspectives for therapeutic improvement. A literature search was conducted in the MEDLINE (via PubMed) database from the inception up 10 May 2020. Eligibility criteria included original articles published in English. Case studies were excluded. Full-text articles were obtained from the selected studies and were reviewed on the following inclusion criteria (1) performed cognitive processes assessment (2) performed HBOT with described protocol. Two neuropsychologists independently reviewed titles, abstracts, full texts and extracted data. The initial search retrieved 1024 articles, and a total of 42 studies were finally included after applying inclusion and exclusion criteria. The search yielded controversial results with regard to the efficiency of HBOT in various neurological conditions with cognitive disturbance outcome. To the best of our knowledge this is the first state-of-the art, systematic review in the field. More objective and precise neuropsychological assessment methods are needed to exact evaluation of the efficacy of HBOT for neuropsychological deficits. Future studies should widen the assessment of HBOT effects on different cognitive domains because most of the existing studies have focussed on a single process. Finally, there is a need for further longitudinal studies.
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Affiliation(s)
- Anna B Marcinkowska
- Applied Cognitive Neuroscience Lab, Department of Human Physiology, Medical University of Gdańsk, Tuwima Str. 15 80-210, Gdańsk, Poland.
- 2nd Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland.
| | - Natalia D Mankowska
- Applied Cognitive Neuroscience Lab, Department of Human Physiology, Medical University of Gdańsk, Tuwima Str. 15 80-210, Gdańsk, Poland
| | - Jacek Kot
- National Centre for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine in Gdynia, Medical University of Gdansk, Gdańsk, Poland
| | - Pawel J Winklewski
- Applied Cognitive Neuroscience Lab, Department of Human Physiology, Medical University of Gdańsk, Tuwima Str. 15 80-210, Gdańsk, Poland
- 2nd Department of Radiology, Medical University of Gdańsk, Gdańsk, Poland
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5
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Bo-Htay C, Shwe T, Jaiwongkam T, Kerdphoo S, Pratchayasakul W, Pattarasakulchai T, Shinlapawittayatorn K, Chattipakorn SC, Chattipakorn N. Hyperbaric oxygen therapy effectively alleviates D-galactose-induced-age-related cardiac dysfunction via attenuating mitochondrial dysfunction in pre-diabetic rats. Aging (Albany NY) 2021; 13:10955-10972. [PMID: 33861726 PMCID: PMC8109141 DOI: 10.18632/aging.202970] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/27/2021] [Indexed: 12/23/2022]
Abstract
Currently, the prevalence of obesity in aging populations is fast growing worldwide. Aging induced by D-galactose (D-gal) is proven to cause the worsening of cardiac dysfunction in pre-diabetic rats via deteriorating cardiac mitochondrial function. Hyperbaric oxygen therapy (HBOT) has been shown to attenuate D-gal-induced cognitive deterioration through decreased inflammation and apoptosis. We tested the hypothesis that HBOT alleviates D-gal induced cardiac dysfunction via improving mitochondrial function in pre-diabetic rats. Wistar rats (n=56) were fed normal diet or high-fat diet for 12 weeks. For subsequent 8 weeks, they were subcutaneously injected either vehicle (0.9% normal saline) or D-gal (150mg/kg/day). Rats were randomly subdivided into 7 groups at week 21: sham-treated (normal diet fed rats with vehicle (NDV), high-fat diet fed rats with vehicle (HFV), normal diet fed rats with D-gal (NDDg), high-fat diet fed rats with D-gal (HFDg)) and HBOT-treated (HFV, NDDg, HFDg). Sham rats received ambient pressure of oxygen while HBOT-treated ones received 100% oxygen given once daily for 60 minutes at 2 atmosphere absolute. HBOT reduced metabolic impairments, mitochondrial dysfunction and increased autophagy, resulting in an improvement of cardiac function in aged pre-diabetic rats.
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Affiliation(s)
- Cherry Bo-Htay
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Thazin Shwe
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Thidarat Jaiwongkam
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Sasiwan Kerdphoo
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Wasana Pratchayasakul
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Thienchai Pattarasakulchai
- Hyperbaric Oxygen Therapy Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Krekwit Shinlapawittayatorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai 50200, Thailand
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6
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Cozene B, Sadanandan N, Gonzales-Portillo B, Saft M, Cho J, Park YJ, Borlongan CV. An Extra Breath of Fresh Air: Hyperbaric Oxygenation as a Stroke Therapeutic. Biomolecules 2020; 10:biom10091279. [PMID: 32899709 PMCID: PMC7563917 DOI: 10.3390/biom10091279] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/26/2020] [Accepted: 09/02/2020] [Indexed: 12/15/2022] Open
Abstract
Stroke serves as a life-threatening disease and continues to face many challenges in the development of safe and effective therapeutic options. The use of hyperbaric oxygen therapy (HBOT) demonstrates pre-clinical effectiveness for the treatment of acute ischemic stroke and reports reductions in oxidative stress, inflammation, and neural apoptosis. These pathophysiological benefits contribute to improved functional recovery. Current pre-clinical and clinical studies are testing the applications of HBOT for stroke neuroprotection, including its use as a preconditioning regimen. Mild oxidative stress may be able to prime the brain to tolerate full extensive oxidative stress that occurs during a stroke, and HBOT preconditioning has displayed efficacy in establishing such ischemic tolerance. In this review, evidence on the use of HBOT following an ischemic stroke is examined, and the potential for HBOT preconditioning as a neuroprotective strategy. Additionally, HBOT as a stem cell preconditioning is also discussed as a promising strategy, thus maximizing the use of HBOT for ischemic stroke.
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7
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Hyperbaric Oxygen Treatment Ameliorates Hearing Loss and Auditory Cortex Injury in Noise Exposed Mice by Repressing Local Ceramide Accumulation. Int J Mol Sci 2019; 20:ijms20194675. [PMID: 31547176 PMCID: PMC6801451 DOI: 10.3390/ijms20194675] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/08/2019] [Accepted: 09/18/2019] [Indexed: 02/07/2023] Open
Abstract
Noise-induced hearing loss (NIHL) relates closely to auditory cortex (AC) injury, so countermeasures aiming at the AC recovery would be of benefit. In this work, the effect of hyperbaric oxygen treatment on NIHL was elucidated, which was imposed on mice before (HBOP), during (HBOD) or after (HBOA) noise exposure. Morphology of neurons was assayed by hematoxylin-eosin or Nissl staining. Ceramide (Cer) level was measured through immunohistochemistry analysis. Apoptotic neurons were counted using transferase-mediated dUTP nick end labeling (TUNEL) staining. We demonstrated that the intense, broad band noise raised the threshold of auditory brainstem response, evoked neuronal degeneration or apoptosis and triggered the Cer accumulation in AC, all of which were restored significantly by HBOP, but not HBOD or HBOA. Cer over-generation reversed the advantages of HBOP significantly, while its curtailment recapitulated the effect. Next, noise exposure raised the superoxide or malondialdehyde (MDA) production which was blocked by HBOP or Cer repression. Oxidative control not only attenuated the hearing loss or neurodegeneration but, in turn, reduced the Cer formation significantly. In summary, mutual regulation between Cer and oxidative stress underlies the HBOP’s curative effect on hearing loss and neuronal damage in noise-exposed mice.
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8
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You Q, Li L, Xiong SQ, Yan YF, Li D, Yan NN, Chen HP, Liu YP. Meta-Analysis on the Efficacy and Safety of Hyperbaric Oxygen as Adjunctive Therapy for Vascular Dementia. Front Aging Neurosci 2019; 11:86. [PMID: 31057392 PMCID: PMC6478752 DOI: 10.3389/fnagi.2019.00086] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/28/2019] [Indexed: 12/23/2022] Open
Abstract
Background: Vascular dementia (VD) is a common type of disease in the elderly. Numerous clinical trials have suggested that hyperbaric oxygen is an effective and safe complementary therapy for aging-related disorders. However, there is no reliable systematic evidence regarding hyperbaric oxygen therapy (HBOT) for the treatment of VD. Therefore, we performed a meta-analysis to evaluate the clinical efficacy and safety of HBOT in treating VD. Methods: We methodically retrieved the clinical studies from eight databases (PubMed, Cochrane Library, Embase, Web of Science, Sino-Med, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), and WanFang) from their inception to November 2018. RevMan 5.3.5 was used for quality assessment and data analysis. Stata 15.1 was employed for publication bias detection and sensitivity analysis. Results: Twenty-five randomized clinical trials (RCTs) involving 1,954 patients met our inclusion criteria. These articles researched the HBOT + oxiracetam + conventional therapy (CT) vs. oxiracetam + CT (n = 13), HBOT + butylphthalide +CT vs. butylphthalide + CT (n = 5), HBOT + donepezil + CT vs. donepezil + CT (n = 4), HBOT + nicergoline + CT vs. nicergoline + CT (n = 2) and HBOT + CT vs. CT (n = 1). The results indicated that additional HBOT strikingly improved the Mini-Mental State Examination (MMSE) (MD = 4.00; 95% CI = 3.28–4.73; P < 0.00001), activities of daily living (ADL) (MD = −5.91; 95% CI = −6.45, −5.36; P < 0.00001) and ADL by Barthel index (BADL) (MD = 13.86; 95% CI = 5.63–22.10; P = 0.001) and increased the total efficacy rate (TEF) (OR = 4.84, 95% CI = 3.19–7.33, P < 0.00001). The adverse events rates were not statistically significant between the HBOT and CT groups (OR = 0.85, 95% CI = 0.26–2.78, P = 0.79). Conclusion: In view of the effectiveness and safety of HBOT, the present meta-analysis suggested that HBOT can be recommended as an effective and safe complementary therapy for the treatment of VD. Protocol Registration: PROSPERO (ID: CRD42019117178). Available online at: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42019117178.
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Affiliation(s)
- Qiang You
- Standardization Education Ministry Key Laboratory of Traditional Chinese Medicine, Department of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.,The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Lan Li
- Department of Nursing, Southwest Medical University, Luzhou, China
| | - Su-Qin Xiong
- Standardization Education Ministry Key Laboratory of Traditional Chinese Medicine, Department of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yu-Fen Yan
- Standardization Education Ministry Key Laboratory of Traditional Chinese Medicine, Department of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dan Li
- Standardization Education Ministry Key Laboratory of Traditional Chinese Medicine, Department of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Na-Na Yan
- Standardization Education Ministry Key Laboratory of Traditional Chinese Medicine, Department of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hong-Ping Chen
- Standardization Education Ministry Key Laboratory of Traditional Chinese Medicine, Department of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - You-Ping Liu
- Standardization Education Ministry Key Laboratory of Traditional Chinese Medicine, Department of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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9
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The Effect of Hyperbaric Oxygen Therapy on Functional Impairments Caused by Ischemic Stroke. Neurol Res Int 2018; 2018:3172679. [PMID: 30402285 PMCID: PMC6198568 DOI: 10.1155/2018/3172679] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/24/2018] [Indexed: 11/23/2022] Open
Abstract
Background While research suggests a benefit of hyperbaric oxygen therapy (HBOT) for neurologic injury, controlled clinical trials have not been able to clearly define the benefits. Objective To investigate the effects of HBOT on physical and cognitive impairments resulting from an ischemic stroke. Methods Using a within-subject design a baseline for current functional abilities was established over a 3-month period for all subjects (n=7). Each subject then received two 4-week periods of HBOT for a total of 40 90-minute treatments over a 12-week period. Subjects completed a battery of assessments and had blood drawn six times over the 9-month total duration of the study. Results We found improvements in cognition and executive function as well as physical abilities, specifically, improved gait. Participants reported improved sleep and quality of life following HBOT treatment. We also saw changes in serum levels of biomarkers for inflammation and neural recovery. In the functional domains where improvement was observed following HBOT treatment, the improvements were maintained up to 3 months following the last treatment. However, the physiological biomarkers showed a pattern of more transient changes following HBOT treatment. Conclusions Findings from this study support the idea of HBOT as a potential intervention following stroke.
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Hentia C, Rizzato A, Camporesi E, Yang Z, Muntean DM, Săndesc D, Bosco G. An overview of protective strategies against ischemia/reperfusion injury: The role of hyperbaric oxygen preconditioning. Brain Behav 2018; 8:e00959. [PMID: 29761012 PMCID: PMC5943756 DOI: 10.1002/brb3.959] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Ischemia/reperfusion (I/R) injury, such as myocardial infarction, stroke, and peripheral vascular disease, has been recognized as the most frequent causes of devastating disorders and death currently. Protective effect of various preconditioning stimuli, including hyperbaric oxygen (HBO), has been proposed in the management of I/R. METHODS In this study, we searched and reviewed up-to-date published papers to explore the pathophysiology of I/R injury and to understand the mechanisms underlying the protective effect of HBO as conditioning strategy. RESULTS Animal study and clinic observation support the notion that HBO therapy and conditioning provide beneficial effect against the deleterious effects of postischemic reperfusion. Several explanations have been proposed. The first likely mechanism may be that HBO counteracts hypoxia and reduces I/R injury by improving oxygen delivery to an area with diminished blood flow. Secondly, by reducing hypoxia-ischemia, HBO reduces all the pathological events as a consequence of hypoxia, including tissue edema, increased affective area permeability, postischemia derangement of tissue metabolism, and inflammation. Thirdly, HBO may directly affect cell apoptosis, signal transduction, and gene expression in those that are sensitive to oxygen or hypoxia. HBO provides a reservoir of oxygen at cellular level not only carried by blood, but also by diffusion from the interstitial tissue where it reaches high concentration that may last for several hours, improves endothelial function and rheology, and decreases local inflammation and edema. CONCLUSION Evidence suggests the benefits of HBO when used as a preconditioning stimulus in the setting of I/R injury. Translating the beneficial effects of HBO into current practice requires, as for the "conditioning strategies", a thorough consideration of risk factors, comorbidities, and comedications that could interfere with HBO-related protection.
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Affiliation(s)
- Ciprian Hentia
- Master II level in Hyperbaric Medicine Department of Biomedical Sciences University of Padova Padova Italy.,Faculty of Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania
| | - Alex Rizzato
- Master II level in Hyperbaric Medicine Department of Biomedical Sciences University of Padova Padova Italy
| | | | - Zhongjin Yang
- The Institute for Human Performance SUNY Upstate Medical University Syracuse NY USA
| | - Danina M Muntean
- Faculty of Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania.,Center for Translational Research and Systems Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania
| | - Dorel Săndesc
- Faculty of Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania
| | - Gerardo Bosco
- Master II level in Hyperbaric Medicine Department of Biomedical Sciences University of Padova Padova Italy
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11
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Luo D, Xu J, Hu L, Yu L, Xie L, Li J. Hyperbaric oxygen therapy to improve cognitive dysfunction and encephalatrophy induced by N 2O for recreational use: a case report. Neuropsychiatr Dis Treat 2018; 14:1963-1967. [PMID: 30122928 PMCID: PMC6080867 DOI: 10.2147/ndt.s170037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
N2O, or laughing gas, is generally used for anesthesia, especially in stomatology and pediatrics but is also commonly used recreationally. Cognitive dysfunction induced by the recreational use of N2O is rare. Here, we present the case of an 18-year-old female with a history of having used N2O recreationally for 5 months who suffered from encephalatrophy and severe cognitive dysfunction. All of the symptoms gradually subsided with ~20 days of treatment by hyperbaric oxygenation. We hypothesize that the long-term use of N2O may have induced a chronic state of systemic hypoxia that further induced cerebral atrophy with impaired cognitive function. Hyperbaric oxygen therapy (HBOT) is reported here for the first time as an important therapeutic element for treating N2O toxicity due to recreational use.
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Affiliation(s)
- Dan Luo
- Department of Psychiatry, Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China,
| | - Jiajun Xu
- Department of Psychiatry, Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China,
| | - Li Hu
- Department of Psychiatry, Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China,
| | - Liangming Yu
- Department of Psychiatry, Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China,
| | - Leling Xie
- Department of Psychiatry, Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China,
| | - Jing Li
- Department of Psychiatry, Mental Health Center, West China Hospital of Sichuan University, Chengdu, Sichuan, People's Republic of China,
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12
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Immediate and delayed hyperbaric oxygen therapy as a neuroprotective treatment for traumatic brain injury in mice. Mol Cell Neurosci 2017; 83:74-82. [DOI: 10.1016/j.mcn.2017.06.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 06/19/2017] [Accepted: 06/19/2017] [Indexed: 01/29/2023] Open
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13
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Rehabilitation Treatment and Progress of Traumatic Brain Injury Dysfunction. Neural Plast 2017; 2017:1582182. [PMID: 28491478 PMCID: PMC5405588 DOI: 10.1155/2017/1582182] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/28/2017] [Accepted: 03/07/2017] [Indexed: 11/17/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of chronic disability. Worldwide, it is the leading cause of disability in the under 40s. Behavioral problems, mood, cognition, particularly memory, attention, and executive function are commonly impaired by TBI. Spending to assist, TBI survivors with disabilities are estimated to be costly per year. Such impaired functional outcomes following TBI can be improved via various rehabilitative approaches. The objective of the present paper is to review the current rehabilitation treatment of traumatic brain injury in adults.
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14
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Hu SL, Feng H, Xi GH. Hyperbaric oxygen therapy and preconditioning for ischemic and hemorrhagic stroke. Med Gas Res 2016; 6:232-236. [PMID: 28217297 PMCID: PMC5223316 DOI: 10.4103/2045-9912.196907] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
To date, the therapeutic methods for ischemic and hemorrhagic stroke are still limited. The lack of oxygen supply is critical for brain injury following stroke. Hyperbaric oxygen (HBO), an approach through a process in which patients breathe in 100% pure oxygen at over 101 kPa, has been shown to facilitate oxygen delivery and increase oxygen supply. Hence, HBO possesses the potentials to produce beneficial effects on stroke. Actually, accumulated basic and clinical evidences have demonstrated that HBO therapy and preconditioning could induce neuroprotective functions via different mechanisms. Nevertheless, the lack of clinical translational study limits the application of HBO. More translational studies and clinical trials are needed in the future to develop effective HBO protocols.
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Affiliation(s)
- Sheng-Li Hu
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA; Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Collaborative Innovation Center for Brain Science, Chongqing, China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Collaborative Innovation Center for Brain Science, Chongqing, China
| | - Guo-Hua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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15
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Hu Q, Manaenko A, Xu T, Guo Z, Tang J, Zhang JH. Hyperbaric oxygen therapy for traumatic brain injury: bench-to-bedside. Med Gas Res 2016; 6:102-110. [PMID: 27867476 PMCID: PMC5110132 DOI: 10.4103/2045-9912.184720] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Traumatic brain injury (TBI) is a serious public health problem in the United States. Survivors of TBI are often left with significant cognitive, behavioral, and communicative disabilities. So far there is no effective treatment/intervention in the daily clinical practice for TBI patients. The protective effects of hyperbaric oxygen therapy (HBOT) have been proved in stroke; however, its efficiency in TBI remains controversial. In this review, we will summarize the results of HBOT in experimental and clinical TBI, elaborate the mechanisms, and bring out our current understanding and opinions for future studies.
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Affiliation(s)
- Qin Hu
- Discipline of Neuroscience, Department of Anatomy, Histology and Embryology, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Anatol Manaenko
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Ting Xu
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Zhenni Guo
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jiping Tang
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- Departments of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA; Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
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16
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Abstract
Stroke is a kind of acute cerebrovascular disease characterized by the focal lack of neurological function, including ischemic stroke and hemorrhagic stroke. As society ages rapidly, stroke has become the second leading cause of disability and death, and also become the main threat to human health and life. In recent years, findings from increasing animal and clinical trials have supplied scientific evidences for the treatment of stroke. Hydrogen sulfide (H2S), which has always been seen as a toxic gas, now has been thought to be the third gaseous signaling molecule following nitric oxide and carbon monoxide. Accumulating evidences indicate that H2S plays an important role in stroke. Given that its neuroprotective effect is dose-dependent, only when its concentration is relatively low, H2S can yield the neuroprotection, while high dose may lead to neurotoxicity. All these study results suggest that H2S may offer a new promising application for the therapy of stroke. Here, our review will present the role of H2S in stroke from its mechanism to animal and clinical studies.
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Affiliation(s)
- Yang Dou
- Department of Neurosurgery & Brain and Nerve Research Laboratory, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Gang Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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17
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Abstract
Stroke, which is defined as a neurologic deficit caused by sudden impaired blood supply, has been considered as a common cause of death and disability for decades. The World Health Organization has declared that almost every 5 seconds a new stroke occurs, placing immense socioeconomic burdens. However, the effective and available treatment strategies are still limited. Additionally, the most effective therapy, such as thrombolysis and stenting for ischemic stroke, generally requires a narrow therapeutic time window after the event. A large majority of patients cannot be admitted to hospital and receive these effective treatments for reperfusion timely. Hyperbaric oxygen therapy (HBOT) has been frequently applied and investigated in stroke since 1960s. Numerous basic and clinical studies have shown the beneficial efficacy for neurological outcome after stroke, and meanwhile many underlying mechanisms associated with neuroprotection have been illustrated, such as cerebral oxygenation promotion and metabolic improvement, blood-brain barrier protection, anti-inflammation and cerebral edema, intracranial pressure modulation, decreased oxidative-stress and apoptosis, increased vascular and neural regeneration. However, HBOT in human stroke is still not sufficiently evidence-based, due to the insufficient randomized double-blind controlled clinical studies. To date, there are no uniform criteria for the dose and session duration of HBOT in different strokes. Furthermore, the additional effect of HBOT combined with drugs and other treatment strategies are being investigated recently. Therefore, more experimental and clinical research is imperative to identify the mechanisms more clearly and to explore the best protocol of HBOT in stroke treatment.
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Affiliation(s)
- Wei-Wei Zhai
- Department of Neurosurgery & Brain and Nerve Research Laboratory, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Liang Sun
- Department of Neurosurgery & Brain and Nerve Research Laboratory, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Zheng-Quan Yu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Gang Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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18
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Xu Y, Ji R, Wei R, Yin B, He F, Luo B. The Efficacy of Hyperbaric Oxygen Therapy on Middle Cerebral Artery Occlusion in Animal Studies: A Meta-Analysis. PLoS One 2016; 11:e0148324. [PMID: 26859390 PMCID: PMC4747521 DOI: 10.1371/journal.pone.0148324] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 01/15/2016] [Indexed: 12/01/2022] Open
Abstract
Background Inconsistent results have been reported for hyperbaric oxygen therapy (HBO) for acute stroke. We conducted a systematic review and meta-analysis to evaluate the benefit of HBO in animal studies of middle cerebral artery occlusion (MCAO). Methods A systematic search of the literature published prior to September 2015 was performed using Embase, Medline (OvidSP), Web of Science and PubMed. Keywords included “hyperoxia” OR “hyperbaric oxygen” OR “HBO” AND “isch(a)emia” OR “focal cerebral ischemia” OR “stroke” OR “infarct” OR “middle cerebral artery occlusion (MCAO).” The primary endpoints were the infarct size and/or neurological outcome score evaluated after HBO treatment in MCAO. Heterogeneity was analyzed using Cochrane Library’s RevMan 5.3.5. Results Fifty-one studies that met the inclusion criteria were identified among the 1198 studies examined. When compared with control group data, HBO therapy resulted in infarct size reduction or improved neurological function (32% decrease in infarct size; 95% confidence interval (CI), range 28%–37%; p < 0.00001). Mortality was 18.4% in the HBO group and 26.7% in the control group (RR 0.72, 95% CI, 0.54–0.98; p = 0.03). Subgroup analysis showed that a maximal neuro-protective effect was reached when HBO was administered immediately after MCAO with an absolute atmospheric pressure (ATA) of 2.0 (50% decrease; 95% CI, 43% -57% decrease; p < 0.0001) and more than 6 hours HBO treatment (53% decrease; 95% CI, 41% -64% decrease; p = 0.0005). Conclusions HBO had a neuro-protective effect and improved survival in animal models of MCAO, especially in animals given more than 6 hours of HBO and when given immediately after MCAO with 2.0 ATA.
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Affiliation(s)
- Yang Xu
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Renjie Ji
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ruili Wei
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bo Yin
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Fangping He
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Benyan Luo
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- * E-mail:
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Liu FF, Liu CY, Li XP, Zheng SZ, Li QQ, Liu Q, Song L. Neuroprotective effects of SMADs in a rat model of cerebral ischemia/reperfusion. Neural Regen Res 2015; 10:438-44. [PMID: 25878593 PMCID: PMC4396107 DOI: 10.4103/1673-5374.153693] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2015] [Indexed: 12/23/2022] Open
Abstract
Previous studies have shown that up-regulation of transforming growth factor β1 results in neuroprotective effects. However, the role of the transforming growth factor β1 downstream molecule, SMAD2/3, following ischemia/reperfusion remains unclear. Here, we investigated the neuroprotective effects of SMAD2/3 by analyzing the relationships between SMAD2/3 expression and cell apoptosis and inflammation in the brain of a rat model of cerebral ischemia/reperfusion. Levels of SMAD2/3 mRNA were up-regulated in the ischemic penumbra 6 hours after cerebral ischemia/reperfusion, reached a peak after 72 hours and were then decreased at 7 days. Phosphorylated SMAD2/3 protein levels at the aforementioned time points were consistent with the mRNA levels. Over-expression of SMAD3 in the brains of the ischemia/reperfusion model rats via delivery of an adeno-associated virus containing the SMAD3 gene could reduce tumor necrosis factor-α and interleukin-1β mRNA levels, down-regulate expression of the pro-apoptotic gene, capase-3, and up-regulate expression of the anti-apoptotic protein, Bcl-2. The SMAD3 protein level was negatively correlated with cell apoptosis. These findings indicate that SMAD3 exhibits neuroprotective effects on the brain after ischemia/reperfusion through anti-inflammatory and anti-apoptotic pathways.
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Affiliation(s)
- Fang-fang Liu
- Department of Neurology, First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Chao-ying Liu
- Department of Respiratory Medicine, First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Xiao-ping Li
- Department of Pediatrics, First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Sheng-zhe Zheng
- Department of Neurology, Affiliated Hospital of Yanbian University, Yanbian, Jilin Province, China
| | - Qing-quan Li
- Department of Hepatic-Biliary-Pancreatic Medicine, First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Qun Liu
- Department of Neurology, First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Lei Song
- Department of Respiratory Medicine, First Hospital of Jilin University, Changchun, Jilin Province, China
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Wang Y, Chen D, Chen G. Hyperbaric oxygen therapy applied research in traumatic brain injury: from mechanisms to clinical investigation. Med Gas Res 2014; 4:18. [PMID: 25905012 PMCID: PMC4406166 DOI: 10.1186/2045-9912-4-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 10/20/2014] [Indexed: 11/10/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of mortality and morbidity for millions of young people and military personnel around the world every year. Regardless of severity, neurological dysfunction is a sequela of TBI. Although many preclinical and clinical trials have been carried out to explore its underlying pathophysiology, few effective treatment options have been used to ameliorate the prognosis of TBI, particularly with regard to the recovery of neurological deficits. Translational medicine has increasingly emphasized secondary brain injury, as distinguished from the mechanical damage occurring at the moment of traumatic impact; this includes cerebral ischemia, vasospasm, metabolic dysfunction, oxygenation absence and edema. Hyperbaric oxygen therapy (HBOT) is defined as the inhalation of pure oxygen in a hyperbaric chamber that is pressurized to greater than 1 atm. High concentrations of oxygen in the blood could affect brain tissue hypoxia readily thereby avoiding neuronal cell death through increased cerebral oxygen metabolism. Therefore, HBOT has been suggested as a scientific and effective treatment for TBI. The effectiveness and feasibility of HBOT has been confirmed by several studies. Following the widespread application of HBOT in cerebrovascular diseases and TBI, non-standard therapies frequently occur in primary care institutions, causing great controversy. The systematic analysis of the progress of both animal and clinical studies in this article provides the basis for further study of HBOT.
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Affiliation(s)
- Yang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Suzhou University, Suzhou, People's Republic of China
| | - Dongdong Chen
- Department of Neurosurgery, The First Affiliated Hospital of Suzhou University, Suzhou, People's Republic of China
| | - Gang Chen
- Department of Neurosurgery, The First Affiliated Hospital of Suzhou University, Suzhou, People's Republic of China
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