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Srichawla BS, Fang T, Kipkorir V, Lalla R. Critical illness-associated cerebral microbleeds involving the corpus callosum following cardiac arrest: A case report. Medicine (Baltimore) 2024; 103:e39273. [PMID: 39121333 PMCID: PMC11315479 DOI: 10.1097/md.0000000000039273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/22/2024] [Indexed: 08/11/2024] Open
Abstract
RATIONALE Critical illness-associated cerebral microbleeds (CI-aCMBs) are emerging as significant radiographic findings in patients with hypoxic ischemic injuries. Their occurrence, particularly in the corpus callosum, warrants a closer examination due to the potential implications for neurological outcomes in critically ill patients. We aim to describe a rare case of CI-aCMBs within the corpus callosum following cardiac arrest with the goal of bolstering the scientific literature on this topic. PATIENT CONCERNS A 34-year-old man with a history of polysubstance abuse was found unconscious and experienced a pulseless electrical activity (PEA) cardiac arrest after a suspected drug overdose. Post-resuscitation, the patient exhibited severe respiratory distress, acute kidney injury, and profound neurological deficits. DIAGNOSES Initial magnetic resonance imaging scans post-cardiac arrest showed no acute brain abnormalities. However, subsequent imaging revealed extensive cerebral microbleeds predominantly in the corpus callosum, diagnosed as CI-aCMBs. These findings were made in the absence of high signal intensity on T2-weighted images, suggesting a unique pathophysiological profile of microhemorrhages. INTERVENTIONS The patient underwent targeted temperature management (TTM) and supportive care in the intensive care unit after cardiac arrest. OUTCOMES He was subsequently extubated and had significant recovery without any neurological deficits. LESSONS CI-aCMBs is a rare radiographic finding after cardiac arrest. These lesions may be confined to the corpus callosum and the long-term clinical and radiographic sequelae are still largely unknown.
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Affiliation(s)
- Bahadar S. Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Ton Fang
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
| | | | - Rakhee Lalla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA
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Moscovicz F, Taborda C, Fernández F, Borda N, Auzmendi J, Lazarowski A. Ironing out the Links: Ferroptosis in epilepsy and SUDEP. Epilepsy Behav 2024; 157:109890. [PMID: 38905915 DOI: 10.1016/j.yebeh.2024.109890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/30/2024] [Accepted: 06/08/2024] [Indexed: 06/23/2024]
Abstract
Iron is a crucial element for almost all organisms because it plays a vital role in oxygen transport, enzymatic processes, and energy generation due to its electron transfer capabilities. However, its dysregulation can lead to a form of programmed cell death known as ferroptosis, which is characterized by cellular iron accumulation, reactive oxygen species (ROS) production, and unrestricted lipid peroxidation. Both iron and ferroptosis have been identified as key players in the pathogenesis of various neurodegenerative diseases. While in epilepsy this phenomenon remains relatively understudied, seizures can be considered hypoxic-ischemic episodes resulting in increased ROS production, lipid peroxidation, membrane disorganization, and cell death. All of this is accompanied by elevated intracellular free Fe2+ concentration and hemosiderin precipitation, as existing reports suggest a significant accumulation of iron in the brain and heart associated with epilepsy. Generalized tonic-clonic seizures (GTCS), a primary risk factor for Sudden Unexpected Death in Epilepsy (SUDEP), not only have an impact on the brain but also lead to cardiogenic dysfunctions associated with "Iron Overload and Cardiomyopathy" (IOC) and "Epileptic heart" characterized by electrical and mechanical dysfunction and a high risk of malignant bradycardia. In line with this phenomenon, studies conducted by our research group have demonstrated that recurrent seizures induce hypoxia in cardiomyocytes, resulting in P-glycoprotein (P-gp) overexpression, prolonged Q-T interval, severe bradycardia, and hemosiderin precipitation, correlating with an elevated spontaneous death ratio. In this article, we explore the intricate connections among ferroptosis, epilepsy, and SUDEP. By synthesizing current knowledge and drawing insights from recent publications, this study provides a comprehensive understanding of the molecular underpinnings. Furthermore, this review offers insights into potential therapeutic avenues and outlines future research directions.
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Affiliation(s)
- F Moscovicz
- University of Buenos Aires, Faculty of Pharmacy and Biochemistry, Institute of Phisiopatology and Clinical Biochemistry (INFIBIOC), Applied Neurobiology Lab, Buenos Aires, Argentina; National Council of Scientific and Technical Research (CONICET), Argentina.
| | - C Taborda
- University of Buenos Aires, Faculty of Pharmacy and Biochemistry, Institute of Phisiopatology and Clinical Biochemistry (INFIBIOC), Applied Neurobiology Lab, Buenos Aires, Argentina; National Council of Scientific and Technical Research (CONICET), Argentina
| | - F Fernández
- University of Buenos Aires, Faculty of Pharmacy and Biochemistry, Institute of Phisiopatology and Clinical Biochemistry (INFIBIOC), Applied Neurobiology Lab, Buenos Aires, Argentina
| | - N Borda
- University of Buenos Aires, Faculty of Pharmacy and Biochemistry, Institute of Phisiopatology and Clinical Biochemistry (INFIBIOC), Applied Neurobiology Lab, Buenos Aires, Argentina
| | - J Auzmendi
- University of Buenos Aires, Faculty of Pharmacy and Biochemistry, Institute of Phisiopatology and Clinical Biochemistry (INFIBIOC), Applied Neurobiology Lab, Buenos Aires, Argentina; National Council of Scientific and Technical Research (CONICET), Argentina.
| | - A Lazarowski
- University of Buenos Aires, Faculty of Pharmacy and Biochemistry, Institute of Phisiopatology and Clinical Biochemistry (INFIBIOC), Applied Neurobiology Lab, Buenos Aires, Argentina.
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Kim CS, Park DW, Kim TY, Lee YJ, Lee JY. Microbleeds in the Corpus Callosum in Anoxic Brain Injury. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:1184-1193. [PMID: 36238025 PMCID: PMC9431861 DOI: 10.3348/jksr.2019.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/08/2019] [Accepted: 10/18/2019] [Indexed: 11/18/2022]
Abstract
Purpose This study was performed to evaluate the relationship between callosal microbleeds and anoxic brain injury. Materials and Methods Twenty-seven patients with anoxic brain injuries were analyzed and retrospectively compared to the control group of patients without a history of anoxic brain injury using Fisher's exact test regarding comorbidities and cerebral microbleeds. The patient group was subdivided according to the presence of callosal microbleeds. Fisher's exact test was used to compare the presence of typical MRI findings of anoxic brain injury, use of cardiopulmonary resuscitation, and prognosis. The Mann-Whitney U test was used to compare the interval between the occurrence of anoxic brain injury to MRI acquisition. Results The prevalence of cerebral microbleeds in the patient group was 29.6%, which was significantly higher than that in the control group at 3.7% (p = 0.012). All cerebral microbleeds in the patient group were in the corpus callosum. Compared with the callosal microbleed-absent group, the callosal microbleed-present group showed a tendency of good prognosis (6/8 vs. 11/19), fewer typical MRI findings of anoxic brain injury (2/8 vs. 10/19), and more cardiopulmonary resuscitation (6/8 vs. 12/19), although these differences did not reach statistical significance (p = 0.35, p = 0.19, and p = 0.45, respectively). Conclusion Callosal microbleeds may be an adjunctive MRI marker for anoxic brain injury.
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Affiliation(s)
- Chang Su Kim
- Department of Radiology, College of Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Dong Woo Park
- Department of Radiology, College of Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Tae Yoon Kim
- Department of Radiology, College of Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Young-Jun Lee
- Department of Radiology, College of Medicine, Hanyang University Hospital, Seoul, Korea
| | - Ji Young Lee
- Department of Radiology, College of Medicine, Hanyang University Hospital, Seoul, Korea
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Rapid Formation of Cerebral Microbleeds in Reversible Cerebral Vasoconstriction Syndrome. Can J Neurol Sci 2019; 47:134-136. [PMID: 31625486 DOI: 10.1017/cjn.2019.300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Prisco L, Ganau M, Aurangzeb S, Moswela O, Hallett C, Raby S, Fitzgibbon K, Kearns C, Sen A. A pragmatic approach to intravenous anaesthetics and electroencephalographic endpoints for the treatment of refractory and super-refractory status epilepticus in critical care. Seizure 2019; 75:153-164. [PMID: 31623937 DOI: 10.1016/j.seizure.2019.09.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/23/2019] [Indexed: 12/13/2022] Open
Abstract
Status epilepticus is a common neurological emergency, with overall mortality around 20%. Over half of cases are first time presentations of seizures. The pathological process by which spontaneous seizures are generated arises from an imbalance in excitatory and inhibitory neuronal networks, which if unchecked, can result in alterations in intracellular signalling pathways and electrolyte shifts, which bring about changes in the blood brain barrier, neuronal cell death and eventually cerebral atrophy. This narrative review focusses on the treatment of status epilepticus in adults. Anaesthetic agents interrupt neuronal activity by enhancing inhibitory or decreasing excitatory transmission, primarily via GABA and NMDA receptors. Intravenous anaesthetic agents are commonly used as second or third line drugs in the treatment of refractory status epilepticus, but the optimal timing and choice of anaesthetic drug has not yet been established by high quality evidence. Titration of antiepileptic and anaesthetic drugs in critically ill patients presents a particular challenge, due to alterations in drug absorbtion and metabolism as well as changes in drug distrubution, which arise from fluid shifts and altered protein binding. Furthermore, side effects associated with prolonged infusions of anaesthetic drugs can lead to multi-organ dysfunction and a need for critical care support. Electroencelography can identify patterns of burst suppression, which may be a target to guide weaning of intravenous therapy. Continuous elctroencephalography has the potential to directly impact clinical care, but despite its utility, major barriers exist which have limited its widespread use in clinical practice. A flow chart outlining the timing and dosage of anaesthetic agents used at our institution is provided.
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Affiliation(s)
- Lara Prisco
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Anaesthesia Neuroimaging Research Group, Wellcome Centre for Integrative Neuroimaging, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK.
| | - Mario Ganau
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sidra Aurangzeb
- Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK; Department of Clinical Neurology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Department of Clinical Neurophysiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Olivia Moswela
- Pharmacy Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Claire Hallett
- Pharmacy Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon Raby
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karina Fitzgibbon
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christopher Kearns
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Arjune Sen
- Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK; Department of Clinical Neurology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Schoeppe F, Rossi A, Levin J, Reiser M, Stoecklein S, Ertl-Wagner B. Increased cerebral microbleeds and cortical superficial siderosis in pediatric patients with Down syndrome. Eur J Paediatr Neurol 2019; 23:158-164. [PMID: 30279085 DOI: 10.1016/j.ejpn.2018.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 07/19/2018] [Accepted: 09/04/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Patients with Down syndrome carry a third copy of the amyloid precursor protein gene, which is localized on chromosome 21. Consequently, these patients are prone to develop early-onset Alzheimer disease and cerebral amyloid angiopathy. Post-mortem studies suggest increased amyloid deposition to be already detectable in children with Down syndrome. The aim of our study was to evaluate if amyloid-related changes in pediatric Down syndrome patients can be detected in vivo using MRI biomarkers of cerebral microbleeds and cortical superficial siderosis. MATERIALS AND METHODS This retrospective study included 12 patients with Down syndrome (mean age = 5.0 years) and 12 age-matched control subjects (mean age = 4.8 years). Frequency and location of microbleeds and siderosis were assessed on blood-sensitive MRI sequences in a consensus reading by two radiologists applying a modified Microbleed Anatomical Rating Scale. RESULTS Down syndrome patients showed a significantly higher mean microbleeds count and likelihood of siderosis than age-matched controls. Across groups, the highest microbleeds count was found in lobar regions (gray and white matter of frontal, parietal, temporal, and occipital lobes, and the insula), while fewer microbleeds were located in subcortical and infratentorial regions. The number of microbleeds increased over time in all three Down syndrome patients with a follow-up exam. CONCLUSION In vivo MRI biomarkers can support the diagnosis of early-onset cerebral amyloid angiopathy, which might already be present in pediatric Down syndrome patients. This might contribute to clinical decision-making and potentially to the development of therapeutic and prophylactic approaches, as cerebral amyloid angiopathy increases the risk for intracranial hemorrhage and may be associated with increased risk of developing Alzheimer disease.
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Affiliation(s)
- Franziska Schoeppe
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Andrea Rossi
- Department of Pediatric Neuroradiology, Instituto Giannina Gaslini, Via G. Gaslini 5, I-16147, Genoa, Italy
| | - Johannes Levin
- Department of Neurology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377, Munich, Germany
| | - Maximilian Reiser
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Sophia Stoecklein
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Birgit Ertl-Wagner
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany; Department of Radiology, The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G1X8, Canada
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Gorter JA, van Vliet EA, Aronica E. Status epilepticus, blood-brain barrier disruption, inflammation, and epileptogenesis. Epilepsy Behav 2015; 49:13-6. [PMID: 25958228 DOI: 10.1016/j.yebeh.2015.04.047] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 04/19/2015] [Indexed: 11/15/2022]
Abstract
Over the last 15 years, attention has been focused on dysfunction of the cerebral vasculature and inflammation as important players in epileptogenic processes, with a specific emphasis on failure of the blood-brain barrier (BBB; Fig. 1) (Seiffert et al., 2004; Marchi et al., 2007; Oby and Janigro, 2006; van Vliet et al., 2014; Vezzani et al., 2011) [3-7]. Here, we discuss how the BBB is disrupted as a consequence of SE and how this BBB breakdown may be involved in epileptogenesis. This article is part of a Special Issue entitled "Status Epilepticus".
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Affiliation(s)
- Jan A Gorter
- Center for Neuroscience, Swammerdam Institute for Life Sciences, University of Amsterdam, Amsterdam, The Netherlands.
| | - Erwin A van Vliet
- Academic Medical Center, Department of (Neuro)Pathology, University of Amsterdam, Amsterdam, The Netherlands
| | - Eleonora Aronica
- Center for Neuroscience, Swammerdam Institute for Life Sciences, University of Amsterdam, Amsterdam, The Netherlands; Academic Medical Center, Department of (Neuro)Pathology, University of Amsterdam, Amsterdam, The Netherlands; SEIN - Stichting Epilepsie Instellingen Nederland, Heemstede, The Netherlands
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Jeon SB, Parikh G, Choi HA, Badjatia N, Lee K, Schmidt JM, Lantigua H, Connolly ES, Mayer SA, Claassen J. Cerebral microbleeds in patients with acute subarachnoid hemorrhage. Neurosurgery 2014; 74:176-81; discussion 181. [PMID: 24176956 DOI: 10.1227/neu.0000000000000244] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cerebral microbleeds (CMBs) are commonly found after stroke but have not previously been studied in patients with subarachnoid hemorrhage (SAH). OBJECTIVE To study the prevalence, radiographic patterns, predictors, and impact on outcome of CMBs in patients with SAH. METHODS We analyzed retrospectively 39 consecutive patients who underwent T2*-weighted gradient-echo imaging within 7 days after onset of spontaneous SAH. We report the frequency and location of CMBs and show their association with demographics, vascular risk factors, the Hunt-Hess grade, the modified Fisher Scale, the Acute Physiological and Chronic Health Evaluation II, magnetic resonance imaging findings including diffusion-weighted imaging lesions, and laboratory data, as well as data on rebleeding, global cerebral edema, delayed cerebral ischemia, seizures, the Telephone Interview for Cognitive Status, and the modified Rankin Scale. RESULTS Eighteen patients (46%) had CMBs. Of these patients, 9 had multiple CMBs, and overall a total of 50 CMBs were identified. The most common locations of CMBs were lobar (n = 23), followed by deep (n = 15) and infratentorial (n = 12). After adjustment for age and history of hypertension, CMBs were related to the presence of diffusion-weighted imaging lesions (odds ratio, 5.24; 95% confidence interval, 1.14-24.00; P = .03). Three months after SAH, patients with CMBs had nonsignificantly higher modified Rankin Scale scores (odds ratio, 2.50; 95% confidence interval, 0.67-9.39; P = .18). CONCLUSION This study suggests that CMBs are commonly observed and associated with diffusion-weighted imaging lesions in patients with SAH. Our findings may represent a new mechanism of tissue injury in SAH. Further studies are needed to investigate the clinical implications of CMBs.
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Affiliation(s)
- Sang-Beom Jeon
- *Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea, Departments of ‡Neurology and ¶Neurosurgery, Columbia University College of Physicians and Surgeons, New York, New York; §Departments of Neurology and Neurosurgery, University of Texas Medical School at Houston, Houston, Texas; ‖Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
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Hocker S, Tatum WO, LaRoche S, Freeman WD. Refractory and Super-Refractory Status Epilepticus—an Update. Curr Neurol Neurosci Rep 2014; 14:452. [DOI: 10.1007/s11910-014-0452-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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