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Xu W, Yan D, Ning Z. Associations between multiple sclerosis and in-hospital outcomes of patients with hemorrhagic stroke. J Stroke Cerebrovasc Dis 2023; 32:107281. [PMID: 37523878 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107281] [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: 03/06/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE To determine the influence of multiple sclerosis (MS) on in-hospital outcomes of patients with hemorrhagic strokes using a large, nationally representative database. MATERIALS AND METHODS This population-based, retrospective study extracted data of adults with hemorrhagic stroke from the US Nationwide Inpatient Sample (NIS) database from 2016 to 2018. Patients with/without MS were then compared. Hemorrhagic stroke and MS were identified by the International Classification of Diseases, Tenth editions (ICD-10) codes. In-hospital outcomes (i.e., in-hospital mortality, discharge destination, length of stay [LOS], total hospital cost, and major complications) were compared between subjects with and without MS using logistic regression analysis. RESULTS Among 107,573 patients with hemorrhagic stroke, 0.3% (n=337) had MS. After 1:10 propensity-score (PS) matching, 3,707 patients remained in the analytic sample. Multivariable analysis revealed that patients with MS had significantly shorter LOS (adjusted β=-1.34 days; 95% CI: -2.41 to -0.26, p=0.015), and lower total hospital costs (adjusted β=-28.82; 95% CI: -43.57 to -14.06, p<0.001) than those without MS. No significant different risks of any major complications, in-hospital mortality, or transfer to nursing homes/long-term care facilities were observed. For major complications, patients with MS had a significantly lower risk of cerebral edema than those without MS (adjusted odds ratio [aOR] = 0.66, 95%CI: 0.51 to 0.86, p =0.002) CONCLUSIONS: In hospitalized patients with hemorrhagic stroke, those with MS have shorter LOS, lower costs, and a lower risk of cerebral edema compared to no MS. More relevant experiments and studies are needed to confirm results of this study.
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Affiliation(s)
- Weiguang Xu
- Department of Neurosurgery, the First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, 510080, China.
| | - Dajun Yan
- Department of Neurosurgery, the First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, 510080, China
| | - Zeqian Ning
- Department of Neurosurgery, the First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, 510080, China
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Sheu ML, Pan LY, Yang CN, Sheehan J, Pan LY, You WC, Wang CC, Chen HS, Pan HC. Neuronal Death Caused by HMGB1-Evoked via Inflammasomes from Thrombin-Activated Microglia Cells. Int J Mol Sci 2023; 24:12664. [PMID: 37628850 PMCID: PMC10454604 DOI: 10.3390/ijms241612664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 08/05/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Microglial cells are a macrophage-like cell type residing within the CNS. These cells evoke pro-inflammatory responses following thrombin-induced brain damage. Inflammasomes, which are large caspase-1-activating protein complexes, play a critical role in mediating the extracellular release of HMGB1 in activated immune cells. The exact role of inflammasomes in microglia activated by thrombin remains unclear, particularly as it relates to the downstream functions of HMGB1. After receiving microinjections of thrombin, Sprague Dawley rats of 200 to 250 gm were studied in terms of behaviors and immunohistochemical staining. Primary culture of microglia cells and BV-2 cells were used for the assessment of signal pathways. In a water maze test and novel object recognition analysis, microinjections of thrombin impaired rats' short-term and long-term memory, and such detrimental effects were alleviated by injecting anti-HMGB-1 antibodies. After thrombin microinjections, the increased oxidative stress of neurons was aggravated by HMGB1 injections but attenuated by anti-HMGB-1 antibodies. Such responses occurred in parallel with the volume of activated microglia cells, as well as their expressions of HMGB-1, IL-1β, IL-18, and caspase-I. In primary microglia cells and BV-2 cell lines, thrombin also induced NO release and mRNA expressions of iNOS, IL-1β, IL-18, and activated caspase-I. HMGB-1 aggravated these responses, which were abolished by anti-HMGB-1 antibodies. In conclusion, thrombin induced microglia activation through triggering inflammasomes to release HMGB1, contributing to neuronal death. Such an action was counteracted by the anti-HMGB-1 antibodies. The refinement of HMGB-1 modulated the neuro-inflammatory response, which was attenuated in thrombin-associated neurodegenerative disorder.
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Affiliation(s)
- Meei-Ling Sheu
- Institute of Biomedical Sciences, National Chung-Hsing University, Taichung 40227, Taiwan;
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40210, Taiwan
- Ph.D. Program in Translational Medicine, Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Liang-Yi Pan
- Faculty of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Cheng-Ning Yang
- Department of Dentistry, School of Dentistry, College of Medicine, National Taiwan University, Taipei 106319, Taiwan;
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22904, USA;
| | - Liang-Yu Pan
- Faculty of Medicine, Poznan University of Medical Sciences, 61-701 Poznań, Poland;
| | - Weir-Chiang You
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung 40210, Taiwan;
| | - Chien-Chia Wang
- Department of Life Sciences, National Central University, Taoyuan 32001, Taiwan;
| | - Hong-Shiu Chen
- Department of Neurosurgery, Tungs’ Taichung Metro-Harbor Hospital, Taichung 40210, Taiwan;
| | - Hung-Chuan Pan
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40210, Taiwan
- Ph.D. Program in Translational Medicine, Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 40227, Taiwan
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung 40210, Taiwan
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3
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Sheu ML, Pan LY, Yang CN, Sheehan J, Pan LY, You WC, Wang CC, Pan HC. Thrombin-Induced Microglia Activation Modulated through Aryl Hydrocarbon Receptors. Int J Mol Sci 2023; 24:11416. [PMID: 37511175 PMCID: PMC10380349 DOI: 10.3390/ijms241411416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
Thrombin is a multifunctional serine protein which is closely related to neurodegenerative disorders. The Aryl hydrocarbon receptor (AhR) is well expressed in microglia cells involving inflammatory disorders of the brain. However, it remains unclear as to how modulation of AhR expression by thrombin is related to the development of neurodegeneration disorders. In this study, we investigated the role of AhR in the development of thrombin-induced neurodegenerative processes, especially those concerning microglia. The primary culture of either wild type or AhR deleted microglia, as well as BV-2 cell lines, was used for an in vitro study. Hippocampal slice culture and animals with either wild type or with AhR deleted were used for the ex vivo and in vivo studies. Simulations of ligand protein docking showed a strong integration between the thrombin and AhR. In thrombin-triggered microglia cells, deleting AhR escalated both the NO release and iNOS expression. Such effects were abolished by the administration of the AhR agonist. In thrombin-activated microglia cells, downregulating AhR increased the following: vascular permeability, pro-inflammatory genetic expression, MMP-9 activity, and the ratio of M1/M2 phenotype. In the in vivo study, thrombin induced the activation of microglia and their volume, thereby contributing to the deterioration of neurobehavior. Deleting AhR furthermore aggravated the response in terms of impaired neurobehavior, increasing brain edema, aggregating microglia, and increasing neuronal death. In conclusion, thrombin caused the activation of microglia through increased vessel permeability, expression of inflammatory response, and phenotype of M1 microglia, as well the MMP activity. Deleting AhR augmented the above detrimental effects. These findings indicate that the modulation of AhR is essential for the regulation of thrombin-induced brain damages and that the AhR agonist may harbor the potentially therapeutic effect in thrombin-induced neurodegenerative disorder.
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Affiliation(s)
- Meei-Ling Sheu
- Institute of Biomedical Sciences, National Chung-Hsing University, Taichung 40227, Taiwan;
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40210, Taiwan
- Ph.D. Program in Translational Medicine, Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 40227, Taiwan
| | - Liang-Yi Pan
- Faculty of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
| | - Cheng-Ning Yang
- Department of Dentistry, School of Dentistry, College of Medicine, National Taiwan University, Taipei 106319, Taiwan;
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22904, USA;
| | - Liang-Yu Pan
- Faculty of Medicine, Poznan University of Medical Sciences, 61-701 Poznań, Poland;
| | - Weir-Chiang You
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung 40210, Taiwan;
| | - Chien-Chia Wang
- Department of Life Sciences, National Central University, Taoyuan 32001, Taiwan;
| | - Hung-Chuan Pan
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40210, Taiwan
- Ph.D. Program in Translational Medicine, Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 40227, Taiwan
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung 40210, Taiwan
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Yuan Z, Wang Q, Sun Q, Li C, Xiong F, Li Z. Hypertensive intracerebral hemorrhage: Which one should we choose between laser navigation and 3D navigation mold? Front Surg 2023; 10:1040469. [PMID: 36911606 PMCID: PMC10001900 DOI: 10.3389/fsurg.2023.1040469] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/17/2023] [Indexed: 03/14/2023] Open
Abstract
Background Hypertensive intracerebral hemorrhage (HICH) is a severe life-threatening disease, and its incidence has gradually increased in recent years. Due to the particularity and diversity of its bleeding sites, the early treatment of hematoma needs to be more meticulous and accurate, and minimally invasive surgery is often one of the measures that are commonly adopted now. The lower hematoma debridement and the navigation template created by 3D printing technology were compared in the external drainage of a hypertensive cerebral hemorrhage. Then the effect and feasibility of the two operations were explicitly evaluated. Material and methods We performed a retrospective analysis of all eligible patients with HICH who underwent laser-guided hematoma evacuation or hematoma puncture under 3D-navigated molds at the Affiliated Hospital of Binzhou Medical University from January 2019 to January 2021. A total of 43 patients were treated. Twenty-three patients were treated with laser navigation-guided hematoma evacuation (group A); 20 patients were treated with 3D navigation minimally invasive surgery (group B). A comparative study was conducted between the two groups to evaluate the preoperative and postoperative conditions. Results The preoperative preparation time of the laser navigation group was significantly shorter than that of the 3D printing group. The operation time of the 3D printing group was better than that of the laser navigation group (0.73 ± 0.26 h vs. 1.03 ± 0.27 h P = 0.00070). In the improvement in the short-term postoperatively, there was no statistically significant difference between the laser navigation group and the 3D printing group (Median hematoma evacuation rate P = 0.14); And in the three-month follow-up NIHESS score, there was no significant difference between the two (P = 0.82). Conclusion Laser-guided hematoma removal is more suitable for emergency operations, with real-time navigation and shortened preoperative preparation time; hematoma puncture under a 3D navigation mold is more personalized and shortens the intraoperative time course. There was no significant difference in therapeutic effect between the two groups.
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Affiliation(s)
- Zhengbo Yuan
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
| | - Qingbo Wang
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China.,Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, China
| | - Qikai Sun
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
| | - Chenglong Li
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
| | - Fengzhen Xiong
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
| | - Zefu Li
- Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, China
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Chen X, Zhang H, Hao H, Zhang X, Song H, He B, Wang Y, Zhou Y, Zhu Z, Hu Y, Wang Y. Thrombin induces morphological and inflammatory astrocytic responses via activation of PAR1 receptor. Cell Death Dis 2022; 8:189. [PMID: 35399122 PMCID: PMC8995373 DOI: 10.1038/s41420-022-00997-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 03/04/2022] [Accepted: 03/28/2022] [Indexed: 12/30/2022]
Abstract
AbstractSpinal cord injury (SCI) will result in the significant elevation of thrombin production at lesion site via either breakage of blood-spinal cord barrier or upregulated expression within nerve cells. Thrombin-induced activation of the protease activated receptors (PARs) evokes various pathological effects that deteriorate the functional outcomes of the injured cord. The cellular consequences of thrombin action on the astrocytes, as well as the underlying mechanism are not fully elucidated by far. In the present study, SCI model of rats was established by contusion, and primary astrocytes were isolated for culture from newborn rats. The expression levels of thrombin and PAR1 receptor at lesion sites of the spinal cord were determined. The primary astrocytes cultured in vitro were stimulated with different concentration of thrombin, and the resultant morphological changes, inflammatory astrocytic responses, as well as PAR1-activated signal pathway of astrocytes were accordingly examined using various agonists or antagonists of the receptor. Thrombin was found to reverse astrocytic stellation, promote proliferation but inhibit migration of astrocytes. Furthermore, the serine protease was shown to facilitate inflammatory response of astrocytes through regulation of MAPKs/NFκB pathway. Our results have provided the morphological evidence of astrocytic reactivity in response to thrombin stimulation and its neuroinflammatory effects following SCI, which will be indicative for the fundamental insights of thrombin-induced neuropathology.
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Christopher E, Loan JJM, Samarasekera N, McDade K, Rose J, Barrington J, Hughes J, Smith C, Al-Shahi Salman R. Nrf2 activation in the human brain after stroke due to supratentorial intracerebral haemorrhage: a case–control study. BMJ Neurol Open 2022; 4:e000238. [PMID: 35265844 PMCID: PMC8860052 DOI: 10.1136/bmjno-2021-000238] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/17/2022] [Indexed: 01/05/2023] Open
Abstract
Aims Pharmacological activation of the antioxidative transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2) improves outcomes in experimental models of intracerebral haemorrhage (ICH). However, the Nrf2 pathway has not been previously studied in humans after ICH. Our study aims to address this gap. Methods We selected cases with fatal ICH from a prospective community-based inception cohort study and age-matched and sex-matched controls who died suddenly of non-neurological disease. We used immunohistochemistry to quantify Nrf2 (% total area stained overall and % of nuclei stained) and CD68 expression in controls and perihaematomal, ipsilateral and contralateral brain tissue from cases. We measured downstream haem oxygenase-1 (HMOX1) and NAD(P)H dehydrogenase quinone 1 [NQO1] expression using RNA in situ hybridisation. Results 26 ICH cases (median age: 82 (IQR 76–86); 13 (50%) male) and eight controls (median age: 79 (IQR 77–80); 3 (37.5%) male) were included. We found no significant differences in overall % of Nrf2 staining between ICH cases and controls. However, the mean % of nuclei staining for Nrf2 seemed higher in perihaematomal compared with contralateral regions, although this was only statistically significant >60 days after ICH (25% (95% CI 17% to 33%) vs 14% (95% CI 11% to 17%), p=0.029). The percentage of perihaematomal tissue staining for CD68 was higher >60 days after ICH (6.75%, 95% CI 2.78% to 10.73%) compared with contralateral tissue (1.45%, 95% CI 0.93% to 1.96%, p=0.027) and controls (1.08%, 95% CI 0.20% to 1.97%, p=0.0008). RNA in situ hybridisation suggested increased abundance of HMOX1 and NQO1 transcripts in perihaematomal versus distant ipsilateral brain tissue obtained <7 days from onset of ICH. Conclusions We found evidence of Nrf2 activation in human brain tissue after ICH. Pharmacological augmentation of Nrf2 activation after ICH might be a promising therapeutic approach.
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Affiliation(s)
- Edward Christopher
- The University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, UK
| | - James J M Loan
- Division of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Neshika Samarasekera
- Division of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Karina McDade
- Academic Neuropathology, The University of Edinburgh, Edinburgh, UK
| | - Jamie Rose
- Academic Neuropathology, The University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Jack Barrington
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Jeremy Hughes
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, UK
| | - Colin Smith
- Academic Neuropathology, The University of Edinburgh, Edinburgh, UK
| | - Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
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Prediction of hemorrhagic complications after ultrasound-guided biopsy of the thyroid and neck. Eur Radiol 2022; 32:4177-4185. [DOI: 10.1007/s00330-021-08524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/18/2021] [Accepted: 12/06/2021] [Indexed: 11/04/2022]
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8
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Shaaban A, Saqqur M, Saleh A, Ahmed A, Hussain H, Babu R A, Alyafai A, Belkhair S, Ayyad A. Retrospective analysis of the surgical management of spontaneous supratentorial intracerebral hemorrhage: A single-center study. Qatar Med J 2021; 2021:53. [PMID: 34712600 PMCID: PMC8525251 DOI: 10.5339/qmj.2021.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 08/08/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Intracerebral hemorrhage (ICH) remains a devastating disease with high morbidity and mortality. The mortality rate ranges from 40% at 1 month to 54% at 1 year, and only 12%–39% achieve good outcomes and functional independence. The current management guidelines for spontaneous supratentorial ICH are still controversial. Objective: Patients who presented with ICH and underwent craniotomy with hematoma evacuation or minimal procedures from January 2016 to May 2020 were included in the analysis. Several clinical, radiological, and surgical variables were collected to identify the variables most likely related to lower mortality and better functional outcomes. Results: A total of 87 patients presented with HMC with ICH from January 2016 to May 2020. The mean age was 44.7 (42.2–47.2) years. There were 76 male (87.4%)/11 female (12.6%) patients, which reflect the population distribution in Qatar, which is mainly male predominant. Although Qatar is mainly a Middle-Eastern country, the ethnic distribution of patients was mainly of South Asian and Indian (60.9%) and Far-Eastern (20.7%) ethnicities because of diversity. The mean baseline Glasgow coma scale (GCS) was 8.2+/ − 3.7. The mean baseline functional independence measure (FIM) score was 59.4+/ − 36.7. Most hematomas were located in the basal ganglia (79.3%%). Baseline characteristics based on long-term outcomes are summarized in Table 1. The following variables were correlated with poor outcome: low GCS on postoperative day 1 (P = 0.06), low FIM score (P = 0.006), ICH location (P = 0.04), distance of the closest point to the surface (P = 0.009), and presence of uncal herniation (P = 0.04). The baseline characteristics based on mortality are outlined in Table 2. The following variables were correlated with mortality: diabetes mellitus (P = 0.02), baseline GCS (P = 0.04), GCS on postoperative day 1 (P = 0.002), unequal pupils (P = 0.05), and postoperative midline shift (P = 0.001). Conclusion: The preoperative clinical neurological status as well as mass effect (uncal herniation and midline shift) can be determinants of functional outcome and mortality. A deeper hematoma may result in poor functional outcome because of more surgical damage in functional brain tissues. Thus, the goal of surgery in spontaneous supratentorial ICH is to reduce mortality, but no evidence support that it can improve functional outcome. Although our findings are interesting, more prospective studies with a larger sample size are needed to confirm our results.
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Affiliation(s)
- Ahmed Shaaban
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Maher Saqqur
- Department of Medicine Division of Neurology, University of Alberta, Edmonton, Alberta, Canada.,Trillium Hospital University of Toronto Mississauga, Ontario, Canada
| | - Ahmed Saleh
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Alaaeldin Ahmed
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Hussain Hussain
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Arun Babu R
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
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Neuroprotective Therapies for Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2021; 35:862-886. [PMID: 34341912 DOI: 10.1007/s12028-021-01311-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 06/25/2021] [Indexed: 12/15/2022]
Abstract
Patients who survive the initial ictus of spontaneous intracerebral hemorrhage (ICH) remain vulnerable to subsequent injury of the perilesional parenchyma by molecular and cellular responses to the hematoma. Secondary brain injury after ICH, which contributes to long-term functional impairment and mortality, has emerged as an attractive therapeutic target. This review summarizes preclinical and clinical evidence for neuroprotective therapies targeting secondary injury pathways following ICH. A focus on therapies with pleiotropic antiinflammatory effects that target thrombin-mediated chemotaxis and inflammatory cell migration has led to studies investigating statins, anticholinergics, sphingosine-1-phosphate receptor modulators, peroxisome proliferator activated receptor gamma agonists, and magnesium. Attempts to modulate ICH-induced blood-brain barrier breakdown and perihematomal edema formation has prompted studies of nonsteroidal antiinflammatory agents, matrix metalloproteinase inhibitors, and complement inhibitors. Iron chelators, such as deferoxamine and albumin, have been used to reduce the free radical injury that ensues from erythrocyte lysis. Stem cell transplantation has been assessed for its potential to enhance subacute neurogenesis and functional recovery. Despite promising preclinical results of numerous agents, their outcomes have not yet translated into positive clinical trials in patients with ICH. Further studies are necessary to improve our understanding of the molecular events that promote damage and inflammation of the perihematomal parenchyma after ICH. Elucidating the temporal and pathophysiologic features of this secondary brain injury could enhance the clinical efficacy of neuroprotective therapies for ICH.
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El Damaty A, Giannoni L, Unterberg A, Baechli H. Thrombocytopenia: is it a prognostic factor for development of post-hemorrhagic hydrocephalus in neonates? Childs Nerv Syst 2021; 37:519-527. [PMID: 32661644 PMCID: PMC7358285 DOI: 10.1007/s00381-020-04790-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/02/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Post-hemorrhagic hydrocephalus (PHH) is a rare but serious complication among premature babies in the neonatal intensive care unit. The causes of PHH are still not entirely understood, and its prevention and treatment are controversial. We tried to analyze the risk factors for such complication in our cohort. METHODS We reviewed our neonatology data bank and included all preterms below 28 weeks who were born in the period between 1999 and 2014 and suffered from an intraventricular hemorrhage (IVH). We reviewed gestational age, gender, birth weight, type of birth, IVH degree, comorbidities, therapy, complications, time to event, protein content of cerebrospinal fluid, and clinical follow-up. RESULTS We identified 180 patients, divided into two subgroups, "B1" with 37 cases (IVH + PHH) and "B2" with 143 cases (IVH - PHH). In group B1, the presence of IVH grades I, II, III, or IV was in 11%, 19%, and 70% respectively. Nineteen patients were treated with a ventricular access device (VAD) or external ventricular drain (EVD). A total of 20 shunts were implanted, with 11 revisions (55%). One patient suffered from thrombocytopenia. In subgroup B2, 51% showed IVH grade I, whereas severe IVH grades were only present in 22%. 25.9% suffered from thrombocytopenia. Thrombocytopenia was significantly higher in patients who did not develop PHH (p value: 0.002). CONCLUSION According to our results, thrombocytopenia could play a decisive role in avoiding development of PHH as a sequel of IVH. We recommend a randomized controlled trial to assess the possible efficacy of antiplatelet drugs in avoiding PHH in this vulnerable group.
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Affiliation(s)
- Ahmed El Damaty
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Luca Giannoni
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Heidi Baechli
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Sagar R, Kumar A, Verma V, Yadav AK, Raj R, Rawat D, Yadav A, Srivastava AK, Pandit AK, Vivekanandhan S, Gulati A, Gupta G, Prasad K. Incremental Accuracy of Blood Biomarkers for Predicting Clinical Outcomes After Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 30:105537. [PMID: 33338706 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105537] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/03/2020] [Accepted: 12/06/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is associated with high mortality, morbidity, and recurrence. Studies have reported the accuracy of several blood biomarkers in predicting clinical outcomes; however, their independent contribution in prediction remains to be established. AIM To investigate the incremental accuracy in predicting clinical outcomes in patients with ICH in a north Indian population using blood-based biomarkers. METHODS In this study, a total of 250 ICH cases were recruited within 72 hours of onset. Baseline clinical and CT scan measurement were recorded. Homocysteine (HCY), C-reactive protein (CRP), matrix metalloproteinase-9 (MMP9), E-selectin (SELE), and P-selectin (SELP) levels were measured through ELISA. Telephonic follow-up was done by using mRS scale at three months. RESULTS The mean age of cohort was 54.9 (SD±12.8) years with 64.8% patients being male. A total of 109 (43.6%) deaths were observed over three months follow-up. Area under the receiver operating characteristics curve-(AUROC) for 90-day mortality were 0.55 (HCY), 0.62 (CRP), 0.57 (MMP9), 0.60 (SELE) and 0.53 (SELP) and for poor outcome at 90-day (mRS: 3-6) were 0.60 (HCY), 0.62 (CRP), 0.54 (MMP9), 0.67 (SELE) and 0.54 (SELP). In multivariable model including age, ICH volume, IVH and GCS at admission, serum SELE (p=0.004) significant for poor outcome with improved AUROC (0.86) and HCY (p=0.04), CRP (p=0.003) & MMP9 (p=0.02) for mortality with least Akaike's Information Criterion-(AIC) (1060.5). CONCLUSIONS Our findings suggest that the serum SELE is a significant predictor of poor outcome and HCY, CRP & MMP9 for Mortality in patients with ICH in the north Indian population.
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Affiliation(s)
- Ram Sagar
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Room No. 02, 6th Floor, Ansari Nagar, New Delhi, India.
| | - Amit Kumar
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Room No. 02, 6th Floor, Ansari Nagar, New Delhi, India.
| | - Vivek Verma
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Room No. 02, 6th Floor, Ansari Nagar, New Delhi, India.
| | - Arun Kumar Yadav
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Room No. 02, 6th Floor, Ansari Nagar, New Delhi, India.
| | - Ritesh Raj
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Room No. 02, 6th Floor, Ansari Nagar, New Delhi, India.
| | - Dimple Rawat
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Room No. 02, 6th Floor, Ansari Nagar, New Delhi, India.
| | - Amarnath Yadav
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Room No. 02, 6th Floor, Ansari Nagar, New Delhi, India.
| | - Achal Kumar Srivastava
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Room No. 02, 6th Floor, Ansari Nagar, New Delhi, India.
| | - Awadh Kishor Pandit
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Room No. 02, 6th Floor, Ansari Nagar, New Delhi, India.
| | - Subiah Vivekanandhan
- Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh, India.
| | - Arti Gulati
- Clinical Epidemiology Unit, All India Institute of Medical Sciences, New Delhi, India.
| | - Garima Gupta
- Department of Biotechnology, Ministry of Science & Technology, New Delhi, India.
| | - Kameshwar Prasad
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, Room No. 02, 6th Floor, Ansari Nagar, New Delhi, India.
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12
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Flores JJ, Klebe D, Tang J, Zhang JH. A comprehensive review of therapeutic targets that induce microglia/macrophage-mediated hematoma resolution after germinal matrix hemorrhage. J Neurosci Res 2019; 98:121-128. [PMID: 30667078 DOI: 10.1002/jnr.24388] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 12/28/2018] [Accepted: 01/02/2019] [Indexed: 01/03/2023]
Abstract
Currently, there is no effective treatment for germinal matrix hemorrhage and intraventricular hemorrhage (GMH-IVH), a common and often fatal stroke subtype in premature infants. Secondary brain injury after GMH-IVH is known to involve blood clots that contribute to inflammation and neurological deficits. Furthermore, the subsequent blood clots disrupt normal cerebrospinal fluid circulation and absorption after GMH-IVH, contributing to posthemorrhagic hydrocephalus (PHH). Clinically, GMH-IVH severity is graded on a I to IV scale: Grade I is confined to the germinal matrix, grade II includes intraventricular hemorrhage, grade III includes intraventricular hemorrhage with extension into dilated ventricles, and grade IV includes intraventricular hemorrhage with extension into dilated ventricles as well as parenchymal hemorrhaging. GMH-IVH hematoma volume is the best prognostic indicator, where patients with higher grades have worsened outcomes. Various preclinical studies have shown that rapid hematoma resolution quickly ameliorates inflammation and improves neurological outcomes. Current experimental evidence identifies alternatively activated microglia as playing a pivotal role in hematoma clearance. In this review, we discuss the pathophysiology of GMH-IVH in the development of PHH, microglia/macrophage's role in the neonatal CNS, and established/potential therapeutic targets that enhance M2 microglia/macrophage phagocytosis of blood clots after GMH-IVH.
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Affiliation(s)
- Jerry J Flores
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA
| | - Damon Klebe
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA
| | - Jiping Tang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA.,Department of Anesthesiology and Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA
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13
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Thrombin contributes to the injury development and neurological deficit after acute subdural hemorrhage in rats only in collaboration with additional blood-derived factors. BMC Neurosci 2018; 19:81. [PMID: 30591020 PMCID: PMC6307215 DOI: 10.1186/s12868-018-0481-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/15/2018] [Indexed: 12/13/2022] Open
Abstract
Background Acute subdural hemorrhage (ASDH) is a severe consequence of traumatic brain injury. The occurrence of subdural blood increases the lethality of these patients independent of the amount of blood or elevated intracranial pressure. Thrombin is one of the potential harmful blood components. Possible harmful effects of thrombin are mediated via the Protease-activated-receptor-1 (PAR1) and thus, translating the acute Thrombin release after ASDH into cell loss. The objectives of the present study were twofold, namely to examine (1) the impact of direct thrombin inhibition in the acute phase after hemorrhage on the long-term histological and functional deficits and (2) the early inhibition of PAR1 activation by thrombin with the selective antagonist SCH79797 on lesion volume at 14 days after ASDH. The effects of thrombin on the lesion size were investigated in two separate experiments via (1) direct thrombin inhibition in the subdural infused blood (Argatroban 600 µg) as well as by (2) intraventricular injection of the PAR-1 antagonist SCH79797 (1 µg or 5 µg). Lesion volume and behavior deficits using a neurological deficit score and a motor function test (beam balance test) were analyzed as outcome parameters at 14 days after injury. Results 59 Male Sprague–Dawley rats received a subdural infusion of 300 µl autologous blood or sham operation. Lesion volume at 14 days after ASDH tended to be smaller in the Argatroban-treated group when compared to the vehicle group (8.1 ± 1.1 vs. 10.1 ± 2.3 mm2, n.s.). Motor deficits in the beam balance test were not significantly less severe in the Argatroban-treated group. Animals treated with SCH79797 also showed a trend towards dose-dependent decreased lesion volume in comparison to the vehicle-treated group (1 μg: 4.3 ± 0.7 mm3; 5 μg: 3.8 ± 1.1 mm3; vehicle: 6.5 ± 2.0 mm3, n.s). Conclusions Thrombin inhibition in the subdural blood and local cerebral blockade of PAR-1 cause a tendency towards reduced lesion volume or functional recovery. All results show a trend in favor of the acute treatment on the outcome parameters. Our results suggests that thrombin could be an important blood-derived factor during acute subdural hemorrhage that translates its deleterious effects in concert with other blood-induced factors.
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14
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Choi HJ, Kim NE, Kim J, An S, Yang SH, Ha J, Cho S, Kwon I, Kim YD, Nam HS, Heo JH. Dabigatran reduces endothelial permeability through inhibition of thrombin-induced cytoskeleton reorganization. Thromb Res 2018; 167:S0049-3848(18)30324-4. [PMID: 29735342 DOI: 10.1016/j.thromres.2018.04.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/28/2018] [Accepted: 04/18/2018] [Indexed: 11/23/2022]
Abstract
Dabigatran etexilate (DE), a new oral anti-coagulant, is a direct thrombin inhibitor. Clinical trials showed the favorable benefit-to-risk profile of DE compared to warfarin for the prevention of ischemic stroke in patients with atrial fibrillation. Remarkably, patients treated with dabigatran showed reduced rates of intracerebral hemorrhage compared to warfarin. As the breakdown of endothelial barrier integrity is associated with hemorrhagic events and as thrombin increases endothelial permeability, we hypothesized that dabigatran preserves the endothelial barrier by inhibiting thrombin-induced permeability. We assessed leakage of fluorescein isothiocyanate (FITC)-dextran through the endothelial monolayer and measured trans-endothelial electrical resistance of the endothelial monolayer after treatment of thrombin or thrombin pre-incubated with dabigatran. Thrombin increased the permeability of endothelial cells. Dabigatran effectively blocked the ability of thrombin to increase permeability. Dabigatran inhibited the formation of actin stress fibers induced by thrombin and inhibited consequent destabilization of junctional protein complexes and intercellular gap formation. The interaction of thrombin with protease activated receptor-1 activates the Rho A guanosine triphosphate (GTP)ase-myosin light chain (MLC) phosphorylation signaling axis, leading to actin cytoskeleton changes. This signaling pathway was effectively inhibited by dabigatran in endothelial cells. Consistently, the number of phosphorylated MLC-positive cells was significantly decreased in ischemic tissue of rat brains. These results indicate dabigatran blocks the ability of thrombin to induce vascular permeability and the resulting underlying signaling cascade in endothelial cells. Our findings provide evidence that dabigatran may confer a lower risk of intracerebral hemorrhage by preserving endothelial barrier integrity.
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Affiliation(s)
- Hyun-Jung Choi
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Na-Eun Kim
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jayoung Kim
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sunho An
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul 03722, Republic of Korea
| | - Seung-Hee Yang
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jimin Ha
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul 03722, Republic of Korea
| | - Sunghee Cho
- The Burke-Cornell Medical Research Institute, White Plains, NY 10605, United States; Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10021, United States
| | - Il Kwon
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Dae Kim
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo Suk Nam
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Hoe Heo
- Severance Integrative Research Institute for Cerebral & Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; Brain Korea 21 Plus Project for Medical Science, Yonsei University, Seoul 03722, Republic of Korea.
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15
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Kim DB, Park SK, Moon BH, Cho BR, Jang DK, Jang KS. Comparison of craniotomy and decompressive craniectomy in large supratentorial intracerebral hemorrhage. J Clin Neurosci 2018; 50:208-213. [DOI: 10.1016/j.jocn.2018.01.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 12/26/2017] [Accepted: 01/11/2018] [Indexed: 11/24/2022]
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16
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Abstract
Intracerebral hemorrhage is the most devastating stroke subtype with high rates of mortality and morbidity. Furthermore, no clinically approved treatment exists that effectively increases survival or improves quality of life for survivors. Effective modeling is necessary to elucidate the pathophysiological mechanisms of intracerebral hemorrhage and evaluate potential therapeutic approaches. Rodent models are most utilized because of their cost-effectiveness, and because rodent brain development and structures are well documented. Herein, we describe two intracerebral hemorrhage mouse models: the autologous blood double-injection and collagenase infusion models.
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17
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Zhang Y, Ding Y, Lu T, Zhang Y, Xu N, Yu L, McBride DW, Flores JJ, Tang J, Zhang JH. Bliverdin reductase-A improves neurological function in a germinal matrix hemorrhage rat model. Neurobiol Dis 2017; 110:122-132. [PMID: 29203281 DOI: 10.1016/j.nbd.2017.11.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/11/2017] [Accepted: 11/30/2017] [Indexed: 12/15/2022] Open
Abstract
Germinal matrix hemorrhage is induced by stereotaxic injection of collagenase into the germinal matrix of P7 Sprague-Dawley rats. Hemoglobin assay, western blot, immunofluorescence and neurobehavioral tests were used to test the effects of BLVRA on hematoma resolution and anti-inflammatory response. We showed that BLVRA triggered a signaling cascade that ameliorated post-hemorrhagic neurological deficits in both short-term and long-term neurobehavioral tests in a GMH rat model. Specifically, BLVRA inhibited toll-like receptor 4 (TLR4) expression by translocating to the nucleus in an endothelial nitric oxide (eNOS)/nitric oxide (NO)-dependent manner. BLVRA also induced the upregulation of CD36 scavenger receptor level in microglia/microphages, of which the prominent role is to enhance hematoma resolution. However, the beneficial effects of BLVRA were abolished with the knockdown of eNOS, indicating that the eNOS/NO system is an important downstream factor of BLVRA. Our results demonstrate a mechanism of BLVRA modulating hematoma resolution and suppressing inflammation through eNOS/NO/TLR4 pathway in the GMH rat model.
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Affiliation(s)
- Yiting Zhang
- Department of Ophthalmology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Yan Ding
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Tai Lu
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Yixin Zhang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Ningbo Xu
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Lingyan Yu
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Devin W McBride
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jerry J Flores
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Jiping Tang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA; Departments of Anesthesiology and Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA, USA.
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18
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Ahmad AS, Mendes M, Hernandez D, Doré S. Efficacy of Laropiprant in Minimizing Brain Injury Following Experimental Intracerebral Hemorrhage. Sci Rep 2017; 7:9489. [PMID: 28842638 PMCID: PMC5573370 DOI: 10.1038/s41598-017-09994-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 08/01/2017] [Indexed: 12/31/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is one of the most devastating and disabling forms of stroke, yet effective treatments are still lacking. Prostaglandins and their receptors have been implicated in playing vital roles in ICH outcomes. Recently, laropiprant, a DP1 receptor antagonist, has been used in combination with niacin to abolish the prostaglandin D2-(PGD2)-induced flushing. Here, we test the hypothesis that laropiprant limits bleeding and rescues the brain from ICH. Wildtype (WT) and DP1-/- mice were subjected ICH and neurologic deficits and hemorrhagic lesion outcomes were evaluated at 72 hours after the ICH. To test the therapeutic potential of laropiprant, WT mice subjected to ICH were treated with laropiprant at 1 hour after the ICH. The putative effect of laropiprant on limiting hematoma expansion was tested by an in vivo tail bleeding cessation method and an ex vivo coagulation method. Finally, the roles of laropiprant on gliosis and iron accumulation were also investigated. A significant decrease in the injury volume was observed in DP1-/- as well as laropiprant-treated WT mice. The tail bleeding time was significantly lower in laropiprant group as compared with the vehicle group. Significantly lower Iba-1 and Perls' iron staining in DP1-/- and laropiprant-treated WT groups were observed. Altogether, the data suggest that laropiprant treatment post-ICH attenuates brain damage by targeting primary as well as secondary injuries.
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Affiliation(s)
- Abdullah Shafique Ahmad
- Department of Anesthesiology, University of Florida, Gainesville, FL, USA.
- Center for Translational Research in Neurodegenerative Disease and McKnight Brain Institute, University of Florida, Gainesville, FL, USA.
| | - Monique Mendes
- Department of Anesthesiology, University of Florida, Gainesville, FL, USA
- Center for Translational Research in Neurodegenerative Disease and McKnight Brain Institute, University of Florida, Gainesville, FL, USA
| | - Damian Hernandez
- Department of Anesthesiology, University of Florida, Gainesville, FL, USA
- Center for Translational Research in Neurodegenerative Disease and McKnight Brain Institute, University of Florida, Gainesville, FL, USA
| | - Sylvain Doré
- Department of Anesthesiology, University of Florida, Gainesville, FL, USA.
- Center for Translational Research in Neurodegenerative Disease and McKnight Brain Institute, University of Florida, Gainesville, FL, USA.
- Departments of Neurology, Psychiatry, Pharmaceutics, Psychology, and Neuroscience, University of Florida, Gainesville, FL, USA.
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19
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Rajapathy SK, Idris Z, Kandasamy R, Hieng AWS, Abdullah JM. Inflammatory Biomarkers and Their Value in Predicting Survival and Outcome among Patients with Spontaneous Intracerebral Haemorrhage. Malays J Med Sci 2017; 24:51-65. [PMID: 28814933 DOI: 10.21315/mjms2017.24.3.7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/23/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Spontaneous intracerebral haemorrhage (SICH) has emerged as one of the most devastating forms of stroke in recent decades. This disease is noted to carry a 30-day mortality rate of approximately 45%. An increasing number of studies have implicated a complex immune-mediated and inflammation-mediated cascade of responses in the pathophysiology of SICH and the resultant neurologic outcome. Several clinical studies have demonstrated an association between inflammatory markers and outcome in patients with SICH. However, the exact relationship between serum biomarkers and functional outcomes amongst survivors has not been clearly elucidated. This study aimed to evaluate the changes in peripheral leukocyte count (WBC count) and C-reactive protein (CRP) levels in patients with SICH and to correlate these findings with survival and functional outcome. METHODOLOGY A prospective, descriptive and correlational study was conducted at Sarawak General Hospital (SGH) over the span of two years (April 2013-April 2015). Patients aged between 30 years and 75 years with supratentorial intracerebral bleed secondary to uncontrolled hypertension were recruited in this study. Data pertaining to the demography, clinical and radiological parameters, peripheral WBC count and CRP levels were obtained. Mortality and functional outcomes were determined at 6 months post ictus. Patients were recruited following the fulfilment of exclusion and inclusion criteria, and all obtained data were analysed with the Statistical Package for Social Sciences (SPSS) for Windows version 21.0. RESULTS A total of 60 patients with a mean age of 56 years were recruited in this study. We found that approximately 16 patients were less than or equal to 50 years old (26.7%) and that 44 patients belonged to the older age group of above 50 years (73.3%). The Glasgow Coma Scale (GCS) score on admission ranged from 9 to 14/15 with a median value of 11/15. The mean clot volume was 20.1 cm3. The GCS score on admission and clot volume were significantly associated with the Glasgow Outcome Scale (GOS) at 6 months and overall survival (P < 0.05). The elevated WBC count and CRP level on admission and at 72 hours post admission were significantly associated with GOS at 6 months and overall survival (P < 0.05). Thus, the GCS score, clot volume, WBC count and CRP levels on admission and at 72 hours post admission can be used to predict functional outcome at 6 months and overall survival in patients with SICH. CONCLUSION We could conclude via this study that for patients with SICH, the main determinants or predictors of functional outcome at 6 months and overall survival were noted to be the GCS score on admission, clot size, WBC count and CRP levels on admission and at 72 hours post admission.
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Affiliation(s)
- Senthil Kumar Rajapathy
- Department of Neurosciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia.,Department of Neurosurgery, Sarawak General Hospital, Jalan Hospital, 93586 Kuching, Sarawak, Malaysia
| | - Zamzuri Idris
- Department of Neurosciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Regunath Kandasamy
- Department of Neurosciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Albert Wong Sii Hieng
- Department of Neurosurgery, Sarawak General Hospital, Jalan Hospital, 93586 Kuching, Sarawak, Malaysia
| | - Jafri Malin Abdullah
- Department of Neurosciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia.,Center for Neuroscience Services and Research, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
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20
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Li Y, Yang R, Li Z, Yang Y, Tian B, Zhang X, Wang B, Lu D, Guo S, Man M, Yang Y, Luo T, Gao G, Li L. Surgical Evacuation of Spontaneous Supratentorial Lobar Intracerebral Hemorrhage: Comparison of Safety and Efficacy of Stereotactic Aspiration, Endoscopic Surgery, and Craniotomy. World Neurosurg 2017; 105:332-340. [PMID: 28578111 DOI: 10.1016/j.wneu.2017.05.134] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The safety and efficacy of craniotomy, endoscopic surgery, and stereotactic aspiration for surgical evacuation of spontaneous supratentorial lobar intracerebral hemorrhage (ICH) is yet uncertain. The present study analyzed the clinical and radiographic data from 99 patients with spontaneous supratentorial lobar ICH, retrospectively, to address this issue. METHODS Patients who underwent craniotomy, endoscopy surgery, or stereotactic aspiration were assigned to the craniotomy group (n = 31), endoscopy surgery group (n = 32), or stereotactic aspiration group (n = 36), respectively. The characteristics of all the enrolled patients at the time of admission were assimilated. Also, the therapeutic effects of the three surgical procedures were evaluated based on short-term outcomes within 30 days and long-term outcomes at 6 months after the ictus. RESULTS The results showed that stereotactic aspiration and endoscopic surgery were associated with a superior clinical therapeutic effect in both short-term and long-term outcomes than craniotomy for the treatment of spontaneous supratentorial lobar ICH. Notably, severely affected patients with hematoma volume > 60 mL or Glasgow Coma Scale score 4-8 may benefit more from endoscopic surgery than the two other surgical procedures. CONCLUSIONS The current findings demonstrate that both stereotactic aspiration and endoscopic surgery possess an apparent advantage over craniotomy for the evacuation of spontaneous supratentorial lobar ICH. The endoscopic surgery might be more safe and effective with higher evacuation rate, better functional neurological outcomes, and lower complication and mortality rates.
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Affiliation(s)
- Yuqian Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Ruixin Yang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhihong Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yanping Yang
- Department of Neurosurgery, Xi'an Central Hospital, Xi'an, Shaanxi, China
| | - Bo Tian
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xingye Zhang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Bao Wang
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Dan Lu
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Shaochun Guo
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Minghao Man
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yang Yang
- Department of Neurosurgery, The 451th hospital of PLA, Xi'an, Shaanxi, China
| | - Tao Luo
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Guodong Gao
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China.
| | - Lihong Li
- Department of Neurosurgery, Tangdu Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China.
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21
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Wu H, Wu T, Han X, Wan J, Jiang C, Chen W, Lu H, Yang Q, Wang J. Cerebroprotection by the neuronal PGE2 receptor EP2 after intracerebral hemorrhage in middle-aged mice. J Cereb Blood Flow Metab 2017; 37:39-51. [PMID: 26746866 PMCID: PMC5363749 DOI: 10.1177/0271678x15625351] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 11/20/2015] [Accepted: 12/01/2015] [Indexed: 11/16/2022]
Abstract
Inflammatory responses mediated by prostaglandins such as PGE2 may contribute to secondary brain injury after intracerebral hemorrhage (ICH). However, the cell-specific signaling by PGE2 receptor EP2 differs depending on whether the neuropathic insult is acute or chronic. Using genetic and pharmacologic approaches, we investigated the role of EP2 receptor in two mouse models of ICH induced by intrastriatal injection of collagenase or autologous arterial whole blood. We used middle-aged male mice to enhance the clinical relevance of the study. EP2 receptor was expressed in neurons but not in astrocytes or microglia after collagenase-induced ICH. Brain injury after collagenase-induced ICH was associated with enhanced cellular and molecular inflammatory responses, oxidative stress, and matrix metalloproteinase (MMP)-2/9 activity. EP2 receptor deletion exacerbated brain injury, brain swelling/edema, neuronal death, and neurobehavioral deficits, whereas EP2 receptor activation by the highly selective agonist AE1-259-01 reversed these outcomes. EP2 receptor deletion also exacerbated brain edema and neurologic deficits in the blood ICH model. These findings support the premise that neuronal EP2 receptor activation by PGE2 protects brain against ICH injury in middle-aged mice through its anti-inflammatory and anti-oxidant effects and anti-MMP-2/9 activity. PGE2/EP2 signaling warrants further investigation for potential use in ICH treatment.
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Affiliation(s)
- He Wu
- Department of Pathology, First Clinical Hospital, Harbin Medical University, Harbin, China
| | - Tao Wu
- Stroke Center, Stroke Screening and Intervention Base, Changhai Hospital, Second Military Medical University, Shanghai, China.,Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Xiaoning Han
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Jieru Wan
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Chao Jiang
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Wenwu Chen
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Hong Lu
- Department of Neurology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Jian Wang
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
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Cheng S, Gao W, Xu X, Fan H, Wu Y, Li F, Zhang J, Zhu X, Zhang Y. Methylprednisolone sodium succinate reduces BBB disruption and inflammation in a model mouse of intracranial haemorrhage. Brain Res Bull 2016; 127:226-233. [PMID: 27746369 DOI: 10.1016/j.brainresbull.2016.10.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 09/20/2016] [Accepted: 10/12/2016] [Indexed: 01/30/2023]
Abstract
Inflammation and disruption of the blood-brain barrier (BBB) cause oedema and secondary brain injury after intracranial haemorrhage (ICH), which is closely related to patient prognosis. Methylprednisolone sodium succinate (MPSS), a well-known immunosuppressive agent, is widely applied in many diseases to inhibit inflammation. In this study, we investigated the effect of MPSS on inflammation and disruption of the BBB in a model mouse of ICH. ICH was induced by injecting collagenase into the right striatum of male C57/BL mice. Permeability of BBB was measured with Evans Blue assay and brain oedema was detected by measurement of brain water content. Expressions of NF-κB, TLR4, occludin, ZO-1, IL-1β, TNF-α, Bax, and Bcl-2 were determined by Western Blot. Neutrophils, microglia were measured by immunohistochemistry staining, neuronal apoptosis was measured by TUNEL and NeuN co-stained. Administration of MPSS post-ICH significantly reduced permeability of the BBB and brain oedema and upregulated expression of ZO-1 and Occludin. MPSS inhibited inflammatory responses, including reducing proinflammatory cytokines (IL-1β, TNF-α), suppressing infiltration of neutrophils and activation of microglia. This was accompanied by attenuated activation of the TLR4/NF-κB signalling pathway. In addition, MPSS reduced neuronal apoptosis through increasing Bcl-2 expression and reducing Bax expression. MPSS suppressed inflammatory responses, attenuated disruption of the BBB and reduced neuronal apoptosis, contributing to reduction of secondary brain injury after ICH. These results suggest that MPSS may be a potential therapy for ICH.
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Affiliation(s)
- Shiqi Cheng
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang 330006, Jiangxi, People's Republic of China
| | - WeiWei Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin 300052, People's Republic of China
| | - Xin Xu
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin 300052, People's Republic of China
| | - Hengyi Fan
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang 330006, Jiangxi, People's Republic of China
| | - Yingang Wu
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin 300052, People's Republic of China
| | - Fei Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin 300052, People's Republic of China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin 300052, People's Republic of China
| | - Xingen Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang 330006, Jiangxi, People's Republic of China.
| | - Yan Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang 330006, Jiangxi, People's Republic of China.
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Moussa WMM, Khedr W. Decompressive craniectomy and expansive duraplasty with evacuation of hypertensive intracerebral hematoma, a randomized controlled trial. Neurosurg Rev 2016; 40:115-127. [PMID: 27235128 DOI: 10.1007/s10143-016-0743-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/22/2016] [Accepted: 05/05/2016] [Indexed: 12/25/2022]
Abstract
Hypertensive intracerebral hemorrhage (ICH) has high morbidity and mortality rates. Decompressive craniectomy (DC) is generally used for the treatment of cases associated with refractory increased intracranial pressure (ICP). In this study, we investigated the beneficial effects of adding DC and expansive duraplasty (ED) to hematoma evacuation in patients who underwent surgery for large hypertensive ICH. A prospective randomized controlled clinical trial where 40 patients diagnosed having large hypertensive ICH was randomly allocated to either group A or B, each comprised 20 patients. Group A patients, the treatment group, were submitted to hematoma evacuation together with DC and ED, whereas group B patients, the control group, were submitted only to hematoma evacuation. Twenty-three (57.5 %) of the patients were males, with an overall age range of 34-79 years (mean 59.3 years). Preoperative Glasgow Coma Scale (GCS) scores in group A ranged from 4 to 13 (mean 7.1), while in group B it ranged from 4 to 12 (mean 6.8). Postoperative hydrocephalus occurred in 3 (15 %) patients in group A and in 4 (20 %) patients in group B, whereas meningitis occurred in one patient (5 %) in group A. The mortality rate was 2 (10 %) patients in group A as compared to 5 (25 %) patients in group B (p = 0.407). High admission GCS (p = 0.0032), younger age (p = 0.0023), smaller hematoma volume (p = 0.044), subcortical hematoma location (p = 0.041), absent or minimal preoperative (p = 0.0068), and postoperative (p = 0.0031) midline shift as well as absent intraventricular extension of the hematoma (p = 0.036) contributed significantly to a better outcome. Selected patients' subgroups who benefited from adding DC and ED to ICH evacuation were age category of 30 to less than 50 (p = 0.0015) and from 50 to less than 70 (p = 0.00619) as well as immediate preoperative GCS from 6 to 8 (p = 0.000436) and from 9 to 12 (p = 0.00774). At 6 months' follow-up, 14 (70 %) patients of group A had favorable outcome as compared to 4 (20 %) patients of group B (p = 0.0015). Adding DC with ED to evacuation of a large hypertensive hemispheric ICH might improve the outcome in selected group of patients.
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Affiliation(s)
- Wael Mohamed Mohamed Moussa
- Department of Neurosurgery, Faculty of Medicine, Alexandria University, Champolion Street, Khartoum Square, Azareeta, Alexandria, Egypt.
| | - Wael Khedr
- Department of Neurosurgery, Faculty of Medicine, Alexandria University, Champolion Street, Khartoum Square, Azareeta, Alexandria, Egypt
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Flores JJ, Klebe D, Rolland WB, Lekic T, Krafft PR, Zhang JH. PPARγ-induced upregulation of CD36 enhances hematoma resolution and attenuates long-term neurological deficits after germinal matrix hemorrhage in neonatal rats. Neurobiol Dis 2016; 87:124-33. [PMID: 26739391 PMCID: PMC4724557 DOI: 10.1016/j.nbd.2015.12.015] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 12/11/2015] [Accepted: 12/25/2015] [Indexed: 12/11/2022] Open
Abstract
Germinal matrix hemorrhage remains the leading cause of morbidity and mortality in preterm infants in the United States with little progress made in its clinical management. Survivors are often afflicted with long-term neurological sequelae, including cerebral palsy, mental retardation, hydrocephalus, and psychiatric disorders. Blood clots disrupting normal cerebrospinal fluid circulation and absorption after germinal matrix hemorrhage are thought to be important contributors towards post-hemorrhagic hydrocephalus development. We evaluated if upregulating CD36 scavenger receptor expression in microglia and macrophages through PPARγ stimulation, which was effective in experimental adult cerebral hemorrhage models and is being evaluated clinically, will enhance hematoma resolution and ameliorate long-term brain sequelae using a neonatal rat germinal matrix hemorrhage model. PPARγ stimulation (15d-PGJ2) increased short-term PPARγ and CD36 expression levels as well as enhanced hematoma resolution, which was reversed by a PPARγ antagonist (GW9662) and CD36 siRNA. PPARγ stimulation (15d-PGJ2) also reduced long-term white matter loss and post-hemorrhagic ventricular dilation as well as improved neurofunctional outcomes, which were reversed by a PPARγ antagonist (GW9662). PPARγ-induced upregulation of CD36 in macrophages and microglia is, therefore, critical for enhancing hematoma resolution and ameliorating long-term brain sequelae.
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Affiliation(s)
- Jerry J Flores
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Damon Klebe
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - William B Rolland
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Tim Lekic
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Paul R Krafft
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - John H Zhang
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, USA; Departments of Anesthesiology and Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA, USA.
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Klebe D, McBride D, Flores JJ, Zhang JH, Tang J. Modulating the Immune Response Towards a Neuroregenerative Peri-injury Milieu After Cerebral Hemorrhage. J Neuroimmune Pharmacol 2015; 10:576-86. [PMID: 25946986 PMCID: PMC4636976 DOI: 10.1007/s11481-015-9613-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 04/29/2015] [Indexed: 01/06/2023]
Abstract
Cerebral hemorrhages account for 15-20 % of stroke sub-types and have very poor prognoses. The mortality rate for cerebral hemorrhage patients is between 40 and 50 %, of which at least half of the deaths occur within the first 2 days, and 75 % of survivors are incapable of living independently after 1 year. Current emergency interventions involve lowering blood pressure and reducing intracranial pressure by controlled ventilations or, in the worst case scenarios, surgical intervention. Some hemostatic and coagulatherapeutic interventions are being investigated, although a few that were promising in experimental studies have failed in clinical trials. No significant immunomodulatory intervention, however, exists for clinical management of cerebral hemorrhage. The inflammatory response following cerebral hemorrhage is particularly harmful in the acute stage because blood-brain barrier disruption is amplified and surrounding tissue is destroyed by secreted proteases and reactive oxygen species from infiltrated leukocytes. In this review, we discuss both the destructive and regenerative roles the immune response play following cerebral hemorrhage and focus on microglia, macrophages, and T-lymphocytes as the primary agents directing the response. Microglia, macrophages, and T-lymphocytes each have sub-types that significantly influence the over-arching immune response towards either a pro-inflammatory, destructive, or an anti-inflammatory, regenerative, state. Both pre-clinical and clinical studies of cerebral hemorrhages that selectively target these immune cells are reviewed and we suggest immunomodulatory therapies that reduce inflammation, while augmenting neural repair, will improve overall cerebral hemorrhage outcomes.
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Affiliation(s)
- Damon Klebe
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, 92350, USA
| | - Devin McBride
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, 92350, USA
| | - Jerry J Flores
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, 92350, USA
| | - John H Zhang
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, 92350, USA
- Departments of Anesthesiology and Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA, 92350, USA
| | - Jiping Tang
- Department of Physiology & Pharmacology, Loma Linda University School of Medicine, Loma Linda, CA, 92350, USA.
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Przybylowski CJ, Ding D, Starke RM, Webster Crowley R, Liu KC. Endoport-assisted surgery for the management of spontaneous intracerebral hemorrhage. J Clin Neurosci 2015; 22:1727-32. [DOI: 10.1016/j.jocn.2015.05.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 05/17/2015] [Indexed: 11/26/2022]
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27
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Egashira Y, Hua Y, Keep RF, Xi G. Intercellular cross-talk in intracerebral hemorrhage. Brain Res 2015; 1623:97-109. [PMID: 25863131 DOI: 10.1016/j.brainres.2015.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/31/2015] [Accepted: 04/01/2015] [Indexed: 12/22/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating cerebrovascular disorder with high mortality and morbidity. Currently, there are few treatment strategies for ICH-induced brain injury. A recent increase in interest in the pathophysiology of ICH has led to elucidation of the pathways underlying ICH-induced brain injury, pathways where intercellular and hematoma to cell signaling play important roles. In this review, we summarize recent advances in ICH research focusing on intercellular and hematoma:cell cross-talk related to brain injury and recovery after ICH. This article is part of a Special Issue entitled SI: Cell Interactions In Stroke.
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Affiliation(s)
- Yusuke Egashira
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
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28
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Zhao XR, Gonzales N, Aronowski J. Pleiotropic role of PPARγ in intracerebral hemorrhage: an intricate system involving Nrf2, RXR, and NF-κB. CNS Neurosci Ther 2014; 21:357-66. [PMID: 25430543 DOI: 10.1111/cns.12350] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 10/10/2014] [Accepted: 10/11/2014] [Indexed: 12/13/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a subtype of stroke involving formation of hematoma within brain parenchyma, which accounts for 8-15% of all strokes in Western societies and 20-30% among Asian populations, and has a 1-year mortality rate >50%. The high mortality and severe morbidity make ICH a major public health problem. Only a few evidence-based targeted treatments are used for ICH management, and interventions focus primarily on supportive care and comorbidity prevention. Even in patients who survive the ictus, extravasated blood (including plasma components) and subsequent intrahematoma hemolytic products trigger a series of adverse events within the brain parenchyma, leading to secondary brain injury, edema and severe neurological deficits or death. Although the hematoma in humans gradually resolves within months, full restoration of neurological function can be slow and often incomplete, leaving survivors with devastating neurological deficits. During past years, peroxisome proliferator-activated receptor gamma (PPARγ) transcription factor and its agonists received recognition as important players in regulating not only glucose and lipid metabolism (which underlies its therapeutic effect in type 2 diabetes mellitus), and more recently, as an instrumental pleiotropic regulator of antiinflammation, antioxidative regulation, and phagocyte-mediated cleanup processes. PPARγ agonists have emerged as potential therapeutic target for stroke. The use of PPARγ as a therapeutic target appears to have particularly strong compatibility toward pathogenic components of ICH. In addition to its direct genomic effect, PPARγ may interact with transcription factor, NF-κB, which may underlie many aspects of the antiinflammatory effect of PPARγ. Furthermore, PPARγ appears to regulate expression of Nrf2, another transcription factor and master regulator of detoxification and antioxidative regulation. Finally, the synergistic costimulation of PPARγ and retinoid X receptor, RXR, may play an additional role in the therapeutic modulation of PPARγ function. In this article, we outline the main components of the role of PPARγ in ICH pathogenesis.
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Affiliation(s)
- Xiu-Rong Zhao
- Department of Neurology, Stroke Research Center, University of Texas Medical School - Houston, Houston, TX, USA
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29
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Keep RF, Zhou N, Xiang J, Andjelkovic AV, Hua Y, Xi G. Vascular disruption and blood-brain barrier dysfunction in intracerebral hemorrhage. Fluids Barriers CNS 2014; 11:18. [PMID: 25120903 PMCID: PMC4130123 DOI: 10.1186/2045-8118-11-18] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 08/07/2014] [Indexed: 12/11/2022] Open
Abstract
This article reviews current knowledge of the mechanisms underlying the initial hemorrhage and secondary blood-brain barrier (BBB) dysfunction in primary spontaneous intracerebral hemorrhage (ICH) in adults. Multiple etiologies are associated with ICH, for example, hypertension, Alzheimer's disease, vascular malformations and coagulopathies (genetic or drug-induced). After the initial bleed, there can be continued bleeding over the first 24 hours, so-called hematoma expansion, which is associated with adverse outcomes. A number of clinical trials are focused on trying to limit such expansion. Significant progress has been made on the causes of BBB dysfunction after ICH at the molecular and cell signaling level. Blood components (e.g. thrombin, hemoglobin, iron) and the inflammatory response to those components play a large role in ICH-induced BBB dysfunction. There are current clinical trials of minimally invasive hematoma removal and iron chelation which may limit such dysfunction. Understanding the mechanisms underlying the initial hemorrhage and secondary BBB dysfunction in ICH is vital for developing methods to prevent and treat this devastating form of stroke.
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Affiliation(s)
- Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA ; Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, USA
| | - Ningna Zhou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA ; Department of Pharmacology, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Jianming Xiang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| | | | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
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30
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Yang Z, Liu Y, Yuan F, Li Z, Huang S, Shen H, Yuan B. Sinomenine inhibits microglia activation and attenuates brain injury in intracerebral hemorrhage. Mol Immunol 2014; 60:109-14. [PMID: 24815539 DOI: 10.1016/j.molimm.2014.03.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 02/10/2014] [Accepted: 03/18/2014] [Indexed: 11/18/2022]
Abstract
Intracerebral hemorrhage (ICH) causes morbidity and mortality and commonly follows the reperfusion after an ischemic event. Microglial activation mediated cytokine and protease secretion contributes to brain injury in ICH. Previous studies have shown that sinomenine possesses potent immunoregulatory properties. However, little is known about its exact role in ICH. In the present study, to investigate the effect of sinomenine on microglial cells inflammation, we treated ICH-challenged BV2 microglial cells with sinomenine in vitro, and explored its neuroprotection role in intracerebral hemorrhage in vivo. Changes in inflammatory cytokines, such as TNF-α, IL-1β and IL-6, reactive oxygen species (ROS) and NF-κB activation NF-κB were observed. In addition, the neurological deficit and cerebral water content of ICH mice were studied. The results demonstrated that sinomenine could inhibit the release of these cytokines and attenuate ROS production in a dose-dependent manner, and reduce NF-κB activation. Furthermore, sinomenine markedly inhibited cerebral water content and neurological deficit. In conclusion, our findings suggest that sinomenine played the protective effects through inhibition of microglial inflammation, and the findings also provided a novel therapy to treat ICH induced brain injury.
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Affiliation(s)
- Zhao Yang
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China
| | - Yongping Liu
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China
| | - Fang Yuan
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China
| | - Zhen Li
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China
| | - Shaokuan Huang
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China
| | - Hanchao Shen
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China
| | - Bangqing Yuan
- Department of Neurosurgery, The 476th Hospital of PLA, Fuzhou, Fujian 350025, China.
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32
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Belur PK, Chang JJ, He S, Emanuel BA, Mack WJ. Emerging experimental therapies for intracerebral hemorrhage: targeting mechanisms of secondary brain injury. Neurosurg Focus 2013; 34:E9. [PMID: 23634928 DOI: 10.3171/2013.2.focus1317] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) is associated with a higher degree of morbidity and mortality than other stroke subtypes. Despite this burden, currently approved treatments have demonstrated limited efficacy. To date, therapeutic strategies have principally targeted hematoma expansion and resultant mass effect. However, secondary mechanisms of brain injury are believed to be critical effectors of cell death and neurological outcome following ICH. This article reviews the pathophysiology of secondary brain injury relevant to ICH, examines pertinent experimental models, and highlights emerging therapeutic strategies. Treatment paradigms discussed include thrombin inhibitors, deferoxamine, minocycline, statins, granulocyte-colony stimulating factors, and therapeutic hypothermia. Despite promising experimental and preliminary human data, further studies are warranted prior to effective clinical translation.
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Affiliation(s)
- Praveen K Belur
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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33
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Easton AS. Neutrophils and stroke – Can neutrophils mitigate disease in the central nervous system? Int Immunopharmacol 2013; 17:1218-25. [DOI: 10.1016/j.intimp.2013.06.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 02/15/2013] [Accepted: 06/09/2013] [Indexed: 12/19/2022]
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34
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Wu HM, Huang SC, Vespa P, Hovda DA, Bergsneider M. Redefining the pericontusional penumbra following traumatic brain injury: evidence of deteriorating metabolic derangements based on positron emission tomography. J Neurotrauma 2013; 30:352-60. [PMID: 23461651 DOI: 10.1089/neu.2012.2610] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract The pathophysiological changes in the pericontusional region after traumatic brain injury (TBI) have classically been considered to be ischemic. Using [F-18]fluorodeoxyglucose (FDG) and triple-oxygen PET studies, we examined the pericontusional "penumbra" to assess for increased oxygen extraction fraction (OEF), anaerobic metabolism, and tissue viability. Acute (≤4 days) CT, MRI, and PET studies were performed in eight patients with TBI who had contusions. Four regions-of-interest (ROI) containing the contusion core, pericontusional hypodense gray matter (GM), pericontusional normal-appearing GM, and remote normal-appearing GM, were defined using a semi-automatic method. The correlations of cerebral blood flow (CBF) with OEF, cerebral metabolic rate of oxygen (CMRO2), and cerebral metabolic rate of glucose (CMRglc) were examined. The oxygen-glucose ratio (OGR) in each brain region was evaluated for anaerobic metabolism. The results show that pericontusional tissue had progressively diminishing OEF, CBF, CMRO2, or CMRglc approaching the contusion core. In general, there was a preserved ratio of CBF to CMRO2 in pericontusional hypodense GM. The OGR of the pericontusional hypodense GM was low (<4.0) and was inversely correlated (r=-0.68) with time after injury. A large proportion (%area: 22-76%) of pericontusional hypodense GM tissue had CMRO2 values less than 35 μmol/100 g/min, with this percentage increased with time after injury.
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Affiliation(s)
- Hsiao-Ming Wu
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095-7039, USA
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35
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Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013; 382:397-408. [PMID: 23726393 PMCID: PMC3906609 DOI: 10.1016/s0140-6736(13)60986-1] [Citation(s) in RCA: 825] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The balance of risk and benefit from early neurosurgical intervention for conscious patients with superficial lobar intracerebral haemorrhage of 10-100 mL and no intraventricular haemorrhage admitted within 48 h of ictus is unclear. We therefore tested the hypothesis that early surgery compared with initial conservative treatment could improve outcome in these patients. METHODS In this international, parallel-group trial undertaken in 78 centres in 27 countries, we compared early surgical haematoma evacuation within 12 h of randomisation plus medical treatment with initial medical treatment alone (later evacuation was allowed if judged necessary). An automatic telephone and internet-based randomisation service was used to assign patients to surgery and initial conservative treatment in a 1:1 ratio. The trial was not masked. The primary outcome was a prognosis-based dichotomised (favourable or unfavourable) outcome of the 8 point Extended Glasgow Outcome Scale (GOSE) obtained by questionnaires posted to patients at 6 months. Analysis was by intention to treat. This trial is registered, number ISRCTN22153967. FINDINGS 307 of 601 patients were randomly assigned to early surgery and 294 to initial conservative treatment; 298 and 291 were followed up at 6 months, respectively; and 297 and 286 were included in the analysis, respectively. 174 (59%) of 297 patients in the early surgery group had an unfavourable outcome versus 178 (62%) of 286 patients in the initial conservative treatment group (absolute difference 3·7% [95% CI -4·3 to 11·6], odds ratio 0·86 [0·62 to 1·20]; p=0·367). INTERPRETATION The STICH II results confirm that early surgery does not increase the rate of death or disability at 6 months and might have a small but clinically relevant survival advantage for patients with spontaneous superficial intracerebral haemorrhage without intraventricular haemorrhage. FUNDING UK Medical Research Council.
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Affiliation(s)
- A David Mendelow
- Newcastle University, Neurosurgical Trials Unit, Newcastle upon Tyne, UK
| | - Barbara A Gregson
- Newcastle University, Neurosurgical Trials Unit, Newcastle upon Tyne, UK.
| | - Elise N Rowan
- Newcastle University, Neurosurgical Trials Unit, Newcastle upon Tyne, UK
| | - Gordon D Murray
- Edinburgh University, Centre for Population Health Sciences, Medical School, Edinburgh, UK
| | - Anil Gholkar
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Patrick M Mitchell
- Newcastle University, Neurosurgical Trials Unit, Newcastle upon Tyne, UK
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Role of PGE₂ EP1 receptor in intracerebral hemorrhage-induced brain injury. Neurotox Res 2013; 24:549-59. [PMID: 23824501 DOI: 10.1007/s12640-013-9410-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 06/18/2013] [Accepted: 06/21/2013] [Indexed: 01/02/2023]
Abstract
Prostaglandin E₂ (PGE₂) has been described to exert beneficial and detrimental effects in various neurologic disorders. These conflicting roles of PGE₂ could be attributed to its diverse receptor subtypes, EP1-EP4. At present, the precise role of EP1 in intracerebral hemorrhage (ICH) is unknown. Therefore, to elucidate its possible role in ICH, intrastriatal injection of collagenase was given in randomized groups of adult male wildtype (WT) and EP1 receptor knockout (EP1⁻/⁻)C57BL/6 mice. Functional outcomes including neurologic deficits, rotarod performance, open field activity, and adhesive removal performance were evaluated at 24, 48, and 72 h post-ICH. Lesion volume, cell survival and death, were assessed using Cresyl Violet, and Fluoro-Jade staining, respectively. Microglial activation and phagocytosis were estimated using Iba1 immunoreactivity and fluorescently-labeled microspheres. Following 72 h post-ICH, EP1⁻/⁻ mice showed deteriorated outcomes compared to the WT control mice. These outcomes were demonstrated by elevated neurological deficits, exacerbated lesion volume, and significantly worsened sensorimotor functions. Fluoro-Jade staining showed significantly increased numbers of degenerating neurons and reduced neuronal survival in EP1⁻/⁻ compared to WT mice. To assess in vivo phagocytosis, the number of microspheres phagocytosed by Iba1-positive cells was 145.4 ± 15.4 % greater in WT compared to EP1⁻/⁻ mice. These data demonstrate that EP1 deletion exacerbates neuro-behavioral impairments following ICH, potentially by slowing down/impairing microglial phagocytosis. A better understanding of this EP1 mechanism could lead to improved intervention strategies for hemorrhagic stroke.
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Yoon H, Radulovic M, Wu J, Blaber SI, Blaber M, Fehlings MG, Scarisbrick IA. Kallikrein 6 signals through PAR1 and PAR2 to promote neuron injury and exacerbate glutamate neurotoxicity. J Neurochem 2013; 127:283-98. [PMID: 23647384 DOI: 10.1111/jnc.12293] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 04/18/2013] [Accepted: 04/29/2013] [Indexed: 01/19/2023]
Abstract
CNS trauma generates a proteolytic imbalance contributing to secondary injury, including axonopathy and neuron degeneration. Kallikrein 6 (Klk6) is a serine protease implicated in neurodegeneration, and here we investigate the role of protease-activated receptors 1 (PAR1) and PAR2 in mediating these effects. First, we demonstrate Klk6 and the prototypical activator of PAR1, thrombin, as well as PAR1 and PAR2, are each elevated in murine experimental traumatic spinal cord injury (SCI) at acute or subacute time points. Recombinant Klk6 triggered extracellular signal-regulated kinase (ERK1/2) signaling in cerebellar granule neurons and in the NSC34 spinal cord motoneuron cell line, in a phosphoinositide 3-kinae and MEK-dependent fashion. Importantly, lipopeptide inhibitors of PAR1 or PAR2, and PAR1 genetic deletion, each reduced Klk6-ERK1/2 activation. In addition, Klk6 and thrombin promoted degeneration of cerebellar neurons and exacerbated glutamate neurotoxicity. Moreover, genetic deletion of PAR1 blocked thrombin-mediated cerebellar neurotoxicity and reduced the neurotoxic effects of Klk6. Klk6 also increased glutamate-mediated Bim signaling, poly-ADP-ribose polymerase cleavage and lactate dehydrogenase release in NSC34 motoneurons and these effects were blocked by PAR1 and PAR2 lipopeptide inhibitors. Taken together, these data point to a novel Klk6-signaling axis in CNS neurons that is mediated by PAR1 and PAR2 and is positioned to contribute to neurodegeneration.
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Affiliation(s)
- Hyesook Yoon
- Neurobiology of Disease Program, Mayo Medical and Graduate School, Rochester, Minnesota, USA; Department of Physical Medicine and Rehabilitation, Mayo Medical and Graduate School, Rochester, Minnesota, USA
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Easton AS. Regulation of permeability across the blood-brain barrier. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 763:1-19. [PMID: 23397617 DOI: 10.1007/978-1-4614-4711-5_1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The blood-brain barrier refers to the very low permeability across microvessels in the Central Nervous System (CNS), created by the interaction between vascular endothelial cells and surrounding cells of the neurovascular unit. Permeability can be modulated (increased and decreased) by a variety of factors including inflammatory mediators, inflammatory cells such as neutrophils and through alterations in the phenotype of blood vessels during angiogenesis and apoptosis. In this chapter, some of these factors are discussed as well as the challenge of treating harmful increases in permeability that result in brain swelling (vasogenic cerebral edema).
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Affiliation(s)
- Alexander S Easton
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada.
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Maira G, Doglietto F. Intracerebral Hemorrhage: A Transition Phase Toward Better Prognosis. World Neurosurg 2012; 78:583-5. [DOI: 10.1016/j.wneu.2011.12.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 12/10/2011] [Indexed: 11/29/2022]
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Abstract
Mechanisms of ischemic neuronal and vascular injury remain obscure. Here we test the hypothesis that thrombin, a blood-borne coagulation factor, contributes to neurovascular injury during acute focal ischemia. Stroke was induced in adult Sprague Dawley rats by occluding the middle cerebral artery. Intra-arterial thrombin infusion during ischemia significantly increased vascular disruption and cellular injury. Intravenous infusion of argatroban, a direct thrombin inhibitor, alleviated neurovascular injury. Immunostaining showed thrombin on neurons in the ischemic core. Using an activatable cell-penetrating peptide engineered to detect thrombin activity, we discovered that thrombin proteolytic activity was specifically associated with neuronal damage during ischemia. Protease activated receptor-1, the presumptive thrombin receptor, appeared to mediate ischemic neurovascular injury. Furthermore, rats receiving thrombin during ischemia showed cognitive deficit, whereas rats receiving argatroban retained intact learning and memory. These results suggest a potential role for thrombin contributing to neurovascular injury and several potential avenues for neuroprotection.
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Chemokines and their receptors in intracerebral hemorrhage. Transl Stroke Res 2012; 3:70-9. [PMID: 24323863 DOI: 10.1007/s12975-012-0155-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 03/12/2012] [Accepted: 03/13/2012] [Indexed: 12/11/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating clinical event which results in a high rate of disability and death. At present, no effective treatment is available for ICH. Accumulating evidence suggests that inflammatory responses contribute significantly to the ICH-induced secondary brain outcomes. During ICH, inflammatory cells accumulate at the ICH site attracted by gradients of chemokines. This review summarizes recent progress in ICH studies and the chemoattractants that act during the injury and focuses on and introduces the basic biology of the chemokine monocyte chemoattractant protein-1 (MCP1) and its role in the progression of ICH. Better understanding of MCP1 signaling cascade and the compensation after its inhibition could shed light on the development of effective treatments for ICH.
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Yilmaz C, Kabatas S, Gulsen S, Cansever T, Gurkanlar D, Caner H, Altinors N. Spontaneous supratentorial intracerebral hemorrhage: Does surgery benefit comatose patients? Ann Indian Acad Neurol 2011; 13:184-7. [PMID: 21085528 PMCID: PMC2981755 DOI: 10.4103/0972-2327.70881] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Revised: 01/24/2010] [Accepted: 04/29/2010] [Indexed: 11/06/2022] Open
Abstract
Introduction: Treatment of spontaneous supratentorial intracerebral hemorrhage (SICH) is still controversial. We therefore analyzed the comatose patients diagnosed as having spontaneous SICH and treated by surgery. Materials and Methods: We retrospectively analyzed the collected data of 25 comatose patients with initial Glasgow Coma Scale (GCS) ≤ 8 diagnosed as having spontaneous SICH and they had been treated by surgical evacuation between 1996 and 2008. The outcome was assessed using Glasgow outcome scale (GOS). The side and location of the hematoma and ventricular extension of the hematoma were recorded. The hematoma volume was graded as mild (<30 cc), moderate (30–60 cc) and massive (>60 cc). Results: Age of the patients ranged from 25 to 78 years (mean: 59.6 ± 15.14 years). Among the 25 patients studied, 11 (44%) were females and 14 (56%) were males. GCS before surgery was <5 in 8 (32%) patients and between 5 and 8 in 17 (68%) patients. The hematoma volume was less than 30 cc in 2 patients, between 30 and 60 cc in 9 patients and more than 60 cc in 14 patients. Fourteen of the patients had no ventricular connection and 11 of the hematomas were connected to ventricle. All the 25 patients were treated with craniotomy and evacuation of the hematoma was done within an average of 2 hours on admission to the emergency department. Postoperatively, no rebleeding occurred in our patients. The most important complication was infection in 14 of the patients. The mortality of our surgical series was 56%. GCS before surgery was one of the strongest factors affecting outcome GCS (oGCS) (P = 0.017). Income GCS (iGCS), however, did not affect GOS (P = 0.64). The volume of the hematoma also affected the outcome (P = 0.037). Ventricular extension of the hematoma did affect the oGCS and GOS (P = 0.002), but not the iGCS of the patients (P = 0.139). Conclusion: Our data suggest that being surgically oriented is very important to achieve successful outcomes in a select group of patients with SICH.
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Affiliation(s)
- Cem Yilmaz
- Department of Neurosurgery, Baskent University, Ankara, Turkey
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Serum C-reactive protein and lipid hydroperoxides in predicting short-term clinical outcome after spontaneous intracerebral hemorrhage. J Clin Neurosci 2011; 18:247-52. [DOI: 10.1016/j.jocn.2010.07.125] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Revised: 07/13/2010] [Accepted: 07/17/2010] [Indexed: 11/17/2022]
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Manaenko A, Fathali N, Khatibi NH, Lekic T, Hasegawa Y, Martin R, Tang J, Zhang JH. Arginine-vasopressin V1a receptor inhibition improves neurologic outcomes following an intracerebral hemorrhagic brain injury. Neurochem Int 2011; 58:542-8. [PMID: 21256175 DOI: 10.1016/j.neuint.2011.01.018] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 01/10/2011] [Accepted: 01/13/2011] [Indexed: 01/23/2023]
Abstract
Cerebral edema is a devastating consequence of brain injury leading to cerebral blood flow compromise and worsening parenchyma damage. In the present study, we investigated the effects of arginine-vasopressin (AVP) V(1a) receptor inhibition following an intracerebral hemorrhagic (ICH) brain injury in mice and closely assessed the role it played in cerebral edema formation, neurobehavioral functioning, and blood-brain-barrier (BBB) disruption. To support our investigation, SR49059, an AVP V(1a) receptor competitive antagonist, and NC1900, an arginine-vasopressin analogue, were used. Male CD1 mice (n=205) were randomly assigned to the following groups: naïve, sham, ICH, ICH with SR49059 at 0.5 mg/kg, ICH with SR49059 at 2mg/kg, ICH with NC1900 at 1 ng/kg, ICH with NC1900 at 10 ng/kg, and ICH with a combination of SR49059 at 2 mg/kg and NC1900 at 10 ng/kg. ICH was induced by using the collagenase injection model and treatment was given 1h after surgery. Post assessment was conducted at 6, 12, 24, and 72 h after surgery and included brain water content, neurobehavioral testing, Evans Blue assay, western blotting, and hemoglobin assay. The study found that inhibition of the AVP V(1a) receptor significantly reduced cerebral edema at 24 and 72 h post-ICH injury and improved neurobehavioral function while reducing BBB disruption at 72 h. Western blot analysis demonstrated increased protein expression of aquaporin 4 (AQP4) in vehicle, which was reduced with AVP V(1a) receptor inhibition. Our study suggests that blockage of the AVP V(1a) receptor, is a promising treatment target for improving ICH-induced brain injury. Further studies will be needed to confirm this relationship and determine future clinical direction.
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Affiliation(s)
- Anatol Manaenko
- Department of Physiology and Pharmacology, Loma Linda University, United States
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Post-treatment with SR49059 improves outcomes following an intracerebral hemorrhagic stroke in mice. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 111:191-6. [PMID: 21725754 DOI: 10.1007/978-3-7091-0693-8_32] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating stroke subtype characterized by severe brain edema formation leading to cerebral blood flow compromise and parenchymal damage. Arginine vasopressin (AVP), a non-peptide antidiuretic hormone, has recently been implicated as a modulator of brain edema following injury. In this study, we investigated the effects of SR49059, a highly specific AVP V1a receptor antagonist, on brain injury outcomes following ICH, specifically assessing the ability of SR49059 in reducing brain edema and improving neurobehavioral deficits. Male CD1 mice (n=35) were randomly assigned to the following groups: sham, ICH, ICH with SR49059 at 0.5 mg/kg, and ICH with SR49059 at 2 mg/kg. ICH was induced by using the collagenase injection model, and treatment was given 1 h after surgery. Post-assessment was conducted at 24 and 72 h after surgery, and included brain water content and neurobehavioral testing. The study found that SR49059 significantly reduced cerebral edema at 24 and 72 h post-ICH injury and improved neurobehavioral deficits at 72 h. Our study suggests that blockage of the AVP V1a receptor is a promising treatment target for improving ICH-induced brain injury. Further studies will be needed to confirm this relationship and determine future clinical direction.
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Hwang BY, Appelboom G, Ayer A, Kellner CP, Kotchetkov IS, Gigante PR, Haque R, Kellner M, Connolly ES. Advances in neuroprotective strategies: potential therapies for intracerebral hemorrhage. Cerebrovasc Dis 2010; 31:211-22. [PMID: 21178344 DOI: 10.1159/000321870] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 09/25/2010] [Indexed: 12/14/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is associated with higher mortality and morbidity than any other form of stroke. However, there currently are no treatments proven to improve outcomes after ICH, and therefore, new effective therapies are urgently needed. Growing insight into ICH pathophysiology has led to the development of neuroprotective strategies that aim to improve the outcome through reduction of secondary pathologic processes. Many neuroprotectants target molecules or pathways involved in hematoma degradation, inflammation or apoptosis, and have demonstrated potential clinical benefits in experimental settings. We extensively reviewed the current understanding of ICH pathophysiology as well as promising experimental neuroprotective agents with particular focus on their mechanisms of action. Continued advances in ICH knowledge, increased understanding of neuroprotective mechanisms, and improvement in the ability to modulate molecular and pathologic events with multitargeting agents will lead to successful clinical trials and bench-to-bedside translation of neuroprotective strategies.
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Affiliation(s)
- Brian Y Hwang
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, N.Y. 10032, USA
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Wang J. Preclinical and clinical research on inflammation after intracerebral hemorrhage. Prog Neurobiol 2010; 92:463-77. [PMID: 20713126 DOI: 10.1016/j.pneurobio.2010.08.001] [Citation(s) in RCA: 454] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 07/24/2010] [Accepted: 08/09/2010] [Indexed: 12/15/2022]
Abstract
Intracerebral hemorrhage (ICH) is one of the most lethal stroke subtypes. Despite the high morbidity and mortality associated with ICH, its pathophysiology has not been investigated as well as that of ischemic stroke. Available evidence from preclinical and clinical studies suggests that inflammatory mechanisms are involved in the progression of ICH-induced secondary brain injury. For example, in preclinical ICH models, microglial activation has been shown to occur within 1h, much earlier than neutrophil infiltration. Recent advances in our understanding of neuroinflammatory pathways have revealed several new molecular targets, and related therapeutic strategies have been tested in preclinical ICH models. This review summarizes recent progress made in preclinical models of ICH, surveys preclinical and clinical studies of inflammatory cells (leukocytes, macrophages, microglia, and astrocytes) and inflammatory mediators (matrix metalloproteinases, nuclear factor erythroid 2-related factor 2, heme oxygenase, and iron), and highlights the emerging areas of therapeutic promise.
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Affiliation(s)
- Jian Wang
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University, School of Medicine, 720 Rutland Avenue, Traylor Building 809, Baltimore, MD 21205, USA.
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Chen B, Cheng Q, Yang K, Lyden PD. Thrombin mediates severe neurovascular injury during ischemia. Stroke 2010; 41:2348-52. [PMID: 20705928 DOI: 10.1161/strokeaha.110.584920] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral ischemia initiates cascades of pathological events such as edema, blood-brain barrier breakdown, and tissue degeneration. Thrombin activation is a key step in coagulation, and thrombin has recently been shown to mediate endothelial permeability and cellular toxicity in vitro. We examined the effect of thrombin on vasculature during ischemia in vivo. METHODS Focal ischemia was induced in adult Sprague-Dawley rats by occlusion of the middle cerebral artery for 4 hours followed by a short period of reperfusion. High-molecular-weight fluorescein isothiocyanate-dextran was injected before surgery to label the severe vascular disruption. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining was used to identify dying cells, which were quantified with manual counts. Intra-arterial thrombin or intravenous thrombin inhibitors were infused during ischemia and reperfusion. RESULTS Infusion of thrombin (3 U/kg) intra-arterially during ischemia greatly enlarged the volume of severe vascular disruption, as visualized by fluorescein isothiocyanate-dextran extravasation (P<0.05). Thrombin also promoted blood-brain barrier leakage of IgG during ischemia. Vascular disruption was blocked by intravenous infusion of the direct thrombin inhibitor argatroban (1.69 mg/kg, P<0.05). Greater numbers of dying cells were found in regions of severe vascular disruption, and interventions that reduced vascular leakage also reduced the numbers of dying cells. CONCLUSIONS Thrombin mediates severe vascular disruption during ischemia and thrombin inhibitors may partially ameliorate vascular disruption. Further work is needed to establish whether thrombin, entering parenchyma due to increased vascular permeability, augments neurotoxicity during ischemia.
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Affiliation(s)
- Bo Chen
- Division of Biological Sciences, Department of Neuroscience, University of California–San Diego, La Jolla, Calif, USA.
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Joice SL, Mydeen F, Couraud PO, Weksler BB, Romero IA, Fraser PA, Easton AS. Modulation of blood-brain barrier permeability by neutrophils: in vitro and in vivo studies. Brain Res 2009; 1298:13-23. [PMID: 19728990 DOI: 10.1016/j.brainres.2009.08.076] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 08/06/2009] [Accepted: 08/21/2009] [Indexed: 11/28/2022]
Abstract
The blood-brain barrier (BBB) restricts solute permeability across healthy cerebral endothelial cells. However, during inflammation, permeability is increased and can lead to deleterious cerebral edema. Neutrophils are early cellular participants in acute inflammation, but their effect on BBB permeability is unclear. To study this, neutrophils were applied in a resting and activated state to in vitro and in vivo models of the BBB. In vitro, human neutrophils (5 x 10(6)/ml) were activated with tumor necrosis factor (100 U/ml) and leukotriene B(4) (10(-7) mol/l). Untreated neutrophils reduced permeability across the human brain endothelial cell line hCMEC/D3. Activated neutrophils returned permeability to baseline, an effect blocked by the reactive oxygen scavengers superoxide dismutase (10 U/ml) and catalase (1000 U/ml). In vivo, human neutrophils (2.5 x1 0(5) in 4 microl) were injected into the striatum of anesthetized juvenile Wistar rats, and BBB permeability measured 30 min later. This was compared to control injections (4 microl) of vehicle (0.9% saline) and arachidonic acid (10(-3) mol/l). The injection generated a small hematoma around the injection tract (<3 microl). Untreated neutrophils induced significantly lower permeability in their vicinity than activated neutrophils, with a trend to lowered permeability compared to the vehicle control. Neither untreated nor activated neutrophils induced permeability increases, while arachidonic acid increased permeability as a positive control. This study further delineates the effect of neutrophils on the BBB, and demonstrates that resting neutrophils induce acute reductions in permeability while activated neutrophils have a neutral effect. The in vivo model reiterates some aspects of acute intracerebral hemorrhage.
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Affiliation(s)
- Shannon L Joice
- Department of Pathology, Dalhousie University, 5850 College Street, Halifax, Nova Scotia, Canada
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