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Hladky SB, Barrand MA. Alterations in brain fluid physiology during the early stages of development of ischaemic oedema. Fluids Barriers CNS 2024; 21:51. [PMID: 38858667 PMCID: PMC11163777 DOI: 10.1186/s12987-024-00534-8] [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: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 06/12/2024] Open
Abstract
Oedema occurs when higher than normal amounts of solutes and water accumulate in tissues. In brain parenchymal tissue, vasogenic oedema arises from changes in blood-brain barrier permeability, e.g. in peritumoral oedema. Cytotoxic oedema arises from excess accumulation of solutes within cells, e.g. ischaemic oedema following stroke. This type of oedema is initiated when blood flow in the affected core region falls sufficiently to deprive brain cells of the ATP needed to maintain ion gradients. As a consequence, there is: depolarization of neurons; neural uptake of Na+ and Cl- and loss of K+; neuronal swelling; astrocytic uptake of Na+, K+ and anions; swelling of astrocytes; and reduction in ISF volume by fluid uptake into neurons and astrocytes. There is increased parenchymal solute content due to metabolic osmolyte production and solute influx from CSF and blood. The greatly increased [K+]isf triggers spreading depolarizations into the surrounding penumbra increasing metabolic load leading to increased size of the ischaemic core. Water enters the parenchyma primarily from blood, some passing into astrocyte endfeet via AQP4. In the medium term, e.g. after three hours, NaCl permeability and swelling rate increase with partial opening of tight junctions between blood-brain barrier endothelial cells and opening of SUR1-TPRM4 channels. Swelling is then driven by a Donnan-like effect. Longer term, there is gross failure of the blood-brain barrier. Oedema resolution is slower than its formation. Fluids without colloid, e.g. infused mock CSF, can be reabsorbed across the blood-brain barrier by a Starling-like mechanism whereas infused serum with its colloids must be removed by even slower extravascular means. Large scale oedema can increase intracranial pressure (ICP) sufficiently to cause fatal brain herniation. The potentially lethal increase in ICP can be avoided by craniectomy or by aspiration of the osmotically active infarcted region. However, the only satisfactory treatment resulting in retention of function is restoration of blood flow, providing this can be achieved relatively quickly. One important objective of current research is to find treatments that increase the time during which reperfusion is successful. Questions still to be resolved are discussed.
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Affiliation(s)
- Stephen B Hladky
- Department of Pharmacology, Tennis Court Rd., Cambridge, CB2 1PD, UK.
| | - Margery A Barrand
- Department of Pharmacology, Tennis Court Rd., Cambridge, CB2 1PD, UK
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2
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Xiao X, Bi M, Du X, Jiang H. The ATP-sensitive potassium channel: a therapeutic target for neurodegeneration? Expert Opin Ther Targets 2023; 27:517-521. [PMID: 37489110 DOI: 10.1080/14728222.2023.2240023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/19/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Xue Xiao
- Physiology, School of Basic Medicine, Medical College of Qingdao University, Qingdao, China
| | - Mingxia Bi
- Physiology, School of Basic Medicine, Medical College of Qingdao University, Qingdao, China
| | - Xixun Du
- Physiology, School of Basic Medicine, Medical College of Qingdao University, Qingdao, China
| | - Hong Jiang
- Physiology, School of Basic Medicine, Medical College of Qingdao University, Qingdao, China
- School of Health and Life Sciences, University of Health and Rehabilitation Sciences, Qingdao City, Shandong, China
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3
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Jha RM, Rani A, Desai SM, Raikwar S, Mihaljevic S, Munoz-Casabella A, Kochanek PM, Catapano J, Winkler E, Citerio G, Hemphill JC, Kimberly WT, Narayan R, Sahuquillo J, Sheth KN, Simard JM. Sulfonylurea Receptor 1 in Central Nervous System Injury: An Updated Review. Int J Mol Sci 2021; 22:ijms222111899. [PMID: 34769328 PMCID: PMC8584331 DOI: 10.3390/ijms222111899] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 12/17/2022] Open
Abstract
Sulfonylurea receptor 1 (SUR1) is a member of the adenosine triphosphate (ATP)-binding cassette (ABC) protein superfamily, encoded by Abcc8, and is recognized as a key mediator of central nervous system (CNS) cellular swelling via the transient receptor potential melastatin 4 (TRPM4) channel. Discovered approximately 20 years ago, this channel is normally absent in the CNS but is transcriptionally upregulated after CNS injury. A comprehensive review on the pathophysiology and role of SUR1 in the CNS was published in 2012. Since then, the breadth and depth of understanding of the involvement of this channel in secondary injury has undergone exponential growth: SUR1-TRPM4 inhibition has been shown to decrease cerebral edema and hemorrhage progression in multiple preclinical models as well as in early clinical studies across a range of CNS diseases including ischemic stroke, traumatic brain injury, cardiac arrest, subarachnoid hemorrhage, spinal cord injury, intracerebral hemorrhage, multiple sclerosis, encephalitis, neuromalignancies, pain, liver failure, status epilepticus, retinopathies and HIV-associated neurocognitive disorder. Given these substantial developments, combined with the timeliness of ongoing clinical trials of SUR1 inhibition, now, another decade later, we review advances pertaining to SUR1-TRPM4 pathobiology in this spectrum of CNS disease—providing an overview of the journey from patch-clamp experiments to phase III trials.
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Affiliation(s)
- Ruchira M. Jha
- Department of Neurology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (R.M.J.); (S.M.D.)
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Anupama Rani
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Shashvat M. Desai
- Department of Neurology, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (R.M.J.); (S.M.D.)
| | - Sudhanshu Raikwar
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Sandra Mihaljevic
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Amanda Munoz-Casabella
- Department of Translational Neuroscience, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (A.R.); (S.R.); (S.M.); (A.M.-C.)
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA;
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
- Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Joshua Catapano
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Ethan Winkler
- Department of Neurosurgery, Barrow Neurological Institute and St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA; (J.C.); (E.W.)
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, 20126 Milan, Italy;
- Neurointensive Care Unit, Department of Neuroscience, San Gerardo Hospital, ASST—Monza, 20900 Monza, Italy
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA 94143, USA;
| | - W. Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Raj Narayan
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY 11549, USA;
| | - Juan Sahuquillo
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute (VHIR), 08035 Barcelona, Spain;
- Neurotraumatology and Neurosurgery Research Unit, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
- Department of Neurosurgery, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, School of Medicine, Yale University, New Haven, CT 06510, USA;
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, 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
- Correspondence:
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Jeon H, Kim M, Park W, Lim JS, Lee E, Cha H, Ahn JS, Kim JH, Hong SH, Park JE, Lee EJ, Woo CW, Lee S. Upregulation of AQP4 Improves Blood-Brain Barrier Integrity and Perihematomal Edema Following Intracerebral Hemorrhage. Neurotherapeutics 2021; 18:2692-2706. [PMID: 34545550 PMCID: PMC8804112 DOI: 10.1007/s13311-021-01126-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 01/08/2023] Open
Abstract
In intracerebral hemorrhage (ICH), delayed secondary neural damages largely occur from perihematomal edema (PHE) resulting from the disruption of the blood-brain barrier (BBB). PHE is often considered the principal cause of morbidity and mortality in patients with ICH. Nevertheless, the main cellular mechanism as well as the specific BBB component involved in the formation of PHE after ICH remains elusive. Herein, we evaluated the role of AQP4, a water channel expressed on the astrocytes of the BBB, in the formation of PHE in ICH. The static and dynamic functions of the BBB were evaluated by analyzing the microstructure and leakage assay. Protein changes in the PHE lesion were analyzed and the control mechanism of AQP4 expression by reactive oxygen species was also investigated. Delayed PHE formation due to BBB disruption after ICH was confirmed by the decreased coverage of multiple BBB components and increased dynamic leakages. Microstructure assay showed that among the BBB components, AQP4 showed a markedly decreased expression in the PHE lesions. The decrease in AQP4 was due to microenvironmental ROS derived from the hemorrhage and was restored by treatment with ROS scavenger. AQP4-deficient mice had significantly larger PHE lesions and unfavorable survival outcomes compared with wild-type mice. Our data identify AQP4 as a specific BBB-modulating target for alleviating PHE in ICH. Further comprehensive studies are needed to form the preclinical basis for the use of AQP4 enhancers as BBB modulators for preventing delayed cerebral edema after ICH.
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Affiliation(s)
- Hanwool Jeon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Medical Science, Asan Medical Center, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Moinay Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Wonhyoung Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon Seo Lim
- Clinical Research Center, Asan Medical Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eunyeup Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Medical Science, Asan Medical Center, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyeuk Cha
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Medical Science, Asan Medical Center, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Sung Ahn
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seok Ho Hong
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Eun Park
- University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Neuroradiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun-Jae Lee
- Department of Medical Science, Asan Medical Center, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, Seoul, Republic of Korea
- University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chul-Woong Woo
- Convergence Medicine Research Center, Asan Medical Center, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seungjoo Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
- Department of Medical Science, Asan Medical Center, Asan Medical Institute of Convergence Science and Technology, University of Ulsan College of Medicine, Seoul, Republic of Korea.
- University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Igarashi T, Sastre C, Wolcott Z, Kimberly WT. Continuous Glibenclamide Prevents Hemorrhagic Transformation in a Rodent Model of Severe Ischemia-Reperfusion. J Stroke Cerebrovasc Dis 2021; 30:105595. [PMID: 33450605 PMCID: PMC7894607 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105595] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/20/2020] [Accepted: 12/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is highly effective but may also lead to hemorrhagic transformation (HT) and edema, which may be more pronounced in severe ischemia. We sought to determine whether glibenclamide can attenuate HT and edema in a severe ischemia-reperfusion model that reflects EVT. METHODS Using a transient middle cerebral artery occlusion (tMCAo) rodent model of stroke, we studied two rat cohorts, one without rt-PA and a second cohort treated with rt-PA. Glibenclamide or vehicle control was administered as an intravenous bolus at reperfusion, followed by continuous subcutaneous administration with an osmotic pump. RESULTS Compared to vehicle control, glibenclamide improved neurological outcome (median 7, interquartile range [IQR 6-8] vs. control median 6 [IQR 0-6], p = 0.025), reduced stroke volume (323 ± 42 vs. 484 ± 60 mm3, p < 0.01), swelling volume (10 ± 4 vs. 28 ± 7%, p < 0.01) and water content (84 ± 1 vs. 85 ± 1%, p < 0.05). Glibenclamide administration also reduced HT based on ECASS criteria, densitometry (0.94 ± 0.1 vs. 1.15 ± 0.2, p < 0.01), and quantitative hemoglobin concentration (2.7 ± 1.5 vs. 6.2 ± 4.6 uL, p = 0.011). In the second cohort with rt-PA coadministration, concordant effects on HT were observed with glibenclamide. CONCLUSIONS Taken together, these studies demonstrated that glibenclamide reduced the amount of edema and HT after severe ischemia. This study suggests that co-administration of glibenclamide may be worth further study in severe stroke patients treated with EVT with or without IV rt-PA.
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Affiliation(s)
- Takahiro Igarashi
- Division of Neurocritical Care, Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Cristina Sastre
- Division of Neurocritical Care, Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Zoe Wolcott
- Division of Neurocritical Care, Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - W Taylor Kimberly
- Division of Neurocritical Care, Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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Bloodletting Puncture at Hand Twelve Jing-Well Points Relieves Brain Edema after Severe Traumatic Brain Injury in Rats via Inhibiting MAPK Signaling Pathway. Chin J Integr Med 2021; 27:291-299. [PMID: 33515398 DOI: 10.1007/s11655-021-3326-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate whether blood-brain barrier (BBB) served a key role in the edema-relief effect of bloodletting puncture at hand twelve Jing-well points (HTWP) in traumatic brain injury (TBI) and the potential molecular signaling pathways. METHODS Adult male Sprague-Dawley rats were assigned to the sham-operated (sham), TBI, and bloodletting puncture (bloodletting) groups (n=24 per group) using a randomized number table. The TBI model rats were induced by cortical contusion and then bloodletting puncture were performed at HTWP twice a day for 2 days. The neurological function and cerebral edema were evaluated by modified neurological severity score (mNSS), cerebral water content, magnetic resonance imaging and hematoxylin and eosin staining. Cerebral blood flow was measured by laser speckles. The protein levels of aquaporin 4 (AQP4), matrix metalloproteinases 9 (MMP9) and mitogen-activated protein kinase pathway (MAPK) signaling were detected by immunofluorescence staining and Western blot. RESULTS Compared with TBI group, bloodletting puncture improved neurological function at 24 and 48 h, alleviated cerebral edema at 48 h, and reduced the permeability of BBB induced by TBI (all P<0.05). The AQP4 and MMP9 which would disrupt the integrity of BBB were downregulated by bloodletting puncture (P<0.05 or P<0.01). In addition, the extracellular signal-regulated kinase (ERK) and p38 signaling pathways were inhibited by bloodletting puncture (P<0.05). CONCLUSIONS Bloodletting puncture at HTWP might play a significant role in protecting BBB through regulating the expressions of MMP9 and AQP4 as well as corresponding regulatory upstream ERK and p38 signaling pathways. Therefore, bloodletting puncture at HTWP may be a promising therapeutic strategy for TBI-induced cerebral edema.
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Pergakis M, Badjatia N, Simard JM. An update on the pharmacological management and prevention of cerebral edema: current therapeutic strategies. Expert Opin Pharmacother 2021; 22:1025-1037. [PMID: 33467932 DOI: 10.1080/14656566.2021.1876663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Cerebral edema is a common complication of multiple neurological diseases and is a strong predictor of outcome, especially in traumatic brain injury and large hemispheric infarction.Areas Covered: Traditional and current treatments of cerebral edema include treatment with osmotherapy or decompressive craniectomy at the time of clinical deterioration. The authors discuss preclinical and clinical models of a variety of neurological disease states that have identified receptors, ion transporters, and channels involved in the development of cerebral edema as well as modulation of these receptors with promising agents.Expert opinion: Further study is needed on the safety and efficacy of the agents discussed. IV glibenclamide has shown promise in preclinical and clinical trials of cerebral edema in large hemispheric infarct and traumatic brain injury. Consideration of underlying pathophysiology and pharmacodynamics is vital, as the synergistic use of agents has the potential to drastically mitigate cerebral edema and secondary brain injury thusly transforming our treatment paradigms.
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Affiliation(s)
- Melissa Pergakis
- Program in Trauma Department of Neurology University of Maryland School of Medicine,Baltimore MD USA
| | - Neeraj Badjatia
- Program in Trauma Department of Neurology University of Maryland School of Medicine,Baltimore MD USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Jha RM, Mondello S, Bramlett HM, Dixon CE, Shear DA, Dietrich WD, Wang KKW, Yang Z, Hayes RL, Poloyac SM, Empey PE, Lafrenaye AD, Yan HQ, Carlson SW, Povlishock JT, Gilsdorf JS, Kochanek PM. Glibenclamide Treatment in Traumatic Brain Injury: Operation Brain Trauma Therapy. J Neurotrauma 2020; 38:628-645. [PMID: 33203303 DOI: 10.1089/neu.2020.7421] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Glibenclamide (GLY) is the sixth drug tested by the Operation Brain Trauma Therapy (OBTT) consortium based on substantial pre-clinical evidence of benefit in traumatic brain injury (TBI). Adult Sprague-Dawley rats underwent fluid percussion injury (FPI; n = 45), controlled cortical impact (CCI; n = 30), or penetrating ballistic-like brain injury (PBBI; n = 36). Efficacy of GLY treatment (10-μg/kg intraperitoneal loading dose at 10 min post-injury, followed by a continuous 7-day subcutaneous infusion [0.2 μg/h]) on motor, cognitive, neuropathological, and biomarker outcomes was assessed across models. GLY improved motor outcome versus vehicle in FPI (cylinder task, p < 0.05) and CCI (beam balance, p < 0.05; beam walk, p < 0.05). In FPI, GLY did not benefit any other outcome, whereas in CCI, it reduced 21-day lesion volume versus vehicle (p < 0.05). On Morris water maze testing in CCI, GLY worsened performance on hidden platform latency testing versus sham (p < 0.05), but not versus TBI vehicle. In PBBI, GLY did not improve any outcome. Blood levels of glial fibrillary acidic protein and ubiquitin carboxyl terminal hydrolase-1 at 24 h did not show significant treatment-induced changes. In summary, GLY showed the greatest benefit in CCI, with positive effects on motor and neuropathological outcomes. GLY is the second-highest-scoring agent overall tested by OBTT and the only drug to reduce lesion volume after CCI. Our findings suggest that leveraging the use of a TBI model-based phenotype to guide treatment (i.e., GLY in contusion) might represent a strategic choice to accelerate drug development in clinical trials and, ultimately, achieve precision medicine in TBI.
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Affiliation(s)
- Ruchira M Jha
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Departments of Neurology, Neurobiology, and Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Helen M Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, and Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA
| | - C Edward Dixon
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah A Shear
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - W Dalton Dietrich
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kevin K W Wang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Department of Emergency Medicine, McKnight Brin Institute of the University of Florida, Gainesville, Florida, USA
| | - Zhihui Yang
- Program for Neurotrauma, Neuroproteomics & Biomarkers Research, Department of Emergency Medicine, McKnight Brin Institute of the University of Florida, Gainesville, Florida, USA
| | - Ronald L Hayes
- Center for Innovative Research, Center for Proteomics and Biomarkers Research, Banyan Biomarkers, Inc., Alachua, Florida, USA
| | - Samuel M Poloyac
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Audrey D Lafrenaye
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Hong Q Yan
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shaun W Carlson
- Department of Neurological Surgery, Brain Trauma Research Center, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John T Povlishock
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Janice S Gilsdorf
- Brain Trauma Neuroprotection Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Departments of Pediatrics, Anesthesiology, and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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9
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Liu C, Xie J, Sun S, Li H, Li T, Jiang C, Chen X, Wang J, Le A, Wang J, Li Z, Wang J, Wang W. Hemorrhagic Transformation After Tissue Plasminogen Activator Treatment in Acute Ischemic Stroke. Cell Mol Neurobiol 2020; 42:621-646. [PMID: 33125600 DOI: 10.1007/s10571-020-00985-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022]
Abstract
Hemorrhagic transformation (HT) is a common complication after thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) in ischemic stroke. In this article, recent research progress of HT in vivo and in vitro studies was reviewed. We have discussed new potential mechanisms and possible experimental models of HT development, as well as possible biomarkers and treatment methods. Meanwhile, we compared and analyzed rodent models, large animal models and in vitro BBB models of HT, and the limitations of these models were discussed. The molecular mechanism of HT was investigated in terms of BBB disruption, rt-PA neurotoxicity and the effect of neuroinflammation, matrix metalloproteinases, reactive oxygen species. The clinical features to predict HT were represented including blood biomarkers and clinical factors. Recent progress in neuroprotective strategies to improve HT after stroke treated with rt-PA is outlined. Further efforts need to be made to reduce the risk of HT after rt-PA therapy and improve the clinical prognosis of patients with ischemic stroke.
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Affiliation(s)
- Chengli Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Shanshan Sun
- Department of Ultrasound Imaging, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Hui Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Tianyu Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Chao Jiang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xuemei Chen
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Junmin Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Anh Le
- Washington University in St. Louis, Saint Louis, MO, 63130, USA
| | - Jiarui Wang
- The Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Zhanfei Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jian Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China.
| | - Wei Wang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
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10
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Huang K, Ji Z, Wu Y, Huang Y, Li G, Zhou S, Yang Z, Huang W, Yang G, Weng G, Chen P, Pan S. Safety and efficacy of glibenclamide combined with rtPA in acute cerebral ischemia with occlusion/stenosis of anterior circulation (SE-GRACE): study protocol for a randomized controlled trial. BMC Neurol 2020; 20:239. [PMID: 32527232 PMCID: PMC7291425 DOI: 10.1186/s12883-020-01823-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 06/05/2020] [Indexed: 12/11/2022] Open
Abstract
Background Thrombolysis with recombinant tissue plasminogen activator (rtPA) improves outcome for patients with acute ischemic stroke (AIS), but many of them still have substantial disability. Glibenclamide (US adopted name, glyburide), a long-acting sulfonylurea, shows promising result in treating AIS from both preclinical and clinical studies. This study investigates the safety and efficacy of glibenclamide combined with rtPA in treating AIS patients. Methods This is a prospective, randomized, double-blind, placebo-controlled, multicenter trial with an estimated sample size of 306 cases, starting in January 2018. Patients aged 18 to 74 years, presented with a symptomatic anterior circulation occlusion with a deficit on the NIHSS of 4 to 25 points and treated with intravenous rtPA within the first 4.5 h of their clinical onsets, are eligible for participation in this study. The target time from the onset of symptoms to receive the study drug is of 10 h. Subjects are randomized 1: 1 to receive glibenclamide or placebo with a loading dose of 1.25 mg, followed by 0.625 mg every 8 h for total 5 days. The primary efficacy endpoint is 90-day good outcome, measured as modified Rankin Scale of 0 to 2. Safety outcomes are all-cause 30-day mortality and early neurological deterioration, with a focus on cardiac- and glucose-related serious adverse events. Discussion This study will provide valuable information about the safety and efficacy of oral glibenclamide for AIS patients treated with rtPA. This would bring benefits to a large number of patients if the agent is proved to be effective. Trial registration The trial was registered on September 14th 2017 at www.clinicaltrials.gov having identifier NCT03284463. Registration was performed before recruitment was initiated.
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Affiliation(s)
- Kaibin Huang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou North Avenue 1838#, Guangzhou, 510515, China
| | - Zhong Ji
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou North Avenue 1838#, Guangzhou, 510515, China
| | - Yongming Wu
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou North Avenue 1838#, Guangzhou, 510515, China
| | - Yunqiang Huang
- Department of Neurology, Heyuan People's Hospital, Heyuan, China
| | - Guangning Li
- Department of Neurology, Huadu district People's Hospital, Guangzhou, China
| | - Saijun Zhou
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhi Yang
- Department of Neurology, Maoming People's Hospital, Maoming, China
| | - Wenguo Huang
- Department of Neurology, Maoming Hospital of Traditional Chinese Medicine, Maoming, China
| | - Guoshuai Yang
- Department of Neurology, Haikou People's Hospital, Haikou, China
| | - Guohu Weng
- Department of Neurology, Hainan Hospital of Traditional Chinese Medicine, Haikou, China
| | - Pingyan Chen
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou North Avenue 1838#, Guangzhou, 510515, China.
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11
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Abstract
Translational genomics represents a broad field of study that combines genome and transcriptome-wide studies in humans and model systems to refine our understanding of human biology and ultimately identify new ways to treat and prevent disease. The approaches to translational genomics can be broadly grouped into two methodologies, forward and reverse genomic translation. Traditional (forward) genomic translation begins with model systems and aims at using unbiased genetic associations in these models to derive insight into biological mechanisms that may also be relevant in human disease. Reverse genomic translation begins with observations made through human genomic studies and refines these observations through follow-up studies using model systems. The ultimate goal of these approaches is to clarify intervenable processes as targets for therapeutic development. In this review, we describe some of the approaches being taken to apply translational genomics to the study of diseases commonly encountered in the neurocritical care setting, including hemorrhagic and ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and status epilepticus, utilizing both forward and reverse genomic translational techniques. Further, we highlight approaches in the field that could be applied in neurocritical care to improve our ability to identify new treatment modalities as well as to provide important information to patients about risk and prognosis.
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Affiliation(s)
- Pavlos Myserlis
- Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge Street, CPZN 6818, Boston, MA, 02114, USA
- Program in Medical and Population Genetics, Broad Institute, Cambridge, MA, USA
| | - Farid Radmanesh
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher D Anderson
- Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge Street, CPZN 6818, Boston, MA, 02114, USA.
- Program in Medical and Population Genetics, Broad Institute, Cambridge, MA, USA.
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA.
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12
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Jha RM, Bell J, Citerio G, Hemphill JC, Kimberly WT, Narayan RK, Sahuquillo J, Sheth KN, Simard JM. Role of Sulfonylurea Receptor 1 and Glibenclamide in Traumatic Brain Injury: A Review of the Evidence. Int J Mol Sci 2020; 21:E409. [PMID: 31936452 PMCID: PMC7013742 DOI: 10.3390/ijms21020409] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 12/28/2019] [Accepted: 01/03/2020] [Indexed: 02/07/2023] Open
Abstract
Cerebral edema and contusion expansion are major determinants of morbidity and mortality after TBI. Current treatment options are reactive, suboptimal and associated with significant side effects. First discovered in models of focal cerebral ischemia, there is increasing evidence that the sulfonylurea receptor 1 (SUR1)-Transient receptor potential melastatin 4 (TRPM4) channel plays a key role in these critical secondary injury processes after TBI. Targeted SUR1-TRPM4 channel inhibition with glibenclamide has been shown to reduce edema and progression of hemorrhage, particularly in preclinical models of contusional TBI. Results from small clinical trials evaluating glibenclamide in TBI have been encouraging. A Phase-2 study evaluating the safety and efficacy of intravenous glibenclamide (BIIB093) in brain contusion is actively enrolling subjects. In this comprehensive narrative review, we summarize the molecular basis of SUR1-TRPM4 related pathology and discuss TBI-specific expression patterns, biomarker potential, genetic variation, preclinical experiments, and clinical studies evaluating the utility of treatment with glibenclamide in this disease.
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Affiliation(s)
- Ruchira M. Jha
- Departments of Critical Care Medicine, Neurology, Neurological Surgery, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15201, USA
| | | | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, 20121 Milan, Italy;
- Anaesthesia and Intensive Care, San Gerardo and Desio Hospitals, ASST-Monza, 20900 Monza, Italy
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA 94110, USA;
| | - W. Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA 02108, USA;
| | - Raj K. Narayan
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030, USA;
| | - Juan Sahuquillo
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d′Hebron Research Institute (VHIR), 08001 Barcelona, Spain;
- Department of Neurosurgery, Universitat Autònoma de Barcelona (UAB), 08001 Barcelona, Spain
- Department of Neurosurgery, Vall d′Hebron University Hospital, 08001 Barcelona, Spain
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT 06501, USA;
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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13
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Jacobson SM, MacAllister TW, Geliebter DM. Found in translation: The rationale behind the early development of glibenclamide in large hemispheric infarction. Neurosci Lett 2020; 716:134672. [DOI: 10.1016/j.neulet.2019.134672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/01/2019] [Indexed: 10/25/2022]
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14
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Woo SK, Tsymbalyuk N, Tsymbalyuk O, Ivanova S, Gerzanich V, Simard JM. SUR1-TRPM4 channels, not K ATP, mediate brain swelling following cerebral ischemia. Neurosci Lett 2019; 718:134729. [PMID: 31899311 DOI: 10.1016/j.neulet.2019.134729] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 12/30/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Preclinical and emerging clinical data show that glibenclamide reduces space occupying edema and brain swelling following cerebral ischemia. Glibenclamide is a potent inhibitor of numerous sulfonylurea receptor (SUR)-regulated channels, including KATP (SUR1-KIR6.2, SUR2A-KIR6.2, SUR2B-KIR6.2, SUR2B-KIR6.1) and SUR1-TRPM4. Here, we used molecularly specific oligodeoxynucleotides (ODNs) to investigate the role of various SUR-regulated ion channel subunits in post-ischemic brain swelling. METHODS Focal cerebral ischemia was induced in adult male rats by permanent middle cerebral artery occlusion (pMCAo). We used this model to study the effects of antisense-ODNs (AS-ODNs) directed against Abcc8/SUR1, Trpm4/TRPM4, Kcnj8/KIR6.1 and Kcnj11/KIR6.2 on hemispheric swelling, with sense or scrambled ODNs used as controls. We used antibody-based Förster resonance energy transfer (immuno-FRET) and co-immunoprecipitation to study the co-assembly of SUR1-TRPM4 heteromers. RESULTS In the combined control groups administered sense or scrambled ODNs, pMCAo resulted in uniformly large infarct volumes (mean ± SD: 57.4 ± 8.8 %; n = 34) at 24 h after onset of ischemia, with no effect of AS-ODNs on infarct size. In controls, hemispheric swelling was 23.9 ± 4.1 % (n = 34), and swelling was linearly related to infarct volume (P < 0.02). In the groups administered anti-Abcc8/SUR1 or anti-Trpm4/TRPM4 AS-ODN, hemispheric swelling was significantly less, 11.6 ± 3.9 % and 12.8 ± 5.8 % respectively (P < 0.0001), and the relationship between infarct volume and swelling was reduced and not significant. AS-ODNs directed against Kcnj8/KIR6.1 and Kcnj11/KIR6.2 had no significant effect on hemispheric swelling (23.3 ± 5.4 % and 22.9 ± 5.8 % respectively). Post-ischemic tissues showed co-assembly of SUR1-TRPM4 heteromers. CONCLUSIONS Post-ischemic hemispheric swelling can be decoupled from infarct volume. SUR1-TRPM4 channels, not KATP, mediate post-ischemic brain swelling.
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Affiliation(s)
- Seung Kyoon Woo
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Natalia Tsymbalyuk
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Orest Tsymbalyuk
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Svetlana Ivanova
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Volodymyr Gerzanich
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - J Marc Simard
- Departments of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, United States; Departments of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, United States; Departments of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, United States.
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15
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Sah RG, Nobakht S, Rajashekar D, Mouches P, Forkert ND, Sitaram A, Tsang A, Hill MD, Demchuk AM, d'Esterre CD, Barber PA. Temporal evolution and spatial distribution of quantitative T2 MRI following acute ischemia reperfusion injury. Int J Stroke 2019; 15:495-506. [DOI: 10.1177/1747493019895673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Determining mechanisms of secondary stroke injury related to cerebral blood flow and the severity of microvascular injury contributing to edema and blood-brain barrier breakdown will be critical for the development of adjuvant therapies for revascularization treatment. Aim To characterize the heterogeneity of the ischemic lesion using quantitative T2 imaging along with diffusion-weighted magnetic resonance imaging (DWI) within five hours of treatment. Methods Quantitative T2 magnetic resonance imaging was acquired within 5 h (baseline) and at 24 h (follow-up) of stroke treatment in 29 patients. Dynamic contrast enhanced permeability imaging was performed at baseline in a subgroup of patients. Absolute volume change and lesion percent change was determined for the quantitative T2, DWI, and absolute volume change sequences. A Gaussian process with RRELIEFF feature selection algorithm was used for prediction of relative quantitative T2 and DWI lesion growth, baseline and follow-up quantitative T2/DWI lesion ratios, and also NIHSS at 24 h and change in NIHSS from admission to 24 h. Results In n = 27 patients, median (interquartile range) lesion percent change was 114.8% (48.9%, 259.1%) for quantitative T2, 48.2% (−12.6%, 179.6%) for absolute volume change, and 62.7% (26.3%, 230.9%) for DWI, respectively. Our model, consisting of baseline NIHSS, CT ASPECTS, and systolic blood pressure, showed a strong correlation with quantitative T2 percent change (cross correlation R2 = 0.80). There was a strong predictive ability for quantitative T2/DWI lesion ratio at 24 h using baseline NIHSS and last seen normal to 24 h magnetic resonance imaging time (cross correlation R2 = 0.93). Baseline dynamic contrast enhanced permeability was moderately correlated to the baseline quantitative T2 values (rho = 0.38). Conclusion Quantitative T2 imaging provides critical information for development of therapeutic approaches that could ameliorate microvascular damage during ischemia reperfusion.
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Affiliation(s)
- Rani Gupta Sah
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
| | | | - Deepthi Rajashekar
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, Canada
| | - Pauline Mouches
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, Canada
| | - Nils D Forkert
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Amith Sitaram
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
| | - Adrian Tsang
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
| | - Christopher D d'Esterre
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
| | - Philip A Barber
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Seaman Family Centre, Foothills Medical Centre, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences
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16
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Yang E, Cai Y, Yao X, Liu J, Wang Q, Jin W, Wu Q, Fan W, Qiu L, Kang C, Wu J. Tissue plasminogen activator disrupts the blood-brain barrier through increasing the inflammatory response mediated by pericytes after cerebral ischemia. Aging (Albany NY) 2019; 11:10167-10182. [PMID: 31740626 PMCID: PMC6914411 DOI: 10.18632/aging.102431] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/28/2019] [Indexed: 12/20/2022]
Abstract
Pericytes, important elements of the blood-brain barrier (BBB), play critical roles in maintaining BBB integrity and modulating hemostasis, angiogenesis, inflammation and phagocytic function. We investigated whether pericytes are involved in the recombinant tissue plasminogen activator (rt-PA)-induced inflammatory response, which disrupts the BBB, and investigated the potential mechanisms. Middle cerebral artery occlusion (MCAO) and oxygen-glucose deprivation (OGD) were employed to mimic hypoxic-ischemic conditions. Rt-PA was intravenously injected into mice 1 h after 1 h MCAO, and Rt-PA was added to the culture medium after 4 h OGD. Rt-PA treatment aggravated the disruption of the BBB compared with hypoxia treatment, and etanercept (TNF-α inhibitor) combined with rt-PA alleviated the rt-PA-induced BBB disruption in vivo and in vitro. Rt-PA treatment increased the TNF-α and MCP-1 levels and decreased the TGF-β, p-Smad2/3 and PDGFR-β levels compared with hypoxia treatment in vivo and vitro. TGF-β combined with rt-PA decreased TNF-α and MCP-1 secretion and alleviated BBB disruption compared with rt-PA; these changes were abrogated by TPO427736 HCL (a TGF-β/p-Smad2/3 pathway inhibitor) cotreatment in vitro. Rt-PA did not decrease TGF-β and p-Smad2/3 expression in PDGFR-β-overexpressing pericytes after OGD. These findings identify PDGFR-β/TGF-β/p-Smad2/3 signaling in pericytes as a new therapeutic target for the treatment of rt-PA-induced BBB damage.
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Affiliation(s)
- Eryan Yang
- Graduate School of Tianjin Medical University, Tianjin 300070, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin 300350, China.,Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Ying Cai
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Xiuhua Yao
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Ji Liu
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Qixue Wang
- Key Laboratory of Neurotrauma, Variation, and Regeneration, Ministry of Education and Tianjin Municipal Government, Tianjin Neurological Institute, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Weili Jin
- Graduate School of Tianjin Medical University, Tianjin 300070, China.,Key Laboratory of Neurotrauma, Variation, and Regeneration, Ministry of Education and Tianjin Municipal Government, Tianjin Neurological Institute, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Qiaoli Wu
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Weijia Fan
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Lina Qiu
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Chunsheng Kang
- Key Laboratory of Neurotrauma, Variation, and Regeneration, Ministry of Education and Tianjin Municipal Government, Tianjin Neurological Institute, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Jialing Wu
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin 300350, China.,Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300350, China
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17
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Pergakis M, Badjatia N, Chaturvedi S, Cronin CA, Kimberly WT, Sheth KN, Simard JM. BIIB093 (IV glibenclamide): an investigational compound for the prevention and treatment of severe cerebral edema. Expert Opin Investig Drugs 2019; 28:1031-1040. [PMID: 31623469 DOI: 10.1080/13543784.2019.1681967] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Brain swelling due to edema formation is a major cause of neurological deterioration and death in patients with large hemispheric infarction (LHI) and severe traumatic brain injury (TBI), especially contusion-TBI. Preclinical studies have shown that SUR1-TRPM4 channels play a critical role in edema formation and brain swelling in LHI and TBI. Glibenclamide, a sulfonylurea drug and potent inhibitor of SUR1-TRPM4, was reformulated for intravenous injection, known as BIIB093.Areas covered: We discuss the findings from Phase 2 clinical trials of BIIB093 in patients with LHI (GAMES-Pilot and GAMES-RP) and from a small Phase 2 clinical trial in patients with TBI. For the GAMES trials, we review data on objective biological variables, adjudicated edema-related endpoints, functional outcomes, and mortality which, despite missing the primary endpoint, supported the initiation of a Phase 3 trial in LHI (CHARM). For the TBI trial, we review data on MRI measures of edema and the initiation of a Phase 2 trial in contusion-TBI (ASTRAL).Expert opinion: Emerging clinical data show that BIIB093 has the potential to transform our management of patients with LHI, contusion-TBI and other conditions in which swelling leads to neurological deterioration and death.
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Affiliation(s)
- Melissa Pergakis
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carolyn A Cronin
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - W Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin N Sheth
- Division of Neurocritical Care, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
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18
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Cerebral Edema and Intracranial Pressure in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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19
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Liu M, Pan Y, Zhou L, Wang Y. Low-dose rt-PA may not decrease the incidence of symptomatic intracranial haemorrhage in patients with high risk of symptomatic intracranial haemorrhage. Neurol Res 2019; 41:473-479. [PMID: 30822264 DOI: 10.1080/01616412.2019.1580454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Recombinant tissue plasminogen activator (rt-PA) has been used as the standard treatment for acute ischemic stroke (AIS). The following study investigates whether low-dose rt-PA can decrease the incidence of symptomatic intracranial haemorrhage (sICH) in AIS patients with high-risk sICH compared to standard-dose rt-PA. MATERIALS AND METHODS Data from the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China (TIMS-China) studies were assessed to explore risk factors for sICH after intravenous thrombolysis. For high-risk sICH patients (age ≧70 years old, or with diabetes, or serum glucose on admission >9.0 mmol/L, or NIHSS on admission>20, or with cardioembolism), standard-dose rt-PA (0.85 to 0.95 mg/kg) and low- dose rt-PA (0.5 to 0.7 mg/kg) were compared. Primary outcome measure was the incidence of sICH, and the secondary outcome measures were 7-day mortality and 90-day functional independence outcome (modified Rankin scale, 0-2). RESULTS A total of 554 patients were enrolled (60 cases for low dose, and 494 cases for standard dose). Median rt-PA doses were 0.63 and 0.90 mg, respectively. After adjustment for the baseline variables, low-dose rt-PA did not decrease the incidence of sICH (per SITS-MOST criteria, 3.33% versus 2.23%, P = 0.3467) compared to low dose. The low-dose group revealed less functional independence outcomes (modified Rankin scale, 0-2) compared to standard-dose group (36.67% versus 52.43%; odds ratio = 0.49; p = 0.0204) at 90 days. CONCLUSIONS Our study suggests that low-dose intravenous rt-PA for high-risk sICH stroke in Chinese patients may not decrease the incidence of sICH, and concomitant with a poor outcome compared to standard-dose rt-PA. ABBREVIATIONS rt-PA: recombinant tissue plasminogen activator; AIS: acute ischemic stroke; sICH: symptomatic intracranial haemorrhage.
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Affiliation(s)
- Mingyong Liu
- a Department of Neurology , Beijing Chaoyang Hospital, Capital Medical University , Beijing , China
| | - Yuesong Pan
- f Department of Epidemiology and Health Statistics, School of Public Health , Capital Medical University , Beijing , China.,g Beijing Municipal Key Laboratory of Clinical Epidemiology , Beijing , China
| | - Lichun Zhou
- a Department of Neurology , Beijing Chaoyang Hospital, Capital Medical University , Beijing , China
| | - Yongjun Wang
- b Center of Stroke, Beijing Tiantan Hospital , Capital Medical University , Beijing , China.,c National Clinical Research Center for Neurological Diseases , Beijing , China.,d Center of Stroke , Beijing Institute for Brain Disorders , Beijing , China.,e Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease , Beijing , China
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20
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Jha RM, Kochanek PM. A Precision Medicine Approach to Cerebral Edema and Intracranial Hypertension after Severe Traumatic Brain Injury: Quo Vadis? Curr Neurol Neurosci Rep 2018; 18:105. [PMID: 30406315 DOI: 10.1007/s11910-018-0912-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Standard clinical protocols for treating cerebral edema and intracranial hypertension after severe TBI have remained remarkably similar over decades. Cerebral edema and intracranial hypertension are treated interchangeably when in fact intracranial pressure (ICP) is a proxy for cerebral edema but also other processes such as extent of mass lesions, hydrocephalus, or cerebral blood volume. A complex interplay of multiple molecular mechanisms results in cerebral edema after severe TBI, and these are not measured or targeted by current clinically available tools. Addressing these underpinnings may be key to preventing or treating cerebral edema and improving outcome after severe TBI. RECENT FINDINGS This review begins by outlining basic principles underlying the relationship between edema and ICP including the Monro-Kellie doctrine and concepts of intracranial compliance/elastance. There is a subsequent brief discussion of current guidelines for ICP monitoring/management. We then focus most of the review on an evolving precision medicine approach towards cerebral edema and intracranial hypertension after TBI. Personalization of invasive neuromonitoring parameters including ICP waveform analysis, pulse amplitude, pressure reactivity, and longitudinal trajectories are presented. This is followed by a discussion of cerebral edema subtypes (continuum of ionic/cytotoxic/vasogenic edema and progressive secondary hemorrhage). Mechanisms of potential molecular contributors to cerebral edema after TBI are reviewed. For each target, we present findings from preclinical models, and evaluate their clinical utility as biomarkers and therapeutic targets for cerebral edema reduction. This selection represents promising candidates with evidence from different research groups, overlap/inter-relatedness with other pathways, and clinical/translational potential. We outline an evolving precision medicine and translational approach towards cerebral edema and intracranial hypertension after severe TBI.
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Affiliation(s)
- Ruchira M Jha
- Department of Critical Care Medicine, Room 646A, Scaife Hall, 3550 Terrace Street, Pittsburgh, 15261, PA, USA.
- Safar Center for Resuscitation Research John G. Rangos Research Center, 6th Floor; 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
- Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Patrick M Kochanek
- Department of Critical Care Medicine, Room 646A, Scaife Hall, 3550 Terrace Street, Pittsburgh, 15261, PA, USA
- Safar Center for Resuscitation Research John G. Rangos Research Center, 6th Floor; 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh John G. Rangos Research Center, 6th Floor 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
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King ZA, Sheth KN, Kimberly WT, Simard JM. Profile of intravenous glyburide for the prevention of cerebral edema following large hemispheric infarction: evidence to date. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:2539-2552. [PMID: 30147301 PMCID: PMC6101021 DOI: 10.2147/dddt.s150043] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Glyburide (also known as glibenclamide) is a second-generation sulfonylurea drug that inhibits sulfonylurea receptor 1 (Sur1) at nanomolar concentrations. Long used to target KATP (Sur1–Kir6.2) channels for the treatment of diabetes mellitus type 2, glyburide was recently repurposed to target Sur1–transient receptor potential melastatin 4 (Trpm4) channels in acute central nervous system injury. Discovered nearly two decades ago, SUR1–TRPM4 has emerged as a critical target in stroke, specifically in large hemispheric infarction, which is characterized by edema formation and life-threatening brain swelling. Following ischemia, SUR1–TRPM4 channels are transcriptionally upregulated in all cells of the neurovascular unit, including neurons, astrocytes, microglia, oligodendrocytes and microvascular endothelial cells. Work by several independent laboratories has linked SUR1–TRPM4 to edema formation, with blockade by glyburide reducing brain swelling and death in preclinical models. Recent work showed that, following ischemia, SUR1–TRPM4 co-assembles with aquaporin-4 to mediate cellular swelling of astrocytes, which contributes to brain swelling. Additionally, recent work linked SUR1–TRPM4 to secretion of matrix metalloproteinase-9 (MMP-9) induced by recombinant tissue plasminogen activator in activated brain endothelial cells, with blockade of SUR1–TRPM4 by glyburide reducing MMP-9 and hemorrhagic transformation in preclinical models with recombinant tissue plasminogen activator. The recently completed GAMES (Glyburide Advantage in Malignant Edema and Stroke) clinical trials on patients with large hemispheric infarctions treated with intravenous glyburide (RP-1127) revealed promising findings with regard to brain swelling (midline shift), MMP-9, functional outcomes and mortality. Here, we review key elements of the basic science, preclinical experiments and clinical studies, both retrospective and prospective, on glyburide in focal cerebral ischemia and stroke.
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Affiliation(s)
- Zachary A King
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - W Taylor Kimberly
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA,
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Pathophysiology and treatment of cerebral edema in traumatic brain injury. Neuropharmacology 2018; 145:230-246. [PMID: 30086289 DOI: 10.1016/j.neuropharm.2018.08.004] [Citation(s) in RCA: 237] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/24/2018] [Accepted: 08/03/2018] [Indexed: 12/30/2022]
Abstract
Cerebral edema (CE) and resultant intracranial hypertension are associated with unfavorable prognosis in traumatic brain injury (TBI). CE is a leading cause of in-hospital mortality, occurring in >60% of patients with mass lesions, and ∼15% of those with normal initial computed tomography scans. After treatment of mass lesions in severe TBI, an important focus of acute neurocritical care is evaluating and managing the secondary injury process of CE and resultant intracranial hypertension. This review focuses on a contemporary understanding of various pathophysiologic pathways contributing to CE, with a subsequent description of potential targeted therapies. There is a discussion of identified cellular/cytotoxic contributors to CE, as well as mechanisms that influence blood-brain-barrier (BBB) disruption/vasogenic edema, with the caveat that this distinction may be somewhat artificial since molecular processes contributing to these pathways are interrelated. While an exhaustive discussion of all pathways with putative contributions to CE is beyond the scope of this review, the roles of some key contributors are highlighted, and references are provided for further details. Potential future molecular targets for treating CE are presented based on pathophysiologic mechanisms. We thus aim to provide a translational synopsis of present and future strategies targeting CE after TBI in the context of a paradigm shift towards precision medicine. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".
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Gerzanich V, Kwon MS, Woo SK, Ivanov A, Simard JM. SUR1-TRPM4 channel activation and phasic secretion of MMP-9 induced by tPA in brain endothelial cells. PLoS One 2018; 13:e0195526. [PMID: 29617457 PMCID: PMC5884564 DOI: 10.1371/journal.pone.0195526] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/23/2018] [Indexed: 11/25/2022] Open
Abstract
Background Hemorrhagic transformation is a major complication of ischemic stroke, is linked to matrix metalloproteinase-9 (MMP-9), and is exacerbated by tissue plasminogen activator (tPA). Cerebral ischemia/reperfusion is characterized by SUR1-TRPM4 (sulfonylurea receptor 1—transient receptor potential melastatin 4) channel upregulation in microvascular endothelium. In humans and rodents with cerebral ischemia/reperfusion (I/R), the SUR1 antagonist, glibenclamide, reduces hemorrhagic transformation and plasma MMP-9, but the mechanism is unknown. We hypothesized that tPA induces protease activated receptor 1 (PAR1)-mediated, Ca2+-dependent phasic secretion of MMP-9 from activated brain endothelium, and that SUR1-TRPM4 is required for this process. Methods Cerebral I/R, of 2 and 4 hours duration, respectively, was obtained using conventional middle cerebral artery occlusion. Immunolabeling was used to quantify p65 nuclear translocation. Murine and human brain endothelial cells (BEC) were studied in vitro, without and with NF-κB activation, using immunoblot, zymography and ELISA, patch clamp electrophysiology, and calcium imaging. Genetic and pharmacological manipulations were used to identify signaling pathways. Results Cerebral I/R caused prominent nuclear translocation of p65 in microvascular endothelium. NF-κB-activation of BEC caused de novo expression of SUR1-TRPM4 channels. In NF-κB-activated BEC: (i) tPA caused opening of SUR1-TRPM4 channels in a plasmin-, PAR1-, TRPC3- and Ca2+-dependent manner; (ii) tPA caused PAR1-dependent secretion of MMP-9; (iii) tonic secretion of MMP-9 by activated BEC was not influenced by SUR1 inhibition; (iv) phasic secretion of MMP-9 induced by tPA or the PAR1-agonist, TFLLR, required functional SUR1-TRPM4 channels, with inhibition of SUR1 decreasing tPA-induced MMP-9 secretion. Conclusions tPA induces PAR1-mediated, SUR1-TRPM4-dependent, phasic secretion of MMP-9 from activated brain endothelium.
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Affiliation(s)
- Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Min Seong Kwon
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Seung Kyoon Woo
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Alexander Ivanov
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
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Hayman EG, Wessell A, Gerzanich V, Sheth KN, Simard JM. Mechanisms of Global Cerebral Edema Formation in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2017; 26:301-310. [PMID: 27995510 DOI: 10.1007/s12028-016-0354-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A growing body of clinical literature emphasizes the impact of cerebral edema in early brain injury following aneurysmal subarachnoid hemorrhage (aSAH). Aneurysm rupture itself initiates global cerebral edema in up to two thirds of cases. Although cerebral edema is not a universal feature of aSAH, it portends a poor clinical course, with quantitative analysis revealing a direct correlation between cerebral edema and poor outcome, including mortality and cognitive deficits. Mechanistically, global cerebral edema has been linked to global ischemia at the time of aneurysm rupture, dysfunction of autoregulation, blood breakdown products, neuroinflammation, and hyponatremia/endocrine abnormalities. At a molecular level, several culprits have been identified, including aquaporin-4, matrix metalloproteinase-9, SUR1-TRPM4 cation channels, vascular endothelial growth factor, bradykinin, and others. Here, we review these cellular and molecular mechanisms of global cerebral edema formation in aSAH. Given the importance of edema to the outcome of patients with aSAH and its status as a highly modifiable pathological process, a better understanding of cerebral edema in aSAH promises to hasten the development of medical therapies to improve outcomes in this frequently devastating disease.
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Affiliation(s)
- Erik G Hayman
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Aaron Wessell
- 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
| | - Kevin N Sheth
- Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA.,Department of Neurosurgery, Yale New Haven Hospital, New Haven, CT, 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, USA. .,Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA.
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Sulfonylurea Pretreatment and In-Hospital Use Does Not Impact Acute Ischemic Strokes (AIS) Outcomes Following Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2017; 26:795-800. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 10/19/2016] [Indexed: 11/20/2022] Open
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Jiang B, Li L, Chen Q, Tao Y, Yang L, Zhang B, Zhang JH, Feng H, Chen Z, Tang J, Zhu G. Role of Glibenclamide in Brain Injury After Intracerebral Hemorrhage. Transl Stroke Res 2016; 8:183-193. [PMID: 27807801 DOI: 10.1007/s12975-016-0506-2] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 11/28/2022]
Abstract
Brain edema following intracerebral hemorrhage (ICH) causes severe secondary brain injury, and no efficient pharmacological preventions are available. The present study was designed to demonstrate the neuroprotective effects of glibenclamide on brain edema and key factors of the blood-brain barrier (BBB). The study was divided into two parts. First, we utilized an autoblood-induced rat model to investigate the expression of sulfonylurea receptor 1 (Sur1). Second, rats were randomized into sham, vehicle, and glibenclamide groups. Neurological scores, brain water content, Evans blue extravasation, Morris water maze test, western blots, and immunofluorescence were used to study the effects of glibenclamide. The expression of the Sur1-Trpm4 channel but not the Sur1-KATP channel was increased in the perihematomal tissue following ICH. Glibenclamide administration significantly decreased the brain water content, restored the BBB, and reduced the expression of MMPs. In addition, glibenclamide improved long-term cognitive deficits following ICH. Glibenclamide protected BBB integrity and improved neurological outcomes after ICH by inhibiting the Sur1-Trpm4 channel, which reduces the expression of MMPs and thereby increases BBB tight-junction protein levels. Glibenclamide may have potential to protect the BBB after ICH.
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Affiliation(s)
- Bing Jiang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, No. 30, Gaotanyan Street, Chongqing, 400038, People's Republic of China
| | - Lin Li
- Department of Neurosurgery, Nanchong Central Hospital, Sichuan, 637000, China
| | - Qianwei Chen
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, No. 30, Gaotanyan Street, Chongqing, 400038, People's Republic of China
| | - Yihao Tao
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, No. 30, Gaotanyan Street, Chongqing, 400038, People's Republic of China
| | - Liming Yang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, No. 30, Gaotanyan Street, Chongqing, 400038, People's Republic of China
| | - Bo Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, No. 30, Gaotanyan Street, Chongqing, 400038, People's Republic of China
| | - John H Zhang
- Department of Neurosurgery, School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, No. 30, Gaotanyan Street, Chongqing, 400038, People's Republic of China
| | - Zhi Chen
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, No. 30, Gaotanyan Street, Chongqing, 400038, People's Republic of China
| | - Jun Tang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, No. 30, Gaotanyan Street, Chongqing, 400038, People's Republic of China.
| | - Gang Zhu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, No. 30, Gaotanyan Street, Chongqing, 400038, People's Republic of China.
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Safety and efficacy of intravenous glyburide on brain swelling after large hemispheric infarction (GAMES-RP): a randomised, double-blind, placebo-controlled phase 2 trial. Lancet Neurol 2016; 15:1160-9. [DOI: 10.1016/s1474-4422(16)30196-x] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/25/2016] [Accepted: 07/28/2016] [Indexed: 12/22/2022]
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Maciel CB, Sheth KN. Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions. Curr Atheroscler Rep 2015; 17:40. [DOI: 10.1007/s11883-015-0519-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
BACKGROUND Malignant infarction is characterized by the formation of cerebral edema, and medical treatment is limited. Preclinical data suggest that glyburide, an inhibitor of SUR1-TRPM4, is effective in preventing edema. We previously reported feasibility of the GAMES-Pilot study, a two-center prospective, open label, phase IIa trial of 10 subjects at high risk for malignant infarction based on diffusion weighted imaging (DWI) threshold of 82 cm(3) treated with RP-1127 (glyburide for injection). In this secondary analysis, we tested the hypothesis that RP-1127 may be efficacious in preventing poor outcome when compared to controls. METHODS Controls suffering large hemispheric infarction were obtained from the EPITHET and MMI-MRI studies. We first screened subjects for controls with the same DWI threshold used for enrollment into GAMES-Pilot, 82 cm(3). Next, to address imbalances, we applied a weighted Euclidean matching. Ninety day mRS 0-4, rate of decompressive craniectomy, and mortality were the primary clinical outcomes of interest. RESULTS The mean age of the GAMES cohort was 51 years and initial DWI volume was 102 ± 23 cm(3). After Euclidean matching, GAMES subjects showed similar NIHSS, higher DWI volume, younger age and had mRS 0-4-90% versus 50% in controls p = 0.049; with a similar trend in mRS 0-3 (40 vs. 25%; p = 0.43) and trend toward lower mortality (10 vs. 35%; p = 0.21). CONCLUSIONS In this pilot study, RP-1127-treated subjects showed better clinical outcomes when compared to historical controls. An adequately powered and randomized phase II trial of patients at risk for malignant infarction is needed to evaluate the potential efficacy of RP-1127.
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Glibenclamide for the treatment of ischemic and hemorrhagic stroke. Int J Mol Sci 2015; 16:4973-84. [PMID: 25749474 PMCID: PMC4394459 DOI: 10.3390/ijms16034973] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/17/2015] [Accepted: 02/26/2015] [Indexed: 11/16/2022] Open
Abstract
Ischemic and hemorrhagic strokes are associated with severe functional disability and high mortality. Except for recombinant tissue plasminogen activator, therapies targeting the underlying pathophysiology of central nervous system (CNS) ischemia and hemorrhage are strikingly lacking. Sur1-regulated channels play essential roles in necrotic cell death and cerebral edema following ischemic insults, and in neuroinflammation after hemorrhagic injuries. Inhibiting endothelial, neuronal, astrocytic and oligodendroglial sulfonylurea receptor 1-transient receptor potential melastatin 4 (Sur1-Trpm4) channels and, in some cases, microglial KATP (Sur1-Kir6.2) channels, with glibenclamide is protective in a variety of contexts. Robust preclinical studies have shown that glibenclamide and other sulfonylurea agents reduce infarct volumes, edema and hemorrhagic conversion, and improve outcomes in rodent models of ischemic stroke. Retrospective studies suggest that diabetic patients on sulfonylurea drugs at stroke presentation fare better if they continue on drug. Additional laboratory investigations have implicated Sur1 in the pathophysiology of hemorrhagic CNS insults. In clinically relevant models of subarachnoid hemorrhage, glibenclamide reduces adverse neuroinflammatory and behavioral outcomes. Here, we provide an overview of the preclinical studies of glibenclamide therapy for CNS ischemia and hemorrhage, discuss the available data from clinical investigations, and conclude with promising preclinical results that suggest glibenclamide may be an effective therapeutic option for ischemic and hemorrhagic stroke.
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TGF-β1 prevents blood-brain barrier damage and hemorrhagic transformation after thrombolysis in rats. Exp Neurol 2015; 266:120-6. [PMID: 25708985 DOI: 10.1016/j.expneurol.2015.02.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/26/2014] [Accepted: 02/09/2015] [Indexed: 11/20/2022]
Abstract
Transforming growth factor-beta1 (TGF-β1) is well known to promote extracellular matrix accumulation. Recent studies demonstrated that TGF-β1 protects against blood-brain barrier (BBB) disruption in the condition of inflammatory pain and stroke. In the present study, we investigated whether TGF-β1 can maintain BBB integrity and prevent hemorrhagic transformation (HT) after recombinant tissue plasminogen activator (rt-PA) treatment in a rat model of thromboembolic middle cerebral artery occlusion (MCAO). Three hours after MCAO, rats were given saline, rt-PA alone or rt-PA combined with TGF-β1 intravenously. Animals were sacrificed 24h after surgery. HT was calculated as hemorrhagic score. Evans blue dye extravasation was measured for BBB disruption. Basement membrane damage was observed by electron microscopy and quantified by collagen IV and laminin immunostaining. Gelatin zymography was used to measure the activities of matrix metalloproteinase (MMP)-2 and MMP-9. Western blot was performed for the expressions of MMP-2, MMP-9 and plasminogen activator inhibitor type-1 (PAI-1). Rats treated with rt-PA showed elevations in basement membrane damage, BBB disruption and HT. These phenomena were reduced in rats treated by TGF-β1. We also showed that TGF-β1 inhibited rt-PA mediated induction of MMP-2 and MMP-9. Meanwhile, TGF-β1 upregulated PAI-1 expression which was reduced by rt-PA. Taken together, these results suggest that TGF-β1 can reduce rt-PA induced basement membrane degradation, BBB disruption and HT. One possible mechanism is associated with the elevation of PAI-1. Suppression of MMP-2 and MMP-9 elevated by rt-PA may be another mechanism contributing to the protective effects of TGF-β1.
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Kimberly WT, Battey TWK, Pham L, Wu O, Yoo AJ, Furie KL, Singhal AB, Elm JJ, Stern BJ, Sheth KN. Glyburide is associated with attenuated vasogenic edema in stroke patients. Neurocrit Care 2014; 20:193-201. [PMID: 24072459 DOI: 10.1007/s12028-013-9917-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Brain edema is a serious complication of ischemic stroke that can lead to secondary neurological deterioration and death. Glyburide is reported to prevent brain swelling in preclinical rodent models of ischemic stroke through inhibition of a non-selective channel composed of sulfonylurea receptor 1 and transient receptor potential cation channel subfamily M member 4. However, the relevance of this pathway to the development of cerebral edema in stroke patients is not known. METHODS Using a case-control design, we retrospectively assessed neuroimaging and blood markers of cytotoxic and vasogenic edema in subjects who were enrolled in the glyburide advantage in malignant edema and stroke-pilot (GAMES-Pilot) trial. We compared serial brain magnetic resonance images (MRIs) to a cohort with similar large volume infarctions. We also compared matrix metalloproteinase-9 (MMP-9) plasma level in large hemispheric stroke. RESULTS We report that IV glyburide was associated with T2 fluid-attenuated inversion recovery signal intensity ratio on brain MRI, diminished the lesional water diffusivity between days 1 and 2 (pseudo-normalization), and reduced blood MMP-9 level. CONCLUSIONS Several surrogate markers of vasogenic edema appear to be reduced in the setting of IV glyburide treatment in human stroke. Verification of these potential imaging and blood biomarkers is warranted in the context of a randomized, placebo-controlled trial.
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Affiliation(s)
- W Taylor Kimberly
- Center for Human Genetic Research and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,
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Simard JM, Sheth KN, Kimberly WT, Stern BJ, del Zoppo GJ, Jacobson S, Gerzanich V. Glibenclamide in cerebral ischemia and stroke. Neurocrit Care 2014; 20:319-33. [PMID: 24132564 DOI: 10.1007/s12028-013-9923-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The sulfonylurea receptor 1 (Sur1)-transient receptor potential 4 (Trpm4) channel is an important molecular element in focal cerebral ischemia. The channel is upregulated in all cells of the neurovascular unit following ischemia, and is linked to microvascular dysfunction that manifests as edema formation and secondary hemorrhage, which cause brain swelling. Activation of the channel is a major molecular mechanism of cytotoxic edema and "accidental necrotic cell death." Blockade of Sur1 using glibenclamide has been studied in different types of rat models of stroke: (i) in conventional non-lethal models (thromboembolic, 1-2 h temporary, or permanent middle cerebral artery occlusion), glibenclamide reduces brain swelling and infarct volume and improves neurological function; (ii) in lethal models of malignant cerebral edema, glibenclamide reduces edema, brain swelling, and mortality; (iii) in models with rtPA, glibenclamide reduces swelling, hemorrhagic transformation, and death. Retrospective studies of diabetic patients who present with stroke have shown that those whose diabetes is managed with a sulfonylurea drug and who are maintained on the sulfonylurea drug during hospitalization for stroke have better outcomes at discharge and are less likely to suffer hemorrhagic transformation. Here, we provide a comprehensive review of the basic science, preclinical experiments, and retrospective clinical studies on glibenclamide in focal cerebral ischemia and stroke. We also compare the preclinical work in stroke models to the updated recommendations of the Stroke Therapy Academic Industry Roundtable (STAIR). The findings reviewed here provide a strong foundation for a translational research program to study glibenclamide in patients with ischemic stroke.
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Affiliation(s)
- J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA,
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Brogan ME, Manno EM. Treatment of malignant brain edema and increased intracranial pressure after stroke. Curr Treat Options Neurol 2014; 17:327. [PMID: 25398467 DOI: 10.1007/s11940-014-0327-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT The management of patients with large territory ischemic strokes and the subsequent development of malignant brain edema and increased intracranial pressure is a significant challenge in modern neurology and neurocritical care. These patients are at high risk of subsequent neurologic decline and are best cared for in an intensive care unit or a comprehensive stroke center with access to neurosurgical support. Risks include hemorrhagic conversion, herniation, poor functional outcome, and death. This review discusses recent advances in understanding the pathophysiology of edema formation, identifying patients at risk, current management strategies, and emerging therapies.
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Affiliation(s)
- Michael E Brogan
- Neurological Intensive Care Unit, Cerebrovascular Center, Cleveland Clinic, 9500 Euclid Ave H/22, Cleveland, OH, 44139, USA
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Khanna A, Walcott BP, Kahle KT, Simard JM. Effect of glibenclamide on the prevention of secondary brain injury following ischemic stroke in humans. Neurosurg Focus 2014; 36:E11. [PMID: 24380477 DOI: 10.3171/2013.10.focus13404] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Cerebral edema and hemorrhagic conversion are common, potentially devastating complications of ischemic stroke and are associated with high rates of mortality and poor functional outcomes. Recent work exploring the molecular pathophysiology of the neurogliovascular unit in ischemic stroke suggests that deranged cellular ion homeostasis due to altered function and regulation of ion pumps, channels, and secondary active transporters plays an integral role in the development of cytotoxic and vasogenic edema and hemorrhagic conversion. Among these proteins involved in ion homeostasis, the ischemia-induced, nonselective cation conductance formed by the SUR1-TRPM4 protein complex appears to play a prominent role and is potently inhibited by glibenclamide, an FDA-approved drug commonly used in patients with Type 2 diabetes. Several robust preclinical studies have demonstrated the efficacy of glibenclamide blockade of SUR1-TRPM4 activity in reducing edema and hemorrhagic conversion in rodent models of ischemic stroke, prompting the study of the potential protective effects of glibenclamide in humans in an ongoing prospective phase II clinical trial. Preliminary data suggest glibenclamide significantly reduces cerebral edema and lowers the rate of hemorrhagic conversion following ischemic stroke, suggesting the potential use of glibenclamide to improve outcomes in humans.
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Tosun C, Koltz MT, Kurland DB, Ijaz H, Gurakar M, Schwartzbauer G, Coksaygan T, Ivanova S, Gerzanich V, Simard JM. The protective effect of glibenclamide in a model of hemorrhagic encephalopathy of prematurity. Brain Sci 2014; 3:215-38. [PMID: 23667741 PMCID: PMC3647482 DOI: 10.3390/brainsci3010215] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We studied a model of hemorrhagic encephalopathy of prematurity (EP) that closely recapitulates findings in humans with hemorrhagic EP. This model involves tandem insults of 20 min intrauterine ischemia (IUI) plus an episode of elevated venous pressure induced by intraperitoneal glycerol on post-natal day (P) 0. We examined Sur1 expression, which is upregulated after focal ischemia but has not been studied after brief global ischemia including IUI. We found that 20 min IUI resulted in robust upregulation of Sur1 in periventricular microvessels and tissues. We studied tandem insult pups from untreated or vehicle-treated dams (TI-CTR), and tandem insult pups from dams administered a low-dose, non-hypoglycemogenic infusion of the Sur1 blocker, glibenclamide, for 1 week after IUI (TI-GLIB). Compared to pups from the TI-CTR group, pups from the TI-GLIB group had significantly fewer and less severe hemorrhages on P1, performed significantly better on the beam walk and accelerating Rotarod on P35 and in tests of thigmotaxis and rapid learning on P35–49, and had significantly greater body and brain weights at P52. We conclude that low-dose glibenclamide administered to the mother at the end of pregnancy protects pups subjected to IUI from post-natal events of elevated venous pressure and its consequences.
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Affiliation(s)
- Cigdem Tosun
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (C.T.); (M.T.K.); (D.B.K.); (H.I.); (M.G.); (G.S.); (S.I.); (V.G.)
| | - Michael T. Koltz
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (C.T.); (M.T.K.); (D.B.K.); (H.I.); (M.G.); (G.S.); (S.I.); (V.G.)
| | - David B. Kurland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (C.T.); (M.T.K.); (D.B.K.); (H.I.); (M.G.); (G.S.); (S.I.); (V.G.)
| | - Hina Ijaz
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (C.T.); (M.T.K.); (D.B.K.); (H.I.); (M.G.); (G.S.); (S.I.); (V.G.)
| | - Melda Gurakar
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (C.T.); (M.T.K.); (D.B.K.); (H.I.); (M.G.); (G.S.); (S.I.); (V.G.)
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (C.T.); (M.T.K.); (D.B.K.); (H.I.); (M.G.); (G.S.); (S.I.); (V.G.)
| | - Turhan Coksaygan
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mail:
| | - Svetlana Ivanova
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (C.T.); (M.T.K.); (D.B.K.); (H.I.); (M.G.); (G.S.); (S.I.); (V.G.)
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (C.T.); (M.T.K.); (D.B.K.); (H.I.); (M.G.); (G.S.); (S.I.); (V.G.)
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (C.T.); (M.T.K.); (D.B.K.); (H.I.); (M.G.); (G.S.); (S.I.); (V.G.)
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mail:
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-410-328-0850; Fax: +1-410-328-0124
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Jha R, Battey TWK, Pham L, Lorenzano S, Furie KL, Sheth KN, Kimberly WT. Fluid-attenuated inversion recovery hyperintensity correlates with matrix metalloproteinase-9 level and hemorrhagic transformation in acute ischemic stroke. Stroke 2014; 45:1040-5. [PMID: 24619394 DOI: 10.1161/strokeaha.113.004627] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Matrix metalloproteinase-9 (MMP-9) is elevated in patients with acute stroke who later develop hemorrhagic transformation (HT). It is controversial whether early fluid-attenuated inversion recovery (FLAIR) hyperintensity on brain MRI predicts hemorrhagic transformation (HT). We assessed whether FLAIR hyperintensity was associated with MMP-9 and HT. METHODS We analyzed a prospectively collected cohort of acute stroke subjects with acute brain MRI images and MMP-9 values within the first 12 hours after stroke onset. FLAIR hyperintensity was measured using a signal intensity ratio between the stroke lesion and corresponding normal contralateral hemisphere. MMP-9 was measured using enzyme-linked immunosorbent assay. The relationships between FLAIR ratio (FR), MMP-9, and HT were evaluated. RESULTS A total of 180 subjects were available for analysis. Patients were imaged with brain MRI at 5.6±4.3 hours from last seen well time. MMP-9 blood samples were drawn within 7.7±4.0 hours from last seen well time. The time to MRI (r=0.17, P=0.027) and MMP-9 level (r=0.29, P<0.001) were each associated with FR. The association between MMP-9 and FR remained significant after multivariable adjustment (P<0.001). FR was also associated with HT and symptomatic hemorrhage (P=0.012). CONCLUSIONS FR correlates with both MMP-9 level and risk of hemorrhage. FLAIR changes in the acute phase of stroke may predict hemorrhagic transformation, possibly as a reflection of altered blood-brain barrier integrity.
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Affiliation(s)
- Ruchira Jha
- From the Department of Neurology, Massachusetts General Hospital, Boston, MA (R.J., T.W.K.B., L.P., W.T.K.); Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, Sapienza University of Rome, Rome, Italy (S.L.); Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI (K.L.F.); and Department of Neurology, Yale New Haven Hospital, New Haven, CT (K.N.S.)
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Hemorrhagic transformation after ischemic stroke in animals and humans. J Cereb Blood Flow Metab 2014; 34:185-99. [PMID: 24281743 PMCID: PMC3915212 DOI: 10.1038/jcbfm.2013.203] [Citation(s) in RCA: 379] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/10/2013] [Accepted: 10/28/2013] [Indexed: 01/12/2023]
Abstract
Hemorrhagic transformation (HT) is a common complication of ischemic stroke that is exacerbated by thrombolytic therapy. Methods to better prevent, predict, and treat HT are needed. In this review, we summarize studies of HT in both animals and humans. We propose that early HT (<18 to 24 hours after stroke onset) relates to leukocyte-derived matrix metalloproteinase-9 (MMP-9) and brain-derived MMP-2 that damage the neurovascular unit and promote blood-brain barrier (BBB) disruption. This contrasts to delayed HT (>18 to 24 hours after stroke) that relates to ischemia activation of brain proteases (MMP-2, MMP-3, MMP-9, and endogenous tissue plasminogen activator), neuroinflammation, and factors that promote vascular remodeling (vascular endothelial growth factor and high-moblity-group-box-1). Processes that mediate BBB repair and reduce HT risk are discussed, including transforming growth factor beta signaling in monocytes, Src kinase signaling, MMP inhibitors, and inhibitors of reactive oxygen species. Finally, clinical features associated with HT in patients with stroke are reviewed, including approaches to predict HT by clinical factors, brain imaging, and blood biomarkers. Though remarkable advances in our understanding of HT have been made, additional efforts are needed to translate these discoveries to the clinic and reduce the impact of HT on patients with ischemic stroke.
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Malignant Cerebral Edema After Large Anterior Circulation Infarction: A Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:275. [DOI: 10.1007/s11936-013-0275-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Khanna A, Kahle KT, Walcott BP, Gerzanich V, Simard JM. Disruption of ion homeostasis in the neurogliovascular unit underlies the pathogenesis of ischemic cerebral edema. Transl Stroke Res 2013; 5:3-16. [PMID: 24323726 DOI: 10.1007/s12975-013-0307-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 10/22/2013] [Accepted: 11/06/2013] [Indexed: 02/06/2023]
Abstract
Cerebral edema is a major cause of morbidity and mortality following ischemic stroke, but its underlying molecular pathophysiology is incompletely understood. Recent data have revealed the importance of ion flux via channels and transporters expressed in the neurogliovascular unit in the development of ischemia-triggered cytotoxic edema, vasogenic edema, and hemorrhagic conversion. Disruption of homeostatic mechanisms governing cell volume regulation and epithelial/endothelial ion transport due to ischemia-associated energy failure results in the thermodynamically driven re-equilibration of solutes and water across the CSF-blood and blood-brain barriers that ultimately increases the brain's extravascular volume. Additionally, hypoxia, inflammation, and other stress-triggered increases in the functional expression of ion channels and transporters normally expressed at low levels in the neurogliovascular unit cause disruptions in ion homeostasis that contribute to ischemic cerebral edema. Here, we review the pathophysiological significance of several molecular mediators of ion transport expressed in the neurogliovascular unit, including targets of existing FDA-approved drugs, which might be potential nodes for therapeutic intervention.
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Abstract
Supplemental Digital Content is available in the article. In animal models of stroke, sulfonylurea receptor 1 (Sur1), a member of the adenosine triphosphate binding cassette transporter gene family, is transcriptionally upregulated in neural and vascular cells in which it plays a leading role in edema formation and necrotic cell death. To date, expression of Sur1 in the brains of humans with cerebral infarcts has not been systematically evaluated. We examined Sur1 expression in postmortem specimens obtained from 13 patients within the first 31 days after focal infarcts, 5 patients with lacunar infarcts, and 6 normal control brains using immunohistochemistry. Elevated immunoreactivity for Sur1 was detected in all cases of focal infarcts, with 3 distinct temporal patterns of expression: 1) neurons and endothelium showed the greatest elevation during the first week, after which levels declined; 2) astrocytes and microglia/macrophages showed progressive increases during the first 31 days; and 3) neutrophils near the infarct showed prominent immunoreactivity that did not change over time. Upregulation of Sur1 was corroborated using in situ hybridization for Abcc8 mRNA. Sulfonylurea receptor 1 immunoreactivity in lacunar infarcts was less prominent and more sporadic than in nonlacunar infarcts. In conjunction with previous studies, these data suggest that Sur1 may be a promising treatment target in patients with acute cerebral infarction.
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Kurland DB, Tosun C, Pampori A, Karimy JK, Caffes NM, Gerzanich V, Simard JM. Glibenclamide for the treatment of acute CNS injury. Pharmaceuticals (Basel) 2013; 6:1287-303. [PMID: 24275850 PMCID: PMC3817601 DOI: 10.3390/ph6101287] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/17/2013] [Accepted: 09/23/2013] [Indexed: 12/22/2022] Open
Abstract
First introduced into clinical practice in 1969, glibenclamide (US adopted name, glyburide) is known best for its use in the treatment of diabetes mellitus type 2, where it is used to promote the release of insulin by blocking pancreatic KATP [sulfonylurea receptor 1 (Sur1)-Kir6.2] channels. During the last decade, glibenclamide has received renewed attention due to its pleiotropic protective effects in acute CNS injury. Acting via inhibition of the recently characterized Sur1-Trpm4 channel (formerly, the Sur1-regulated NCCa-ATP channel) and, in some cases, via brain KATP channels, glibenclamide has been shown to be beneficial in several clinically relevant rodent models of ischemic and hemorrhagic stroke, traumatic brain injury, spinal cord injury, neonatal encephalopathy of prematurity, and metastatic brain tumor. Glibenclamide acts on microvessels to reduce edema formation and secondary hemorrhage, it inhibits necrotic cell death, it exerts potent anti-inflammatory effects and it promotes neurogenesis—all via inhibition of Sur1. Two clinical trials, one in TBI and one in stroke, currently are underway. These recent findings, which implicate Sur1 in a number of acute pathological conditions involving the CNS, present new opportunities to use glibenclamide, a well-known, safe pharmaceutical agent, for medical conditions that heretofore had few or no treatment options.
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Affiliation(s)
- David B. Kurland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Cigdem Tosun
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Adam Pampori
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Jason K. Karimy
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Nicholas M. Caffes
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; E-Mails: (D.B.K.); (C.T.); (A.P.); (J.K.K.); (N.M.C.); (V.G.)
- 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
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-410-328-0850; Fax: +1-410-328-0124
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Weiser RE, Sheth KN. Clinical Predictors and Management of Hemorrhagic Transformation. Curr Treat Options Neurol 2013; 15:125-49. [DOI: 10.1007/s11940-012-0217-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Kunte H, Busch MA, Trostdorf K, Vollnberg B, Harms L, Mehta R, Castellani RJ, Mandava P, Kent TA, Simard JM. Hemorrhagic transformation of ischemic stroke in diabetics on sulfonylureas. Ann Neurol 2012; 72:799-806. [PMID: 23280795 PMCID: PMC3539226 DOI: 10.1002/ana.23680] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 05/31/2012] [Accepted: 06/15/2012] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Disability or death occurs more frequently in patients with hemorrhagic transformation (HT) after ischemic stroke. In rat models of stroke, sulfonylurea (SU) drugs such as glibenclamide (adopted US name, glyburide) confer protection against swelling and HT through actions on the novel SUR1-regulated NC(Ca-ATP) channel. Here, we sought to determine whether the use of SU drugs in patients with diabetes mellitus (DM) presenting with acute ischemic stroke might influence the incidence of HT. METHODS We retrospectively analyzed data on 220 patients with DM who presented with acute ischemic stroke, 43 of whom were managed with and continued to receive SU drugs, and 177 of whom were managed without (controls). RESULTS During a median length of stay in hospital of 11 days, 20 control patients (11%) experienced symptomatic HT (sHT), whereas no patient in the SU group experienced sHT (p = 0.016). No patient in the SU group died, compared to 18 (10%) in the control group (p = 0.027). Similarly favorable outcomes were observed after matching for baseline imbalances and excluding outliers. In support of the proposed mechanism, we present a case of sHT in which an analysis of brain tissues obtained intraoperatively showed prominent upregulation of SUR1, the target of SU drugs, in microvessels and neurons. INTERPRETATION We conclude that, in diabetic patients with acute ischemic stroke, prior and continued use of SU drugs is associated with reduced sHT compared to those whose treatment regimen does not include SU drugs.
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Affiliation(s)
- Hagen Kunte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus A. Busch
- Department of Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Katrin Trostdorf
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Vollnberg
- Institute of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Lutz Harms
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Rupal Mehta
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rudolf J. Castellani
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pitchaiah Mandava
- Michael E. DeBakey VA Medical Center Comprehensive Stroke Program and the Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Thomas A. Kent
- Michael E. DeBakey VA Medical Center Comprehensive Stroke Program and the Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - J. Marc Simard
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA
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Simard JM, Woo SK, Schwartzbauer GT, Gerzanich V. Sulfonylurea receptor 1 in central nervous system injury: a focused review. J Cereb Blood Flow Metab 2012; 32:1699-717. [PMID: 22714048 PMCID: PMC3434627 DOI: 10.1038/jcbfm.2012.91] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 05/03/2012] [Accepted: 05/09/2012] [Indexed: 01/13/2023]
Abstract
The sulfonylurea receptor 1 (Sur1)-regulated NC(Ca-ATP) channel is a nonselective cation channel that is regulated by intracellular calcium and adenosine triphosphate. The channel is not constitutively expressed, but is transcriptionally upregulated de novo in all cells of the neurovascular unit, in many forms of central nervous system (CNS) injury, including cerebral ischemia, traumatic brain injury (TBI), spinal cord injury (SCI), and subarachnoid hemorrhage (SAH). The channel is linked to microvascular dysfunction that manifests as edema formation and delayed secondary hemorrhage. Also implicated in oncotic cell swelling and oncotic (necrotic) cell death, the channel is a major molecular mechanism of 'accidental necrotic cell death' in the CNS. In animal models of SCI, pharmacological inhibition of Sur1 by glibenclamide, as well as gene suppression of Abcc8, prevents delayed capillary fragmentation and tissue necrosis. In models of stroke and TBI, glibenclamide ameliorates edema, secondary hemorrhage, and tissue damage. In a model of SAH, glibenclamide attenuates the inflammatory response due to extravasated blood. Clinical trials of an intravenous formulation of glibenclamide in TBI and stroke underscore the importance of recent advances in understanding the role of the Sur1-regulated NC(Ca-ATP) channel in acute ischemic, traumatic, and inflammatory injury to the CNS.
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Affiliation(s)
- J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201-1595, USA.
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