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Wang H, Yuan R, Shen P, Yu X, Chen X, Shang Y, Xu J, Tan M, Zhang S, Geng Y. Association between Peripheral Arterial Lactate Levels and Malignant Brain Edema Following Endovascular Treatment for Ischemic Stroke. Curr Neurovasc Res 2024; 20:535-543. [PMID: 39004958 DOI: 10.2174/0115672026283642231212061910] [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: 09/22/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 07/16/2024]
Abstract
AIMS To investigate the factors of postoperative malignant brain edema (MBE) in patients with acute ischemic stroke (AIS) treated with endovascular treatment (EVT). BACKGROUND MBE is a severe complication following EVT for AIS, and it is essential to identify risk factors early. Peripheral arterial lactate (PAL) levels may serve as a potential predictive marker for MBE. OBJECTIVE To determine whether immediate postoperative PAL levels and the highest PAL level within 24 hours of EVT are independently associated with MBE development in AIS patients. METHODS We retrospectively analyzed patients with AIS who underwent EVT from October 2019 to October 2022. Arterial blood was collected every 8 h after EVT to measure PAL, and record the immediate postoperative PAL and the highest PAL level within 24 h. Brain edema was evaluated using brain computed tomography scans within 7 days of EVT. RESULTS The study included 227 patients with a median age of 71 years, of whom 59.5% were male and MBE developed in 25.6% of patients (58/227). Multivariate logistic regression analysis showed that the immediate postoperative PAL (odds ratio, 1.809 [95% confidence interval (CI), 1.215-2.693]; p = 0.004) and the highest PAL level within 24 h of EVT (odds ratio, 2.259 [95% CI, 1.407-3.629]; p = 0.001) were independently associated with MBE. The area under the curve for predicting MBE based on the highest PAL level within 24 hours of EVT was 0.780 (95% CI, 0.711-0.849). CONCLUSION Early increase in PAL levels is an independent predictor of MBE after EVT in AIS patients.
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Affiliation(s)
- Huiyuan Wang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
- Department of Clinical Medicine, Bengbu Medical College, Bengbu, Anhui, China
| | - Ruozhen Yuan
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
| | - Panpan Shen
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
| | - Xinyue Yu
- Alberta Institute, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xinyi Chen
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
| | - Yafei Shang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
- Department of Clinical Medicine, Bengbu Medical College, Bengbu, Anhui, China
| | - Jie Xu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
| | - Mingming Tan
- Department of Quality Management, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang 310014, China
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, 310014, China
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Lang SS, Rahman R, Kumar N, Tucker A, Flanders TM, Kirschen M, Huh JW. Invasive Neuromonitoring Modalities in the Pediatric Population. Neurocrit Care 2023; 38:470-485. [PMID: 36890340 DOI: 10.1007/s12028-023-01684-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 01/30/2023] [Indexed: 03/10/2023]
Abstract
Invasive neuromonitoring has become an important part of pediatric neurocritical care, as neuromonitoring devices provide objective data that can guide patient management in real time. New modalities continue to emerge, allowing clinicians to integrate data that reflect different aspects of cerebral function to optimize patient management. Currently, available common invasive neuromonitoring devices that have been studied in the pediatric population include the intracranial pressure monitor, brain tissue oxygenation monitor, jugular venous oximetry, cerebral microdialysis, and thermal diffusion flowmetry. In this review, we describe these neuromonitoring technologies, including their mechanisms of function, indications for use, advantages and disadvantages, and efficacy, in pediatric neurocritical care settings with respect to patient outcomes.
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Affiliation(s)
- Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA. .,Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Raphia Rahman
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.,School of Osteopathic Medicine, Rowan University, Stratford, NJ, USA
| | - Nankee Kumar
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Alexander Tucker
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Tracy M Flanders
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Matthew Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Liu C, Huai R, Xiang Y, Han X, Chen Z, Liu Y, Liu X, Liu H, Zhang H, Wang S, Hao L, Bo Y, Luo Y, Wang Y, Wang Y. High cerebrospinal fluid lactate concentration at 48 h of hospital admission predicts poor outcomes in patients with tuberculous meningitis: A multicenter retrospective cohort study. Front Neurol 2022; 13:989832. [PMID: 36277931 PMCID: PMC9583930 DOI: 10.3389/fneur.2022.989832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
Objective This study aimed to analyze the cerebrospinal fluid (CSF) parameters affecting the outcomes of patients with tuberculous meningitis (TBM). Methods This is a multi-center, retrospective, cohort study involving 81 patients who were diagnosed with TBM and treated in Haihe Clinical College of Tianjin Medical University, Tianjin Medical University General Hospital, and General Hospital of Air Force PLA from January 2016 to December 2019. Baseline data, Glasgow Coma Scale (GCS) score, and clinical presentations of all patients were collected at admission. CSF samples were collected at 48 h, 1, 2, and 3 weeks after admission. CSF lactate, adenosine deaminase, chloride, protein, glucose levels and intracranial pressure were measured. After a follow-up of 16.14 ± 3.03 months, all patients were assessed using the modified Rankin Scale (mRS) and divided into good (mRS scores of 0–2 points) and poor outcome groups (mRS scores of 3–6 points). The differences in patients' baseline data, GCS score, clinical presentations, and levels of CSF parameters detected at 48 h, 1, 2, and 3 weeks after admission between two groups were compared. Statistically significant variables were added to the binary logistic regression model to identify the factors impacting the outcomes of patients with TBM. Receiver operating characteristic (ROC) curve was used to assess the predictive ability of the model. Results The CSF lactate level exhibited a decreasing trend within 3 weeks of admission in the two groups. For the within-group comparison, statistically significant differences in the lactate level was found in both groups between four different time points. A binary logistic regression model revealed that CSF lactate level at 48 h after admission, age, and GSC score on admission were independently associated with the outcomes of patients with TBM. ROC curve analysis showed that the area under the ROC curve (AUC) was 0.786 for the CSF lactate level (48 h), 0.814 for GCS score, and 0.764 for age. Conclusion High CSF lactate level at 48 h after admission is one of the important factors for poor outcomes in patients with TBM.
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Affiliation(s)
- Chenchao Liu
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Ruixue Huai
- Department of Neurology, Tianjin Jinnan Hospital, Tianjin, China
| | - Yijia Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Xu Han
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Zixiang Chen
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
| | - Yuhan Liu
- Department of Neurosurgery, People's Liberation Army Air Force Medical Center, Beijing, China
| | - Xingjun Liu
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
| | - Huiquan Liu
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
| | - Hong Zhang
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
- Rehabilitation Department, Haihe Clinical School, Tianjin Medical University, Tianjin, China
| | - Sihan Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Lingyu Hao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Yin Bo
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Yuanbo Luo
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Yiyi Wang
- Department of Neurology, Haihe Clinical School, Tianjin Medical University, Tianjin, China
- TCM Key Research Laboratory for Infectious Disease Prevention for State Administration of Traditional Chinese Medicine, Tianjin, China
- Yiyi Wang
| | - Yi Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Key Laboratory of Post-trauma Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin Neurological Institute, Tianjin, China
- *Correspondence: Yi Wang
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Sakal C, Ak R, Taşçı A, Kırkpantur ED, Ünal Akoğlu E, Cimilli Ozturk T. Admission blood lactate levels of patients diagnosed with cerebrovascular disease effects on short- and long-term mortality risk. Int J Clin Pract 2021; 75:e14161. [PMID: 33759312 DOI: 10.1111/ijcp.14161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/08/2021] [Accepted: 03/17/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Our study was carried out on patients admitted to the emergency ward with acute stroke symptoms that were subsequently diagnosed with cerebrovascular disease. We aimed to examine the relationship between these patients' admission lactate levels and their 1-, 3-, and 12-month mortality rates in order to evaluate the prognostic value of lactate levels. METHODS Our data were obtained retrospectively from 568 patients diagnosed with acute ischemic stroke at our emergency department between 1 January 2017 and 1 January 2018. Patient data were accessed via the hospital patient database. Included patients' files were assessed for examination and history taken at admission, comorbid diseases, demographic characteristics, treatments utilized, and laboratory results. Hyperlactatemia was defined as a lactate level of over 2 mmol/L. The relationship between lactate levels and survival was investigated. Patients' complication rates after discharge were assessed alongside their 1-, 3-, and 12-month mortality. RESULTS Our study assessed 568 patients. Out of these patients, 400 patients met our inclusion criteria and constituted the study population. These patients were separated into two groups according to their lactate levels. The hyperlactatemic group had a statistically significant increase in 1-, 3-, and 12-month mortality rates in comparison to the other group. CONCLUSIONS Our study found that hyperlactatemia was associated with a higher risk of 1-, 3-, and 12-month mortality, suggesting that it has predictive prognostic value. In the future, we believe that prospective observational studies and/or large-scale retrospective studies will be of great value in providing more insight into this topic.
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Affiliation(s)
- Cemalettin Sakal
- Department of Emergency Medicine, Binali Yıldırım University Mengücek Gazi Education and Research Hospital, Erzincan, Turkey
| | - Rohat Ak
- Department of Emergency Medicine, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - Abdullah Taşçı
- Department of Emergency Medicine, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - Ecem Deniz Kırkpantur
- Department of Emergency Medicine, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - Ebru Ünal Akoğlu
- Department of Emergency Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Tuba Cimilli Ozturk
- Department of Emergency Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
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Liu J, Wu YY, Yu XL, Jia HY, Mao QY, Fang JQ. Temporal effect of acupuncture on amino acid neurotransmitters in rats with acute cerebral ischaemia. Acupunct Med 2019; 37:252-258. [PMID: 31342771 DOI: 10.1136/acupmed-2017-011417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acupuncture stimulation at GV26 during the acute phase of cerebral ischaemia can effectively reduce brain damage induced by ischaemic injury. However, the time course of the effects of acupuncture stimulation has not yet been thoroughly studied. OBJECTIVE To investigate the effects of manual acupuncture (MA) on glutamic acid (Glu) and γ-aminobutyric acid (GABA) expression in the cerebrospinal fluid of rats with middle cerebral artery occlusion (MCAO) and determine whether there is a temporal effect of acupuncture on the treatment of cerebral ischaemia. METHODS We performed thread occlusion of the right middle cerebral artery in rats to establish an animal model of MCAO. Simultaneously, during acupuncture treatment, microdialysis was used to continuously and dynamically observe immediate alterations in amino acid metabolism with acupuncture stimulation after cerebral ischaemia in vivo in this rat model of MCAO. RESULTS We found that, in comparison with an untreated MCAO group, Glu content was significantly decreased during the first acupuncture stimulation and during the course of the acupuncture treatment in the MCAO+MA group (MCAO vs MCAO+MA: day 1, P=0.032; day 2, P=0.021; day 3, P=0.017). These findings were also seen after the end of treatment when acupuncture was no longer applied (MCAO vs MCAO+MA: day 7, P=0.009). Measurements of GABA content following cerebral ischaemic injury showed that GABA peaks 24 hours after damage, falls thereafter and decreases to baseline levels on day 7. In the MCAO+MA group, GABA content on days 1 to day 2 was lower than in the MCAO group (MCAO+MA vs MCAO: day 1, P=0.003; day 2, P=0.001), although it was higher than in the control group (MCAO+MA vs control: day 1, P=0.024; day 2, P=0.009). GABA content on day 3 and day 7 was higher in the MCAO+MA group than in the MCAO group and the control group (MCAO+MA vs MCAO: day 3, P=0.008; day 7, P=0.013; MCAO+MA vs control: day 3, P=0.002; day 7, P=0.009). CONCLUSION Acupuncture stimulation at GV26 can effectively decrease excessive release of Glu induced by ischaemia and maintain the endogenous inhibitory activity of GABA. This phenomenon was seen during the entire course of acupuncture treatment and continued for some time after the end of acupuncture treatment.
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Affiliation(s)
- Jing Liu
- 1 The Third Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China.,2 The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuan-Yuan Wu
- 1 The Third Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China.,2 The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiao-Lei Yu
- 1 The Third Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China.,2 The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Hong-Yang Jia
- 1 The Third Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China.,2 The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Qun-Yan Mao
- 1 The Third Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China.,2 The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jian-Qiao Fang
- 1 The Third Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China.,2 The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
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Hou S, Wu G, Liang J, Cheng H, Chen C. Hyperbaric oxygen on rehabilitation of brain tumors after surgery and effects on TNF-α and IL-6 levels. Oncol Lett 2019; 17:3277-3282. [PMID: 30867760 PMCID: PMC6396111 DOI: 10.3892/ol.2019.10000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 01/21/2019] [Indexed: 12/16/2022] Open
Abstract
Hyperbaric oxygenation (HBO) on postoperative rehabilitation of brain tumors and effects on tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) levels were explored. A retrospective analysis of 132 patients with brain tumors treated in the People's Hospital of Rizhao from October 2014 to October 2017 was performed. There were 62 patients in the observation group and 70 patients in the control group. Patients in the control group were treated with conventional drugs, and patients in the observation group were treated with HBO on the basis of conventional drug therapy. Levels of serum TNF-α and IL-6 were measured by ELISA before and after treatment. Cerebral arterial flow velocity and spasticity were measured by cranial color Doppler ultrasonography. Neurological function deficit (NFD) and activities of daily living (ADL) were used to evaluate the clinical recovery of the patients. Clinical efficacy was compared and analyzed. There were no significant differences between the two groups before treatment (P>0.05). After treatment, serum TNF-α and IL-6 levels were significantly lower than pretreatment levels (P<0.05), and serum TNF-α and IL-6 levels in the observation group were lower than those in the control group (P<0.05). Cerebral arterial flow velocity in observation group after treatment was significantly lower than that in the control group. The number of patients with cerebral arterial spasm after treatment in the observation group was significantly smaller than that in the control group. NFD scores in the observation group were lower than those in the control group after treatment. After treatment, ADL scores in the observation group were significantly higher than those in the control group (P<0.05). The comprehensive treatment effect of HBO is significant. It can inhibit the expression of inflammatory factors in serum and reduce cerebral arterial flow velocity and effectively reduce the number of patients with cerebral arterial spasm. It can reduce NFD and improve the quality of life of patients. Therefore, it is worthy of clinical popularization.
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Affiliation(s)
- Shicai Hou
- Department of Rehabilitation, People's Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China
| | - Guimei Wu
- Department of Neurosurgery (Ward 1), People's Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China
| | - Jingjing Liang
- Pediatrics (III), People's Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China
| | - Huanchun Cheng
- Department of Surgery, Xujiahu Health Center, Linyi, Shandong 276400, P.R. China
| | - Chao Chen
- Department of Neurosurgery (Ward 1), People's Hospital of Rizhao, Rizhao, Shandong 276800, P.R. China
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Chukanova AS, Chukanova EI, Nadareishvili GG, Gulieva MS, Gusev EI. [Pathogenetic aspects of the development of acute focal cerebral ischemia]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 117:4-10. [PMID: 29411739 DOI: 10.17116/jnevro20171171224-10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Current concepts on the main mechanisms of brain damage in ischemic stroke are considered. Chemical regulation of physiological and pathological processes of maintaining cellular pool is supported by a multistep system that included compounds of different structure and complexity. A complex assessment and comparison of the processes taking place during the development of acute local cerebral ischemia (necrosis, apoptosis, autoimmune inflammatory reaction, neuroplasticity) can help in the objectification and prognosis of individual characteristics of the course and outcome of ischemic stroke. Understanding of the cascade of events that occur during the acute ischemic damage is critical for determining current and future diagnostic and therapeutic approaches.
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Affiliation(s)
- A S Chukanova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - E I Chukanova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - G G Nadareishvili
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M Sh Gulieva
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - E I Gusev
- Pirogov Russian National Research Medical University, Moscow, Russia
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9
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Abstract
Microdialysis enables the chemistry of the extracellular interstitial space to be monitored. Use of this technique in patients with acute brain injury has increased our understanding of the pathophysiology of several acute neurological disorders. In 2004, a consensus document on the clinical application of cerebral microdialysis was published. Since then, there have been significant advances in the clinical use of microdialysis in neurocritical care. The objective of this review is to report on the International Microdialysis Forum held in Cambridge, UK, in April 2014 and to produce a revised and updated consensus statement about its clinical use including technique, data interpretation, relationship with outcome, role in guiding therapy in neurocritical care and research applications.
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Young B, Kalanuria A, Kumar M, Burke K, Balu R, Amendolia O, McNulty K, Marion B, Beckmann B, Ciocco L, Miller K, Schuele D, Maloney-Wilensky E, Frangos S, Wright D. Cerebral Microdialysis. Crit Care Nurs Clin North Am 2016; 28:109-24. [DOI: 10.1016/j.cnc.2015.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Torbey MT, Bösel J, Rhoney DH, Rincon F, Staykov D, Amar AP, Varelas PN, Jüttler E, Olson D, Huttner HB, Zweckberger K, Sheth KN, Dohmen C, Brambrink AM, Mayer SA, Zaidat OO, Hacke W, Schwab S. Evidence-based guidelines for the management of large hemispheric infarction : a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-intensive Care and Emergency Medicine. Neurocrit Care 2016; 22:146-64. [PMID: 25605626 DOI: 10.1007/s12028-014-0085-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Large hemispheric infarction (LHI), also known as malignant middle cerebral infarction, is a devastating disease associated with significant disability and mortality. Clinicians and family members are often faced with a paucity of high quality clinical data as they attempt to determine the most appropriate course of treatment for patients with LHI, and current stroke guidelines do not provide a detailed approach regarding the day-to-day management of these complicated patients. To address this need, the Neurocritical Care Society organized an international multidisciplinary consensus conference on the critical care management of LHI. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. The panel devised a series of clinical questions related to LHI, and assessed the quality of data related to these questions using the Grading of Recommendation Assessment, Development and Evaluation guideline system. They then developed recommendations (denoted as strong or weak) based on the quality of the evidence, as well as the balance of benefits and harms of the studied interventions, the values and preferences of patients, and resource considerations.
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Affiliation(s)
- Michel T Torbey
- Cerebrovascular and Neurocritical Care Division, Department of Neurology and Neurosurgery, The Ohio State University Wexner Medical Center Comprehensive Stroke Center, 395 W. 12th Avenue, 7th Floor, Columbus, OH, 43210, USA,
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Abstract
PURPOSE OF REVIEW Large hemispheric infarction is a devastating disease that continues to be associated with significant mortality and morbidity. Most often these patients are admitted to the ICU requiring significant physician and nursing resources. This review will address some of the ICU management issues and review the evidence supporting medical and surgical management of malignant cerebral edema. RECENT FINDINGS The most recent changes in management of large hemispheric infarct include the American Heart Association and Neurocritical Care Guidelines. These guidelines address airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In addition, they addressed the indication for surgical management of cerebral edema. We review the recent guidelines updates and trials of surgical management of large hemispheric infarcts. SUMMARY Large hemispheric infarcts continue to have significant morbidity and mortality. Recent guidelines have provided an excellent framework to help intensivists manage these complicated patients. Recent surgical data continue to support early hemicraniectomy even in elderly patients.
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Maciel CB, Sheth KN. Malignant MCA Stroke: an Update on Surgical Decompression and Future Directions. Curr Atheroscler Rep 2015; 17:40. [DOI: 10.1007/s11883-015-0519-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Rostami E. Glucose and the injured brain-monitored in the neurointensive care unit. Front Neurol 2014; 5:91. [PMID: 24936196 PMCID: PMC4047514 DOI: 10.3389/fneur.2014.00091] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/23/2014] [Indexed: 12/16/2022] Open
Abstract
Brain has a continuous demand for energy that is met by oxidative metabolism of oxygen and glucose. This demand is compromised in the injured brain and if the inadequate supply persists it will lead to permanent tissue damage. Zero values of cerebral glucose have been associated with infarction and poor neurological outcome. Furthermore, hyperglycemia is common in patients with neurological insults and associated with poor outcome. Intensive insulin therapy (IIT) to control blood glucose has been suggested and used in neurointensive care with conflicting results. This review covers the studies reporting on monitoring of cerebral glucose with microdialysis in patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH) and ischemic stroke. Studies investigating IIT are also discussed. Available data suggest that low cerebral glucose in patients with TBI and SAH provides valuable information on development of secondary ischemia and has been correlated with worse outcome. There is also indication that the location of the catheter is important for correlation between plasma and brain glucose. In conclusion considering catheter location, monitoring of brain glucose in the neurointensive care not only provides information on imminent secondary ischemia it also reveals the effect of peripheral treatment on the injured brain.
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Affiliation(s)
- Elham Rostami
- Department of Neuroscience, Section of Neurosurgery, Uppsala University , Uppsala , Sweden ; Department of Neuroscience, Karolinska Institutet , Stockholm , Sweden
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15
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The intensive care management of acute ischemic stroke: an overview. Intensive Care Med 2014; 40:640-53. [DOI: 10.1007/s00134-014-3266-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/11/2014] [Indexed: 01/21/2023]
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16
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Larach DB, Kofke WA, Le Roux P. Potential non-hypoxic/ischemic causes of increased cerebral interstitial fluid lactate/pyruvate ratio: a review of available literature. Neurocrit Care 2012; 15:609-22. [PMID: 21336786 DOI: 10.1007/s12028-011-9517-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Microdialysis, an in vivo technique that permits collection and analysis of small molecular weight substances from the interstitial space, was developed more than 30 years ago and introduced into the clinical neurosciences in the 1990s. Today cerebral microdialysis is an established, commercially available clinical tool that is focused primarily on markers of cerebral energy metabolism (glucose, lactate, and pyruvate) and cell damage (glycerol), and neurotransmitters (glutamate). Although the brain comprises only 2% of body weight, it consumes 20% of total body energy. Consequently, the ability to monitor cerebral metabolism can provide significant insights during clinical care. Measurements of lactate, pyruvate, and glucose give information about the comparative contributions of aerobic and anaerobic metabolisms to brain energy. The lactate/pyruvate ratio reflects cytoplasmic redox state and thus provides information about tissue oxygenation. An elevated lactate pyruvate ratio (>40) frequently is interpreted as a sign of cerebral hypoxia or ischemia. However, several other factors may contribute to an elevated LPR. This article reviews potential non-hypoxic/ischemic causes of an increased LPR.
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Affiliation(s)
- Daniel B Larach
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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17
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18
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Initial hyperlactatemia in the ED is associated with poor outcome in patients with ischemic stroke. Am J Emerg Med 2012; 30:449-55. [DOI: 10.1016/j.ajem.2011.12.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 12/13/2011] [Accepted: 12/13/2011] [Indexed: 01/18/2023] Open
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Zhang X, Liu L, Zhang X, Ma K, Rao Y, Zhao Q, Li F. Analytical methods for brain targeted delivery system in vivo: perspectives on imaging modalities and microdialysis. J Pharm Biomed Anal 2011; 59:1-12. [PMID: 22088476 DOI: 10.1016/j.jpba.2011.08.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 08/29/2011] [Accepted: 08/29/2011] [Indexed: 01/05/2023]
Abstract
Since the introduction of microdialysis in 1974, the semi-invasive analytical method has grown exponentially. Microdialysis is one of the most potential analysis technologies of pharmacological drug delivery to the brain. In recent decades, analysis of chemicals targeting the brain has led to many improvements. It seems likely that fluorescence imaging was limited to ex vivo and in vitro applications with the exception of several intravital microscopy and photographic imaging approaches. X-ray computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) have been commonly utilized for visualization of distribution and therapeutic effects of drugs. The efficient analytical methods for studies of brain-targeting delivery system is a major challenge in detecting the disposition as well as the variances of the factors that regulate the substances delivery into the brain. In this review, we highlight some of the ongoing trends in imaging modalities and the most recent developments in the field of microdialysis of live animals and present insights into exploiting brain disease for therapeutic and diagnostics purpose.
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Affiliation(s)
- Xingguo Zhang
- College of Pharmaceutical Science, Zhejiang Chinese Medical University, Hangzhou 310053, China
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20
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Su CK, Sun YC, Tzeng SF, Yang CS, Wang CY, Yang MH. In vivo monitoring of the transfer kinetics of trace elements in animal brains with hyphenated inductively coupled plasma mass spectrometry techniques. MASS SPECTROMETRY REVIEWS 2010; 29:392-424. [PMID: 19437493 DOI: 10.1002/mas.20240] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The roles of metal ions to sustain normal function and to cause dysfunction of neurological systems have been confirmed by various studies. However, because of the lack of adequate analytical method to monitor the transfer kinetics of metal ions in the brain of a living animal, research on the physiopathological roles of metal ions in the CNS remains in its early stages and more analytical efforts are still needed. To explicitly model the possible links between metal ions and physiopathological alterations, it is essential to develop in vivo monitoring techniques that can bridge the gap between metalloneurochemistry and neurophysiopathology. Although inductively coupled plasma mass spectrometry (ICP-MS) is a very powerful technique for multiple trace element analyses, when dealing with chemically complex microdialysis samples, the detection capability is largely limited by instrumental sensitivity, selectivity, and contamination that arise from the experimental procedure. As a result, in recent years several high efficient and clean on-line sample pretreatment systems have been developed and combined with microdialysis and ICP-MS for the continuous and in vivo determination of the concentration-time profiles of metal ions in the extracellular space of rat brain. This article reviews the research relevant to the development of analytical techniques for the in vivo determination of dynamic variation in the concentration levels of metal ions in a living animal.
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Affiliation(s)
- Cheng-Kuan Su
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
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21
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Poca MA, Benejam B, Sahuquillo J, Riveiro M, Frascheri L, Merino MA, Delgado P, Alvarez-Sabin J. Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful? J Neurosurg 2010; 112:648-57. [DOI: 10.3171/2009.7.jns081677] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intracranial pressure (ICP) monitoring is increasingly used in the treatment of patients with malignant middle cerebral artery (MCA) infarction. However, neurological deterioration may exist independent from intracranial hypertension. This study aimed to present the findings of continuous ICP monitoring in a cohort of patients with malignant MCA infarction and to correlate these findings with clinical and radiological features.
Methods
The authors studied a prospective cohort of 25 patients with malignant MCA infarction consecutively admitted to the neurotrauma intensive care unit of the Vall d'Hebron University Hospital between March 2002 and September 2006. The patients were treated using a combined protocol of initial moderate hypothermia and hemicraniectomy. The latter was performed when patients showed a midline shift (MLS) ≥ 5 mm or ICP > 20 mm Hg. Six patients had an MLS ≥ 5 mm on the first CT scan and underwent surgery without prior ICP monitoring. This study focuses on the subgroup of 19 patients who underwent intraparenchymatous ICP monitoring before surgery.
Results
Intracranial pressure readings were evaluated and correlated with pupillary abnormalities, MLS, and ischemic tissue volume. In 12 of the 19 patients, ICP values were always ≤ 20 mm Hg, despite a mean (± SD) MLS of 6.7 ± 2 mm and a mean ischemic tissue volume of 241.3 ± 83 cm3. In 2 patients with anisocoria, ICP values were also normal.
Conclusions
In patients with a malignant MCA infarction, pupillary abnormalities and severe brainstem compression may be present despite normal ICP values. Therefore, continuous ICP monitoring cannot substitute for close clinical and radiological follow-up in the management of these patients.
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Affiliation(s)
- Maria Antonia Poca
- 1Department of Neurosurgery,
- 2Neurotraumatology-Neurosurgery Research Unit,
| | | | - Juan Sahuquillo
- 1Department of Neurosurgery,
- 2Neurotraumatology-Neurosurgery Research Unit,
| | | | | | | | - Pilar Delgado
- 5Neurovascular Unit and Neurology Department, Vall d'Hebron University Hospital, Institut Recerca Vall d'Hebron, Autonomous University of Barcelona, Spain
| | - Jose Alvarez-Sabin
- 5Neurovascular Unit and Neurology Department, Vall d'Hebron University Hospital, Institut Recerca Vall d'Hebron, Autonomous University of Barcelona, Spain
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Abstract
INTRODUCTION Cerebral microdialysis is a relatively new, minimally invasive technique that permits sampling and analyzing the chemical constituents of the extracellular fluid. Although mainly used as a research tool, it is also used in the neurointensive care, in combination with other monitoring methods, in patients with severe traumatic brain injury and subarachnoid hemorrhage. Its main clinical utility is the identification of markers of ischemia and cell damage with the ultimate goal of preventing any secondary insults to the brain by instituting early appropriate treatment measures. With few exceptions, all the available data on intracerebral microdialysis in humans comes from studies performed in adults. OBJECTIVE The purpose of this report is to provide a brief review of the intracerebral microdialysis studies performed in children. CONCLUSION Differences in trends of concentrations of structural and excitatory amino acids have been identified in children, in comparison to those observed in adults, the significance of which remains unknown at present.
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Abstract
PURPOSE OF REVIEW This review highlights recent advances in cerebral microdialysis for investigational and clinical neurochemical monitoring in patients with critical neurological conditions. RECENT FINDINGS Use of microdialysis with other methods, including PET, electrophysiological monitoring and brain tissue oximetry in traumatic brain injury, subarachnoid hemorrhage with vasospasm, and infarction with refractory increased intracranial pressure have been reported. Potentially adverse neurochemical effects of nonconvulsive status epilepticus and cortical slow depolarization waves, both of which are increasingly recognized in traumatic brain injury and stroke patients, have been reported. The explosive growth in the use of cerebral oximetry with targeted management of brain tissue oxygen levels is leading to greater understanding of derangements of cerebral bioenergetics in the critically ill brain, but there remain unresolved basic issues. Understanding of the analytes that are measurable at the bedside - glucose, lactate, pyruvate, glutamate and glycerol - continues to evolve with glucose, lactate, pyruvate and the lactate-pyruvate ratio taking center stage. Analytes including inflammatory biomarkers such as cytokines and metabolites of nitric oxide are presently investigational, but hold promise for future application in advancing our understanding of basic pathophysiology, therapeutic target selection and prognostication. Growing consensus on indications for use of clinical microdialysis and advances in commercially available equipment continue to make microdialysis increasingly 'ready for prime time.' SUMMARY Cerebral microdialysis is an established tool for neurochemical research in the ICU. This technique cannot be fruitfully used in isolation, but when combined with other monitoring methods provides unique insights into the biochemical and physiological derangements in the injured brain.
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Brouns R, De Deyn PP. The complexity of neurobiological processes in acute ischemic stroke. Clin Neurol Neurosurg 2009; 111:483-95. [PMID: 19446389 DOI: 10.1016/j.clineuro.2009.04.001] [Citation(s) in RCA: 372] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Revised: 04/04/2009] [Accepted: 04/06/2009] [Indexed: 01/24/2023]
Abstract
There is an urgent need for improved diagnostics and therapeutics for acute ischemic stroke. This is the focus of numerous research projects involving in vitro studies, animal models and clinical trials, all of which are based on current knowledge of disease mechanisms underlying acute focal cerebral ischemia. Insight in the chain of events occurring during acute ischemic injury is essential for understanding current and future diagnostic and therapeutic approaches. In this review, we summarize the actual knowledge on the pathophysiology of acute ischemic stroke. We focus on the ischemic cascade, which is a complex series of neurochemical processes that are unleashed by transient or permanent focal cerebral ischemia and involves cellular bioenergetic failure, excitotoxicity, oxidative stress, blood-brain barrier dysfunction, microvascular injury, hemostatic activation, post-ischemic inflammation and finally cell death of neurons, glial and endothelial cells.
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Affiliation(s)
- R Brouns
- Department of Neurology and Memory Clinic, Middelheim General Hospital, Antwerp, Belgium
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25
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Berger C, Kiening K, Schwab S. Neurochemical monitoring of therapeutic effects in large human MCA infarction. Neurocrit Care 2009; 9:352-6. [PMID: 18415031 DOI: 10.1007/s12028-008-9093-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Cerebral microdialysis is an invasive monitoring tool allowing analysis of various substances derived from the extracellular space in brain tissue such as glutamate, glycerol, lactate, and pyruvate. In order to assess the potential effects of hemicraniectomy, hypothermia and conservative therapy on these substances, we used neurochemical monitoring with microdialysis in large human stroke patients. METHODS This is an open, prospective observational study in 24 patients with large MCA infarction undergoing either hypothermia (33 degrees C), hemicraniectomy, or maximum conservative therapy. Microdialysis probe placement was aimed at the peri-infarct tissue within 24 h after stroke onset. Glutamate, glycerol, pyruvate, and lactate were analyzed every 60 min. Measurements of two consecutive days were pooled for statistical analysis. RESULTS Average glutamate concentrations in patients treated with hemicraniectomy (5.3 +/- 0.5 micromol/l, P < 0.0001; n = 6) and hypothermia (14.5 +/- 3.6 micromol/l, P < 0.0001; n = 14) were significantly lower than in conservatively treated patients (68.3 +/- 5.2 micromol/l; n = 4). Glycerol concentration was significantly lower in patients treated by hypothermia (111 +/- 17 micromol/l; P < 0.0001) and hemicraniectomy (138 +/- 8 micromol/l; P < 0.0001) as compared to conservatively treated patients with 612 +/- 27 micromol/l. The lactate-pyruvate ratio was significantly lower both in the hypothermia (16.2 +/- 3.3) and hemicraniectomy groups (31.3 +/- 1.5) than in the conservative treatment group (56 +/- 2.9). CONCLUSION Microdialysis allows bed-side monitoring of neuroprotective effects of stroke rescue therapies such as hypothermia and hemicraniectomy. Rescue of peri-infarct tissue and/or prevention of secondary ischemic injury could be associated with a lower mortality in invasively treated patients.
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Affiliation(s)
- C Berger
- Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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26
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Brouns R, Sheorajpanday R, Wauters A, De Surgeloose D, Mariën P, De Deyn PP. Evaluation of lactate as a marker of metabolic stress and cause of secondary damage in acute ischemic stroke or TIA. Clin Chim Acta 2008; 397:27-31. [DOI: 10.1016/j.cca.2008.07.016] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Revised: 07/10/2008] [Accepted: 07/10/2008] [Indexed: 11/16/2022]
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Brain metabolic and hemodynamic effects of cyclosporin A after human severe traumatic brain injury: a microdialysis study. Acta Neurochir (Wien) 2008; 150:1019-31; discussion 1031. [PMID: 18781275 DOI: 10.1007/s00701-008-0021-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Accepted: 07/18/2008] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mitochondrial dysfunction is a major limiting factor in neuronal recovery following traumatic brain injury. Cyclosporin A (CsA) has been recently proposed for use in the early phase after severe head injury, for its ability to preserve mitochondrial bioenergetic state, potentially exerting a neuroprotective effect. The aim of this study was, therefore, to evaluate the effect of CsA on brain energy metabolism, as measured by cerebral microdialysis, and on cerebral hemodynamics, in a group of severely head injured patients. METHODS Fifty adult patients with a severe head injury were enrolled in this randomized, double-blind, placebo-controlled study. Patients received 5 mg/kg of CsA over 24 h, or placebo, within 12 h of the injury. A microdialysis probe was placed in all patients, who were managed according to standard protocols for the treatment of severe head injury. FINDINGS The most robust result of this study was that, over most of the monitoring period, brain dialysate glucose was significantly higher in the CsA treated patients than in placebo. Both lactate and pyruvate were also significantly higher in the CsA group. Glutamate concentration and lactate/pyruvate ratio were significantly higher in the placebo group than in CsA treated patients, respectively 1 to 2 days, and 2 to 3 days after the end of the 24-h drug infusion. The administration of CsA was also associated with a significant increase in mean arterial pressure (MAP) and cerebral perfusion pressure (CPP). CONCLUSIONS The administration of CsA in the early phase after head injury resulted in significantly higher extracellular fluid glucose and pyruvate, which may be evidence of a beneficial effect. The early administration of CsA was also associated with a significant increase in MAP and CPP and such a potentially beneficial hemodynamic effect might contribute to a neuroprotective effect.
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Jaramillo A, Illanes S, Díaz V. Is hypothermia useful in malignant ischemic stroke? Current status and future perspectives. J Neurol Sci 2008; 266:1-8. [DOI: 10.1016/j.jns.2007.08.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 08/21/2007] [Accepted: 08/27/2007] [Indexed: 11/16/2022]
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Abstract
Multimodality monitoring of cerebral physiology encompasses the application of different monitoring techniques and integration of several measured physiologic and biochemical variables into assessment of brain metabolism, structure, perfusion, and oxygenation status. Novel monitoring techniques include transcranial Doppler ultrasonography, neuroimaging, intracranial pressure, cerebral perfusion, and cerebral blood flow monitors, brain tissue oxygen tension monitoring, microdialysis, evoked potentials, and continuous electroencephalogram. Multimodality monitoring enables immediate detection and prevention of acute neurologic injury as well as appropriate intervention based on patients' individual disease states in the neurocritical care unit. Real-time analysis of cerebral physiologic, metabolic, and cardiovascular parameters simultaneously has broadened knowledge about complex brain pathophysiology and cerebral hemodynamics. Integration of this information allows for more precise diagnosis and optimization of management of patients with brain injury.
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Affiliation(s)
- Katja Elfriede Wartenberg
- Neurological Intensive Care Unit, New York Presbyterian Hospital, Columbia University Medical Center, 710 W. 168th Street, New York, NY 10032, USA
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Li D, Shao Z, Hoek TLV, Brorson JR. Reperfusion accelerates acute neuronal death induced by simulated ischemia. Exp Neurol 2007; 206:280-7. [PMID: 17599834 PMCID: PMC3648807 DOI: 10.1016/j.expneurol.2007.05.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Revised: 04/12/2007] [Accepted: 05/11/2007] [Indexed: 10/23/2022]
Abstract
Observations in real time can provide insights into the timing of injury and the mechanisms of damage in neural ischemia-reperfusion. Continuous digital imaging of morphology and cell viability was applied in a novel model of simulated ischemia-reperfusion in cultured cortical neurons, consisting of exposure to severe hypoxia combined with glucose deprivation, mild acidosis, hypercapnia, and elevated potassium, followed by return of oxygenated, glucose-containing physiological saline. Substantial acute injury resulted following 1 h of simulated ischemia, with 36+/-8% neurons dying within 2 h of reperfusion. Inclusion of moderate glutamate elevation (30 microM) in the simulation of ischemia increased the acute neuronal death to 51+/-6% at 2 h of reperfusion. While some swelling and neuritic breakdown occurred during ischemia, particularly with inclusion of glutamate, neuronal death, as marked by loss of somatic membrane integrity, was entirely restricted to the reperfusion phase. Morphological and cytoskeletal changes suggested a predominance of necrotic death in the acute phase of reperfusion, with more complete delayed death accompanied by some apoptotic features occurring over subsequent days. Prolonged simulated ischemia, without reperfusion, did not induce significant acute neuronal death even when extended to 3 h. We conclude that while morphological changes suggesting initiation of neuronal injury appear during severe simulated ischemia, the irreversible injury signaled by membrane breakdown is accelerated by the events of reperfusion itself.
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Affiliation(s)
- Dongdong Li
- Department of Neurology, The University of Chicago
| | - Zuohui Shao
- Department of Medicine, The University of Chicago
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31
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Mazzeo AT, Kunene NK, Choi S, Gilman C, Bullock RM. Quantitation of ischemic events after severe traumatic brain injury in humans: a simple scoring system. J Neurosurg Anesthesiol 2006; 18:170-8. [PMID: 16799343 DOI: 10.1097/01.ana.0000210999.18033.f6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cerebral ischemia is recognized as one of the most important mechanisms responsible for secondary brain damage following severe traumatic brain injury (TBI), contributing to an increased mortality and a worse neurologic outcome. METHOD A simple 5-item scoring system, taking into account the occurrence of specific potentially brain-damaging events (hypoxemia, hypotension, low cerebral blood flow, herniation, and low cerebral perfusion pressure) has been tested in a large population of severe TBI patients. Aims of this retrospective study were to validate the ability of the proposed ischemic score to predict neurologic outcome and to correlate the ischemic score with the results of microdialysis-based neurochemical monitoring and brain tissue oxygen monitoring. FINDINGS In a population of 172 severe TBI patients, a significant correlation was found between ischemic score and neurologic outcome, both at 3 months (r = -0.32; P < 0.01) and at 6 months (r = -0.31; P < 0.01). Significant correlations were also found with the most important neurochemical analytes. CONCLUSIONS The ischemic score proposed here, may be determined during the acute intensive care unit period, and correlates closely with outcome, which can only be determined 3 to 6 months, after injury. It also shows a correlation with neurochemical analytes.
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Affiliation(s)
- Anna Teresa Mazzeo
- Department of Neurosurgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, 23219, USA.
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Abstract
Multimodality monitoring of cerebral physiology encompasses the application of different monitoring techniques and integration of several measured physiological and biochemical variables into the assessment of brain metabolism, structure, perfusion and oxygenation status, in addition to clinical evaluation. Novel monitoring techniques include transcranial Doppler ultrasonography, neuroimaging, intracranial pressure, cerebral perfusion and cerebral blood flow monitors, brain tissue oxygen tension monitoring, microdialysis, evoked potentials and continuous electroencephalography. Multimodality monitoring enables the immediate detection and prevention of acute neurological events, as well as appropriate intervention based on a patient’s individual disease state in the neurocritical care unit. Simultaneous real-time analysis of cerebral physiological, metabolic and cardiovascular parameters has broadened knowledge regarding complex brain pathophysiology and cerebral hemodynamics. Integration of this information allows for a more precise diagnosis and optimization of management of patients with brain injury.
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Affiliation(s)
- Katja Elfriede Wartenberg
- Columbia University, Division of Stroke and Critical Care, Neurological Institute, 710 West 168th Street, NY 10032, USA
| | - J Michael Schmidt
- Columbia University, Division of Stroke and Critical Care, Neurological Institute, 710 W, 168th Street, NY 10032, USA
| | - Derk W Krieger
- Cleveland Clinic Foundation, Section of Stroke and Neurologic Intensive Care, Department of Neurology, S91, 9500 Euclid Avenue, OH 44195, USA
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Cantais E, Boret H, Carre E, Pernod G. Utilisation clinique du monitorage biochimique cérébral par microdialyse : revue de la littérature. ACTA ACUST UNITED AC 2006; 25:20-8. [PMID: 16226865 DOI: 10.1016/j.annfar.2005.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2005] [Accepted: 05/25/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To review the current data on clinical bedside use of cerebral microdialysis. DATA SOURCE Search through Medline database of articles in French and English (keywords: microdialysis, cerebral ischaemia, head trauma, subarachnoid haemorrhage, clinical study). STUDY SELECTION All clinical articles published between 1995 and 2005, including original papers and some case reports. DATA SYNTHESIS Microdialysis after occlusive stroke has shown elevated levels of glutamate and lactate. When space-occupying oedema develops, biochemistry abnormalities occur first, before ICP increases. Bedside microdialysis appears to be a sensitive and earlier indicator of space occupying oedema. Most Accurate markers to monitor ischaemia induced by vasospasm are glutamate and lactate/pyruvate ratio. These markers are earlier than clinical abnormalities or pressure measurements (sensibility 82%, specificity 89%). In the field of head trauma, the same compounds were utilised. The level of these compounds correlates with outcome in a different manner whether the area studied is close to a concussion or not. Most of biochemical events are linked to global cerebral ischaemia. We can observe some abnormalities limited to the pericontusional area, which are not detected by the global monitoring. Microdialysis appears a useful tool to investigate disease mechanisms but cannot be recommended for a widespread use after head trauma. CONCLUSION Bedside cerebral microdialysis allows clinical decisions in the setting of subarachnoid haemorrhage and ischaemic stroke. It represents a valuable tool to investigate head trauma pathophysiology.
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Affiliation(s)
- E Cantais
- Service de réanimation, HIA Sainte-Anne, 83800 Toulon, France.
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Miller CM, Vespa P. Intensive care of the acute stroke patient. Tech Vasc Interv Radiol 2005; 8:92-102. [PMID: 16194757 DOI: 10.1053/j.tvir.2005.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Advances in the diagnosis, monitoring, and treatment of stroke have led to the development of specialized units capable of employing new technologies for acute stroke care. This new approach to treatment of the stroke patient has resulted in improved clinical outcomes and a better understanding of the factors that contribute to neurological recovery. Intensive monitoring after treatment, management of medical comorbidities, anticipation of known complications, and prompt treatment of a worsening condition each contribute toward this higher standard of care. While improved outcomes are associated with care in a dedicated stroke unit, many of the therapies employed have not been rigidly tested in randomized controlled trials. The stroke unit creates a unique environment for research and holds an academic responsibility to continue to validate its treatment and explore innovative therapies for treatment of acute stroke. The goal of this article is to discuss the current care of the acute stroke patient and to introduce novel therapies currently being investigated.
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Affiliation(s)
- Chad M Miller
- UCLA Medical Center, Division of Neurosurgery, Department of Neurology, Los Angeles, California 90095-7039, USA.
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35
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Fraser JF, Hartl R. Decompressive craniectomy as a therapeutic option in the treatment of hemispheric stroke. Curr Atheroscler Rep 2005; 7:296-304. [PMID: 15975323 DOI: 10.1007/s11883-005-0022-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Even though severe hemispheric stroke represents a small subtype of ischemic stroke, the extreme morbidity and mortality necessitate aggressive management strategies to improve outcome. Decompressive craniectomy is an important therapeutic tool with demonstrated effects in significantly reducing intracranial hypertension and mortality from herniation related to cerebral edema and elevated intracranial pressure. Its effect on functional outcome and quality of life varies, but there is evidence to suggest beneficial effects in younger patients and in patients treated earlier. Although more prospective data are required to further identify specific indications for the procedure, it represents an important tool in treatment of nondominant hemispheric stroke.
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Affiliation(s)
- Justin F Fraser
- Department of Neurological Surgery, New York Presbyterian Hospital--Weill Cornell Medical Center, New York, NY 10021, USA
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Hillered L, Vespa PM, Hovda DA. Translational neurochemical research in acute human brain injury: the current status and potential future for cerebral microdialysis. J Neurotrauma 2005; 22:3-41. [PMID: 15665601 DOI: 10.1089/neu.2005.22.3] [Citation(s) in RCA: 223] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Microdialysis (MD) was introduced as an intracerebral sampling method for clinical neurosurgery by Hillered et al. and Meyerson et al. in 1990. Since then MD has been embraced as a research tool to measure the neurochemistry of acute human brain injury and epilepsy. In general investigators have focused their attention to relative chemical changes during neurointensive care, operative procedures, and epileptic seizure activity. This initial excitement surrounding this technology has subsided over the years due to concerns about the amount of tissue sampled and the complicated issues related to quantification. The interpretation of mild to moderate MD fluctuations in general remains an issue relating to dynamic changes of the architecture and size of the interstitial space, blood-brain barrier (BBB) function, and analytical imprecision, calling for additional validation studies and new methods to control for in vivo recovery variations. Consequently, the use of this methodology to influence clinical decisions regarding the care of patients has been restricted to a few institutions. Clinical studies have provided ample evidence that intracerebral MD monitoring is useful for the detection of overt adverse neurochemical conditions involving hypoxia/ischemia and seizure activity in subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), thromboembolic stroke, and epilepsy. There is some data strongly suggesting that MD changes precede the onset of secondary neurological deterioration following SAH, hemispheric stroke, and surges of increased ICP in fulminant hepatic failure. These promising investigations have relied on MD-markers for disturbed glucose metabolism (glucose, lactate, and pyruvate) and amino acids. Others have focused on trying to capture other important neurochemical events, such as excitotoxicity, cell membrane degradation, reactive oxygen species (ROS) and nitric oxide (NO) formation, cellular edema, and BBB dysfunction. However, these other applications need additional validation. Although these cerebral events and their corresponding changes in neurochemistry are important, other promising MD applications, as yet less explored, comprise local neurochemical provocations, drug penetration to the human brain, MD as a tool in clinical drug trials, and for studying the proteomics of acute human brain injury. Nevertheless, MD has provided new important insights into the neurochemistry of acute human brain injury. It remains one of very few methods for neurochemical measurements in the interstitial compartment of the human brain and will continue to be a valuable translational research tool for the future. Therefore, this technology has the potential of becoming an established part of multimodality neuro-ICU monitoring, contributing unique information about the acute brain injury process. However, in order to reach this stage, several issues related to quantification and bedside presentation of MD data, implantation strategies, and quality assurance need to be resolved. The future success of MD as a diagnostic tool in clinical neurosurgery depends heavily on the choice of biomarkers, their sensitivity, specificity, and predictive value for secondary neurochemical events, and the availability of practical bedside methods for chemical analysis of the individual markers. The purpose of this review was to summarize the results of clinical studies using cerebral MD in neurosurgical patients and to discuss the current status of MD as a potential method for use in clinical decision-making. The approach was to focus on adverse neurochemical conditions in the injured human brain and the MD biomarkers used to study those events. Methodological issues that appeared critical for the future success of MD as a routine intracerebral sampling method were addressed.
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Affiliation(s)
- Lars Hillered
- Division of Neurosurgery, Department of Surgery, The David Geffen UCLA School of Medicine, Los Angeles, California, USA.
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Toyota S, Graf R, Valentino M, Yoshimine T, Heiss WD. Prediction of malignant infarction: perifocal neurochemical monitoring following prolonged MCA occlusion in cats. ACTA NEUROCHIRURGICA. SUPPLEMENT 2004; 86:153-7. [PMID: 14753424 DOI: 10.1007/978-3-7091-0651-8_32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
Neurochemical monitoring in the ischemic core predicts malignancy in focal ischemia in cats. Since perifocal regions are more suitable for clinical microdialysis (MD) applications, we tested whether monitoring at such site predicts also malignancy.--Laser Doppler (LD) probes, pressure microsensors, and MD/HPLC measured cerebral blood flow (CBF), intracranial pressure (ICP), and extracellular glutamate (Glu), respectively. The middle cerebral artery was occluded (MCAO) for 3 hours followed by 6 hours reperfusion. Additionally, LD measured CBF in ischemic core.--MCAO reduced CBF in the core in all below 25% of control. In animals exhibiting malignancy (eye dilatation during reperfusion), MCAO decreased CBF in the perifocal site to around 35%. CBF primarily recovered following recirculation but decreased thereafter as ICP rose due to progressive edema formation. Glu increased concomitantly. In cats exhibiting a benign course, MCAO decreased CBF in the perifocal site to around 55%. Recirculation normalized CBF, and Glu did not increase. During MCAO, Glu differences between both groups were not significant.--Glu determinations in perifocal sites taken during MCAO do not predict fatal outcome. This contrasts with determinations in the core. After reperfusion, Glu elevation in perifocal sites may serve as a rather late predictor of malignancy.
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Affiliation(s)
- S Toyota
- Max-Planck Institut für neurologische Forschung, Köln, Germany
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Cerebral Infarction: Surgical Treatment. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50084-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Pokela M, Romsi P, Biancari F, Kiviluoma K, Vainionpää V, Heikkinen J, Rönkä E, Kaakinen T, Hirvonen J, Rimpiläinen J, Anttila V, Leo E, Juvonen T. Increase of intracranial pressure after hypothermic circulatory arrest in a chronic porcine model. SCAND CARDIOVASC J 2002; 36:302-7. [PMID: 12470399 DOI: 10.1080/140174302320774528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE An increase in intracranial pressure has been shown to threaten the outcome of patients with ischemic or traumatic brain injury. Its impact on the outcome of pigs undergoing hypothermic circulatory arrest has been evaluated in this study. DESIGN Fifty-six pigs underwent a 75-min period of hypothermic circulatory arrest at 20 degrees C. Intracranial pressure, cerebral microdialysis, hemodynamic and metabolic parameters were monitored throughout the experiment. The animals were allowed to survive until the 7th postoperative day and, then, electively killed. RESULTS The 7-day survival rate was 60.7%, and among survivors, 20 of them (58.8%) developed brain infarction. A significant increase in intracranial pressure as compared with the baseline level was observed since the end of cooling (p = 0.047) and the difference became larger during all the postoperative intervals (p < 0.0001). Animals that died postoperatively tended to have higher intracranial pressure levels during all the postoperative intervals, but such a difference reached significance only at the 4-h postoperative interval (p = 0.040). The same tendency was observed among animals that survived until the 7th postoperative day and that developed brain infarction or not, but the difference between these two groups did not reach statistical significance. The animals that died or developed postoperatively brain infarction had higher intracranial pressure values postoperatively as compared with those that survived without developing brain infarction and such a difference reached significance at the 2-h (p = 0.015) and 4-h postoperative intervals (p = 0.035). The peak intracranial pressure was 17.2 mmHg (IQR, 13.7-20.8) in animals that died or developed brain infarction and 14.1 mmHg (IQR, 11.8-16.4) in those that survived 7 days without developing brain infarction (p = NS). CONCLUSION Intracranial pressure increases significantly after 75 min of experimental hypothermic circulatory arrest and such an increase is associated with a high risk of postoperative death and brain infarction.
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Affiliation(s)
- Matti Pokela
- Department of Surgery, University of Oulu, Oulu, Finland
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Abstract
Cerebral microdialysis is a relatively new technique for measuring the levels of brain extracellular chemicals, which to date has predominantly been used as a research tool. This review considers the technical aspects of microdialysis, the importance of the commonly measured chemicals, and the use of microdialysis to monitor patients with ischemic stroke, head injury, and subarachnoid hemorrhage. The advantages and disadvantages of microdialysis are discussed, as is its future potential.
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Abstract
The reduction of blood flow to parts of the brain is the cause of ischemic stroke leading to functional deficits and, if prolonged, to irreversible neurological and morphological defects. The fast reperfusion, therefore is the most important therapeutic strategy and was proven to be effective in clinical trials. Steps to intervene with secondary biochemical, molecular, or inflammatory disturbances were not successful so far. Since direct therapeutic interventions are limited, the general management of the stroke victim is of utmost importance--and was shown to be most successful in dedicated stroke units. Acute therapeutic interventions in ischemic stroke can only be successful as long as tissue in the area of the ischemic compromise is still viable. The area of irreversible damage can be identified and distinguished from the penumbral zone, i.e., tissue with impaired function but preserved morphology by functional imaging modalities, like positron emission tomography (PET) or perfusion-(PW) and diffusion-weighted (DW) magnetic resonance imaging (MRI). In such studies it was demonstrated that a large portion of the final infarct is irreversibly affected in the first few hours in many patients. A considerable tissue volume is viable but critically hypoperfused; a smaller portion of the final infarct is sufficiently perfused and in this area secondary and delayed biochemical and molecular mechanisms contribute to the damage. Based on this concept the improvement of perfusion within the time window of opportunity must be the primary goal in treatment of ischemic stroke, and neuroprotective and other strategies can only play a supportive and additive role. That this is the case can be seen from the results of many controlled therapeutic trials, in which up to now only thrombolytic therapy with a 3 h time window for systemic and a 6 h time window for intraarterial application proved its efficacy, whereas all trials with neuroprotective, anti-inflammatory or anti-apoptotic strategies failed. Since the direct treatment strategies are limited the acute management of stroke victims is of utmost importance: This can be achieved optimally in dedicated stroke units in which the outcome was significantly improved over the regular care. It is still to be investigated if invasive strategies--e.g., craniectomy and hypothermia--or the combination of reperfusion and neuroprotective therapy can improve the outcome after ischemic stroke.
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Affiliation(s)
- W D Heiss
- Max-Planck-Institut für neurologische Forschung and Neurologische Universitätsklinik, Köln, Federal Republic of Germany.
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