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Xiang T, Feng D, Zhang X, Chen Y, Wang H, Liu X, Gong Z, Yuan J, Liu M, Sha Z, Lv C, Jiang W, Nie M, Fan Y, Wu D, Dong S, Feng J, Ponomarev ED, Zhang J, Jiang R. Effects of increased intracranial pressure on cerebrospinal fluid influx, cerebral vascular hemodynamic indexes, and cerebrospinal fluid lymphatic efflux. J Cereb Blood Flow Metab 2022; 42:2287-2302. [PMID: 35962479 PMCID: PMC9670008 DOI: 10.1177/0271678x221119855] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 12/14/2022]
Abstract
The glymphatic-lymphatic fluid transport system (GLFTS) consists of glymphatic pathway and cerebrospinal fluid (CSF) lymphatic outflow routes, allowing biological liquids from the brain parenchyma to access the CSF along with perivascular space and to be cleaned out of the skull through lymphatic vessels. It is known that increased local pressure due to physical compression of tissue improves lymphatic transport in peripheral organs, but little is known about the exact relationship between increased intracranial pressure (IICP) and GLFTS. In this study, we verify our hypothesis that IICP significantly impacts GLFTS, and this effect depends on severity of the IICP. Using a previously developed inflating balloon model to induce IICP and inject fluorescent tracers into the cisterna magna, we found significant impairment of the glymphatic circulation after IICP. We further found that cerebrovascular occlusion occurred, and cerebrovascular pulsation decreased after IICP. IICP also interrupted the drainage of deep cervical lymph nodes and dorsal meningeal lymphatic function, enhancing spinal lymphatic outflow to the sacral lymph nodes. Notably, these effects were associated with the severity of IICP. Thus, our findings proved that the intensity of IICP significantly impacts GLFTS. This may have translational applications for preventing and treating related neurological disorders.
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Affiliation(s)
- Tangtang Xiang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Dongyi Feng
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Yupeng Chen
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Hanhua Wang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Zhitao Gong
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Mingqi Liu
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Chuanxiang Lv
- Department of Neurosurgery, The First Clinical Hospital, Jilin
University, Changchun, China
| | - Weiwei Jiang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Yibing Fan
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Di Wu
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Shiying Dong
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Jiancheng Feng
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Eugene D Ponomarev
- School of Biomedical Sciences, Faculty of Medicine, The Chinese
University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
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Mahajan C, Kapoor I, Prabhakar H. A Narrative Review on Translational Research in Acute Brain Injury. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1744399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThere has been a constant endeavor to reduce the mortality and morbidity associated with acute brain injury. The associated complex mechanisms involving biomechanics, markers, and neuroprotective drugs/measures have been extensively studied in preclinical studies with an ultimate aim to improve the patients' outcomes. Despite such efforts, only few have been successfully translated into clinical practice. In this review, we shall be discussing the major hurdles in the translation of preclinical results into clinical practice. The need is to choose an appropriate animal model, keeping in mind the species, age, and gender of the animal, choosing suitable outcome measures, ensuring quality of animal trials, and carrying out systematic review and meta-analysis of experimental studies before proceeding to human trials. The interdisciplinary collaboration between the preclinical and clinical scientists will help to design better, meaningful trials which might help a long way in successful translation. Although challenging at this stage, the advent of translational precision medicine will help the integration of mechanism-centric translational medicine and patient-centric precision medicine.
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Affiliation(s)
- Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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ElSaadani M, Ahmed SM, Jacovides C, Lopez A, Johnson VE, Kaplan LJ, Schwab CW, Smith DH, Pascual JL. Antithrombin III ameliorates post-traumatic brain injury cerebral leukocyte mobilization enhancing recovery of blood brain barrier integrity. J Trauma Acute Care Surg 2021; 90:274-280. [PMID: 33093292 PMCID: PMC8878290 DOI: 10.1097/ta.0000000000003000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute traumatic coagulopathy often accompanies traumatic brain injury (TBI) and may impair cognitive recovery. Antithrombin III (AT-III) reduces the hypercoagulability of TBI. Antithrombin III and heparinoids such as enoxaparin (ENX) demonstrate potent anti-inflammatory activity, reducing organ injury and modulating leukocyte (LEU) activation, independent of their anticoagulant effect. It is unknown what impact AT-III exerts on cerebral LEU activation and blood-brain barrier (BBB) permeability after TBI. We hypothesized that AT-III reduces live microcirculatory LEU-endothelial cell (EC) interactions and leakage at the BBB following TBI. METHODS CD1 mice (n = 71) underwent either severe TBI (controlled cortical impact (CCI), 6-m/s velocity, 1-mm depth, and 4-mm diameter) or sham craniotomy and then received either AT-III (250 IU/kg), ENX (1.5 mg/kg), or vehicle (saline) every 24 hours. Forty-eight hours post-TBI, cerebral intravital microscopy visualized in vivo penumbral microvascular LEU-EC interactions and microvascular leakage to assess BBB inflammation/permeability. Body weight loss and the Garcia neurological test (motor, sensory, reflex, balance) served as surrogates of clinical recovery. RESULTS Both AT-III and ENX similarly reduced in vivo penumbral LEU rolling and adhesion (p < 0.05). Antithrombin III also reduced live BBB leakage (p < 0.05). Antithrombin III animals demonstrated the least 48-hour body weight loss (8.4 ± 1%) versus controlled cortical impact and vehicle (11.4 ± 0.5%, p < 0.01). Garcia neurological test scores were similar among groups. CONCLUSION Antithrombin III reduces post-TBI penumbral LEU-EC interactions in the BBB leading to reduced neuromicrovascular permeability. Antithrombin III further reduced body weight loss compared with no therapy. Further study is needed to determine if these AT-III effects on neuroinflammation affect longer-term neurocognitive recovery after TBI.
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Affiliation(s)
- Mohamed ElSaadani
- From the Division of Traumatology, Surgical Critical Care and Emergency Surgery (M.E., S.M.A., C.J., A.L., L.J.K., C.W.S., J.L.P.), and Department of Neurosurgery, Center for Brain Injury and Repair (V.E.J., D.H.S., J.L.P.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Schreibman DL, Hong CM, Keledjian K, Ivanova S, Tsymbalyuk S, Gerzanich V, Simard JM. Mannitol and Hypertonic Saline Reduce Swelling and Modulate Inflammatory Markers in a Rat Model of Intracerebral Hemorrhage. Neurocrit Care 2019; 29:253-263. [PMID: 29700692 DOI: 10.1007/s12028-018-0535-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) leaves most survivors dependent at follow-up. The importance of promoting M2-like microglial responses is increasingly recognized as a key element to ameliorate brain injury following ICH. The osmotherapeutic agents, mannitol and hypertonic saline (HTS), which are routinely used to reduce intracranial pressure, have been shown to reduce neuroinflammation in experimental ischemic and traumatic brain injury, but anti-inflammatory effects of osmotherapies have not been investigated in ICH. METHODS We studied the effects of iso-osmotic mannitol and HTS in rat models of ICH utilizing high-dose and moderate-dose collagenase injections into the basal ganglia, associated with high and low mortality, respectively. We studied the effects of osmotherapies, first given 5 h after ICH induction, and then administered every 12 h thereafter (4 doses total). Immunohistochemistry was used to quantify microglial activation and polarization. RESULTS Compared to controls, mannitol and HTS increased plasma osmolarity 1 h after infusion (301 ± 1.5, 315 ± 4.2 and 310 ± 2.0 mOsm/kg, respectively), reduced mortality at 48 h (82, 36 and 53%, respectively), and reduced hemispheric swelling at 48 h (32, 21, and 17%, respectively). In both perihematomal and contralateral tissues, mannitol and HTS reduced activation of microglia/macrophages (abundance and morphology of Iba1 + cells), and in perihematomal tissues, they reduced markers of the microglia/macrophage M1-like phenotype (nuclear p65, TNF, and NOS2), increased markers of the microglia/macrophage M2-like phenotype (arginase, YM1, and pSTAT3), and reduced infiltration of CD45 + cells. CONCLUSIONS Repeated dosing of osmotherapeutics at regular intervals may be a useful adjunct to reduce neuroinflammation following ICH.
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Affiliation(s)
- David L Schreibman
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Caron M Hong
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Kaspar Keledjian
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Svetlana Ivanova
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Solomiya Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA. .,Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA. .,Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
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5
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Effects of Hypertonic Saline and Sodium Lactate on Cortical Cerebral Microcirculation and Brain Tissue Oxygenation. J Neurosurg Anesthesiol 2018; 30:163-170. [PMID: 28338505 DOI: 10.1097/ana.0000000000000427] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Hyperosmolar solutions have been used in neurosurgery to modify brain bulk. The aim of this animal study was to compare the short-term effects of equivolemic, equiosmolar solutions of hypertonic saline (HTS) and sodium lactate (HTL) on cerebral cortical microcirculation and brain tissue oxygenation in a rabbit craniotomy model. METHODS Rabbits (weight, 1.5 to 2.0 kg) were anesthetized, ventilated mechanically, and subjected to a craniotomy. The animals were allocated randomly to receive a 3.75 mL/kg intravenous infusion of either 3.2% HTS (group HTS, n=9), half-molar sodium lactate (group HTL, n=10), or normal saline (group C, n=9). Brain tissue partial pressure of oxygen (PbtO2) and microcirculation in the cerebral cortex using sidestream dark-field imaging were evaluated before, 20 and 40 minutes after 15 minutes of hyperosmolar solution infusion. Global hemodynamic data were recorded, and blood samples for laboratory analysis were obtained at the time of sidestream dark-field image recording. RESULTS No differences in the microcirculatory parameters were observed between the groups before and after the use of osmotherapy. Brain tissue oxygen deteriorated over time in groups C and HTL, this deterioration was not significant in the group HTS. CONCLUSIONS Our findings suggest that equivolemic, equiosmolar HTS and HTL solutions equally preserve perfusion of cortical brain microcirculation in a rabbit craniotomy model. The use of HTS was better in preventing the worsening of brain tissue oxygen tension.
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Suto Y, Nagata K, Ahmed SM, Jacovides CL, Browne KD, Cognetti J, Johnson VE, Leone R, Kaplan LJ, Smith DH, Pascual JL. Cerebral Edema and Neurological Recovery after Traumatic Brain Injury Are Worsened if Accompanied by a Concomitant Long Bone Fracture. J Neurotrauma 2018; 36:609-618. [PMID: 30084745 DOI: 10.1089/neu.2018.5812] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Progression of severe traumatic brain injury (TBI) is associated with worsening cerebral inflammation, but it is unknown how a concomitant bone fracture (FX) affects this progression. Enoxaparin (ENX), a low molecular weight heparin often used for venous thromboembolic prophylaxis, decreases penumbral leukocyte (LEU) mobilization in isolated TBI and improves neurological recovery. We investigated if TBI accompanied by an FX worsens LEU-mediated cerebral inflammation and if ENX alters this process. CD1 male mice underwent controlled cortical impact (CCI) or sham craniotomy with or without an open tibial FX, and received either ENX (1 mg/kg, three times/day) or saline for 2 days following injury. Randomization defined four groups (Sham, CCI, CCI+FX, CCI+FX+ENX, n = 10/group). Two days after CCI, neurological recovery was assessed with the Garcia Neurological Test (GNT); intravital microscopy (LEU rolling and adhesion, microvascular leakage) and blood hemoglobin levels were also evaluated. Penumbral cerebral neutrophil sequestration (Ly-6G immunohistochemistry [IHC]) were evaluated post-mortem. In vivo LEU rolling was greater in CCI+FX (45.2 ± 4.8 LEUs/100 μm/min) than in CCI alone (26.5 ± 3.1, p = 0.007), and was suppressed by ENX (23.2 ± 5.5, p = 0.003 vs. CCI + FX). Neurovascular permeability was higher in CCI+FX (71.1 ± 2.9%) than CCI alone (42.5 ± 2.3, p < 0.001). GNT scores were lower in CCI+FX (15.2 ± 0.2) than in CCI alone (16.3 ± 0.3, p < 0.001). Hemoglobin was lowest in the CCI+FX+ENX group, lower than in Sham or CCI. IHC demonstrated greatest polymorphonuclear neutrophil (PMN) invasion in CCI+FX in uninjured cerebral territories. A concomitant long bone FX worsens TBI-induced cerebral LEU mobilization, microvascular leakage, and cerebral edema, and impairs neurological recovery at 48 h. ENX suppresses this progression but may increase bleeding.
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Affiliation(s)
- Yujin Suto
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Katsuhiro Nagata
- 3 Department of Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center , Tokyo, Japan
| | - Syed M Ahmed
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Christina L Jacovides
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Kevin D Browne
- 2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - John Cognetti
- 2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Victoria E Johnson
- 2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Ryan Leone
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Lewis J Kaplan
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Douglas H Smith
- 2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Jose L Pascual
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
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Rocha-e-Silva M. Cardiovascular Effects of Shock and Trauma in Experimental Models. A Review. Braz J Cardiovasc Surg 2016; 31:45-51. [PMID: 27074274 PMCID: PMC5062691 DOI: 10.5935/1678-9741.20150065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/06/2015] [Indexed: 12/21/2022] Open
Abstract
Experimental models of human pathology are useful guides to new approaches
towards improving clinical and surgical treatments. A systematic search through
PubMed using the syntax (shock) AND (trauma) AND (animal model) AND
(cardiovascular) AND ("2010/01/01"[PDat]:
"2015/12/31"[PDat]) found 88 articles, which were reduced by
manual inspection to 43 entries. These were divided into themes and each theme
is subsequently narrated and discussed conjointly. Taken together, these
articles indicate that valuable information has been developed over the past 5
years concerning endothelial stability, mesenteric lymph, vascular reactivity,
traumatic injuries, burn and sepsis. A surviving interest in hypertonic saline
resuscitation still exists.
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Price L, Wilson C, Grant G. Blood–Brain Barrier Pathophysiology following Traumatic Brain Injury. TRANSLATIONAL RESEARCH IN TRAUMATIC BRAIN INJURY 2015. [DOI: 10.1201/b18959-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Enoxaparin ameliorates post-traumatic brain injury edema and neurologic recovery, reducing cerebral leukocyte endothelial interactions and vessel permeability in vivo. J Trauma Acute Care Surg 2015; 79:78-84. [PMID: 26091318 DOI: 10.1097/ta.0000000000000697] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) confers a high risk of venous thrombosis, but early prevention with heparinoids is often withheld, fearing cerebral hematoma expansion. Yet, studies have shown heparinoids not only to be safe but also to limit brain edema and contusion size after TBI. Human TBI data also suggest faster radiologic and clinical neurologic recovery with earlier heparinoid administration. We hypothesized that enoxaparin (ENX) after TBI blunts in vivo leukocyte (LEU) mobilization to injured brain and cerebral edema, while improving neurologic recovery without increasing the size of the cerebral hemorrhagic contusion. METHODS CD1 male mice underwent either TBI by controlled cortical impact (CCI, 1-mm depth, 6 m/s) or sham craniotomy. ENX (1 mg/kg) or vehicle (VEH, 0.9% saline, 1 mL/kg) was administered at 2, 8, 14, 23, and 32 hours after TBI. At 48 hours, intravital microscopy was used to visualize live LEUs interacting with endothelium and microvascular leakage of fluorescein isothiocyanate-albumin. Neurologic function (Neurological Severity Score, NSS), activated clotting time, hemorrhagic contusion size, as well as brain and lung wet-to-dry ratios were evaluated post mortem. Analysis of variance with Bonferroni correction was used for statistical comparisons between groups. RESULTS Compared with VEH, ENX significantly reduced in vivo LEU rolling on endothelium (72.7 ± 28.3 LEU/100 μm/min vs. 30.6 ± 18.3 LEU/100 μm/min, p = 0.02) and cerebrovascular albumin leakage (34.5% ± 8.1% vs. 23.8% ± 5.5%, p = 0.047). CCI significantly increased ipsilateral cerebral hemisphere edema, but ENX treatment reduced post-CCI edema to near control levels (81.5% ± 1.5% vs. 77.6% ± 0.6%, p < 0.01). Compared with VEH, ENX reduced body weight loss at 24 hours (8.7% ± 1.2% vs. 5.8% ± 1.1%, p < 0.01) and improved NSS at 24 hours (14.5 ± 0.5 vs. 16.2 ± 0.4, p < 0.01) and 48 hours (15.1 ± 0.4 vs. 16.7 ± 0.5, p < 0.01) after injury. There were no significant differences in activated clotting time, hemorrhagic contusion size, and lung water content between the groups. CONCLUSION ENX reduces LEU recruitment to injured brain, diminishing visible microvascular permeability and edema. ENX may also accelerate neurologic recovery without increasing cerebral contusion size. Further study in humans is necessary to determine safety, appropriate dosage, and timing of ENX administration early after TBI.
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Dostal P, Schreiberova J, Dostalova V, Dostalova V, Tyll T, Paral J, Abdo I, Cihlo M, Astapenko D, Turek Z. Effects of hypertonic saline and mannitol on cortical cerebral microcirculation in a rabbit craniotomy model. BMC Anesthesiol 2015; 15:88. [PMID: 26055873 PMCID: PMC4459466 DOI: 10.1186/s12871-015-0067-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 05/28/2015] [Indexed: 11/12/2022] Open
Abstract
Background Hyperosmolar solutions have been used in neurosurgery to modify brain bulk and prevent neurological deterioration. The aim of this animal study was to compare the short-term effects of equivolemic, equiosmolar solutions of mannitol and hypertonic saline (HTS) on cerebral cortical microcirculation in a rabbit craniotomy model. Methods Rabbits (weight, 2.0–3.0 kg) were anesthetized, ventilated mechanically, and subjected to a craniotomy. The animals were allocated randomly to receive a 3.75 ml/kg intravenous infusion of either 3.2 % HTS (group HTS, n = 8) or 20 % mannitol (group MTL, n = 8). Microcirculation in the cerebral cortex was evaluated using sidestream dark-field (SDF) imaging before and 20 min after the end of the 15-min HTS infusion. Global hemodynamic data were recorded, and blood samples for laboratory analysis were obtained at the time of SDF image recording. Results No differences in the microcirculatory parameters were observed between the groups before the use of osmotherapy. After osmotherapy, lower proportions of perfused small vessel density (P = 0.0474), perfused vessel density (P = 0.0457), and microvascular flow index (P = 0.0207) were observed in the MTL group compared with those in the HTS group. Conclusions Our findings suggest that an equivolemic, equiosmolar HTS solution better preserves perfusion of cortical brain microcirculation compared to MTL in a rabbit craniotomy model.
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Affiliation(s)
- Pavel Dostal
- Department of Anesthesia and Intensive Care Medicine, Charles University, Faculty of Medicine Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Jitka Schreiberova
- Department of Anesthesia and Intensive Care Medicine, Charles University, Faculty of Medicine Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Vlasta Dostalova
- Department of Anesthesia and Intensive Care Medicine, Charles University, Faculty of Medicine Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Vlasta Dostalova
- Department of Anesthesia and Intensive Care Medicine, Charles University, Faculty of Medicine Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Tomas Tyll
- Department of Anesthesia and Intensive Care Medicine, Charles University, 1st Faculty of Medicine Prague, Military University Hospital Prague, Prague, Czech Republic.
| | - Jiri Paral
- Department of Military Surgery, Faculty of Military Health Sciences, Hradec Kralove, University of Defence, Brno, Czech Republic.
| | - Islam Abdo
- Department of Anesthesia and Intensive Care Medicine, Charles University, Faculty of Medicine Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Miroslav Cihlo
- Department of Neurosurgery, Charles University, Faculty of Medicine Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - David Astapenko
- Department of Anesthesia and Intensive Care Medicine, Charles University, Faculty of Medicine Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
| | - Zdenek Turek
- Department of Anesthesia and Intensive Care Medicine, Charles University, Faculty of Medicine Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.
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Kheirbek T, Pascual JL. Hypertonic saline for the treatment of intracranial hypertension. Curr Neurol Neurosci Rep 2015; 14:482. [PMID: 25082273 DOI: 10.1007/s11910-014-0482-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Intracranial hypertension is caused by brain edema generated by different disorders, the commonest of which is traumatic brain injury. The treatment of brain edema focuses on drawing water out of brain tissue into the intravascular space. This is typically accomplished with osmolar therapy, most commonly mannitol and hypertonic saline. Recent human trials suggest that hypertonic saline may have a more profound and long-lasting effect in reducing intracranial hypertension following traumatic brain injury when compared with mannitol. However, reports suffer from inconsistencies in dose, frequency, concentration, and route of administration. Side effect profile, potential complications, and contraindications to administration need to be factored in when considering which first-line osmotherapy to choose for a given patient with head injury.
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Affiliation(s)
- Tareq Kheirbek
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, University of Pennsylvania School of Medicine, Department of Surgery, Philadelphia, PA, USA,
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12
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Mangat HS, Härtl R. Hypertonic saline for the management of raised intracranial pressure after severe traumatic brain injury. Ann N Y Acad Sci 2015; 1345:83-8. [PMID: 25726965 DOI: 10.1111/nyas.12704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hyperosmolar agents are commonly used as an initial treatment for the management of raised intracranial pressure (ICP) after severe traumatic brain injury (TBI). They have an excellent adverse-effect profile compared to other therapies, such as hyperventilation and barbiturates, which carry the risk of reducing cerebral perfusion. The hyperosmolar agent mannitol has been used for several decades to reduce raised ICP, and there is accumulating evidence from pilot studies suggesting beneficial effects of hypertonic saline (HTS) for similar purposes. An ideal therapeutic agent for ICP reduction should reduce ICP while maintaining cerebral perfusion (pressure). While mannitol can cause dehydration over time, HTS helps maintain normovolemia and cerebral perfusion, a finding that has led to a large amount of pilot data being published on the benefits of HTS, albeit in small cohorts. Prophylactic therapy is not recommended with mannitol, although it may be beneficial with HTS. To date, no large clinical trial has been performed to directly compare the two agents. The best current evidence suggests that mannitol is effective in reducing ICP in the management of traumatic intracranial hypertension and carries mortality benefit compared to barbiturates. Current evidence regarding the use of HTS in severe TBI is limited to smaller studies, which illustrate a benefit in ICP reduction and perhaps mortality.
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Affiliation(s)
- Halinder S Mangat
- Division of Stroke and Critical Care, Department of Neurology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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14
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Mangat HS, Chiu YL, Gerber LM, Alimi M, Ghajar J, Härtl R. Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury. J Neurosurg 2015; 122:202-10. [DOI: 10.3171/2014.10.jns132545] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECT
Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI.
METHODS
The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples.
RESULTS
A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56).
CONCLUSIONS
HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.
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Affiliation(s)
- Halinder S. Mangat
- Departments of 1Neurology and
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
| | | | - Linda M. Gerber
- Departments of 3Public Health and
- 4Medicine, Weill Cornell Medical College
| | - Marjan Alimi
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
| | - Jamshid Ghajar
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 6The Brain Trauma Foundation, New York, New York
| | - Roger Härtl
- 2Neurological Surgery, Weill Cornell Brain and Spine Center, and
- 5NewYork-Presbyterian Hospital; and
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15
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Zweckberger K, Hackenberg K, Jung C, Hertle D, Kiening K, Unterberg A, Sakowitz O. Glibenclamide reduces secondary brain damage after experimental traumatic brain injury. Neuroscience 2014; 272:199-206. [DOI: 10.1016/j.neuroscience.2014.04.040] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/15/2014] [Accepted: 04/17/2014] [Indexed: 12/21/2022]
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Pascual JL, Murcy MA, Li S, Gong W, Eisenstadt R, Kumasaka K, Sims C, Smith DH, Browne K, Allen S, Baren J. Neuroprotective effects of progesterone in traumatic brain injury: blunted in vivo neutrophil activation at the blood-brain barrier. Am J Surg 2013; 206:840-5; discussion 845-6. [PMID: 24112683 DOI: 10.1016/j.amjsurg.2013.07.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 07/23/2013] [Accepted: 07/25/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Progesterone (PRO) may confer a survival advantage in traumatic brain injury (TBI) by reducing cerebral edema. We hypothesized that PRO reduces edema by blocking polymorphonuclear (PMN) interactions with endothelium (EC) in the blood-brain barrier (BBB). METHODS CD1 mice received repeated PRO (16 mg/kg intraperitoneally) or vehicle (cyclodextrin) for 36 hours after TBI. Sham animals underwent craniotomy without TBI. The modified Neurological Severity Score graded neurologic recovery. A second craniotomy allowed in vivo observation of pial EC/PMN interactions and vascular macromolecule leakage. Wet/dry ratios assessed cerebral edema. RESULTS Compared with the vehicle, PRO reduced subjective cerebral swelling (2.9 ± .1 vs 1.2 ± .1, P < .001), PMN rolling (95 ± 1.8 vs 57 ± 2.0 cells/100 μm/min, P < .001), total EC/PMN adhesion (2.0 ± .4 vs .8 ± .1 PMN/100 μm, P < .01), and vascular permeability (51.8% ± 4.9% vs 27.1% ± 4.6%, P < .01). TBI groups had similar a Neurological Severity Score and cerebral wet/dry ratios (P > .05). CONCLUSIONS PRO reduces live pericontusional EC/PMN and BBB macromolecular leakage after TBI. Direct PRO effects on the microcirculation warrant further investigation.
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Affiliation(s)
- Jose L Pascual
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, The Trauma Center at Penn, 3400 Spruce Street, Maloney Building, 5th Floor, Philadelphia, PA 19104, USA.
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