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Schmitt R, Qayum S, Pliss A, Kuzmin AN, Muthaiah VPK, Kaliyappan K, Prasad PN, Mahajan SD. Mitochondrial Dysfunction and Apoptosis in Brain Microvascular Endothelial Cells Following Blast Traumatic Brain Injury. Cell Mol Neurobiol 2023; 43:3639-3651. [PMID: 37314617 DOI: 10.1007/s10571-023-01372-2] [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: 04/20/2022] [Accepted: 06/01/2023] [Indexed: 06/15/2023]
Abstract
Blood brain barrier (BBB) breakdown is a key driver of traumatic brain injury (TBI), contributing to prolonged neurological deficits and increased risk of death in TBI patients. Strikingly, the role of endothelium in the progression of BBB breakdown has not been sufficiently investigated, even though it constitutes the bulk of BBB structure. In the current study, we investigate TBI-induced changes in the brain endothelium at the subcellular level, particularly focusing on mitochondrial dysfunction, using a combination of confocal imaging, gene expression analysis, and molecular profiling by Raman spectrometry. Herein, we developed and applied an in-vitro blast-TBI (bTBI) model that employs an acoustic shock tube to deliver injury to cultured human brain microvascular endothelial cells (HBMVEC). We found that this injury results in aberrant expression of mitochondrial genes, as well as cytokines/ inflammasomes, and regulators of apoptosis. Furthermore, injured cells exhibit a significant increase in reactive oxygen species (ROS) and in Ca2+ levels. These changes are accompanied by overall reduction of intracellular proteins levels as well as profound transformations in mitochondrial proteome and lipidome. Finally, blast injury leads to a reduction in HBMVEC cell viability, with up to 50% of cells exhibiting signs of apoptosis following 24 h after injury. These findings led us to hypothesize that mitochondrial dysfunction in HBMVEC is a key component of BBB breakdown and TBI progression.
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Affiliation(s)
- Rebecca Schmitt
- Institute for Lasers, Photonics and Biophotonics, Department of Chemistry, University at Buffalo, The State University of New York, Buffalo, NY, 14260, USA
| | - Sana Qayum
- Department of Medicine, Division of Allergy, Immunology, and Rheumatology, Clinical Translational Research Center, State University of New York at Buffalo, Buffalo, NY, 14203, USA
| | - Artem Pliss
- Institute for Lasers, Photonics and Biophotonics, Department of Chemistry, University at Buffalo, The State University of New York, Buffalo, NY, 14260, USA
| | - Andrey N Kuzmin
- Institute for Lasers, Photonics and Biophotonics, Department of Chemistry, University at Buffalo, The State University of New York, Buffalo, NY, 14260, USA
| | - Vijaya Prakash Krishnan Muthaiah
- Department of Rehabilitation Science, School of Public Health and Health Professions, The State University of New York, 633 Kimball Tower, Buffalo, NY, 14214, USA
| | - Kathiravan Kaliyappan
- Department of Rehabilitation Science, School of Public Health and Health Professions, The State University of New York, 633 Kimball Tower, Buffalo, NY, 14214, USA
| | - Paras N Prasad
- Institute for Lasers, Photonics and Biophotonics, Department of Chemistry, University at Buffalo, The State University of New York, Buffalo, NY, 14260, USA.
| | - Supriya D Mahajan
- Department of Medicine, Division of Allergy, Immunology, and Rheumatology, Clinical Translational Research Center, State University of New York at Buffalo, Buffalo, NY, 14203, USA.
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2
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Bolden CT, Skibber MA, Olson SD, Zamorano Rojas M, Milewicz S, Gill BS, Cox CS. Validation and characterization of a novel blood-brain barrier platform for investigating traumatic brain injury. Sci Rep 2023; 13:16150. [PMID: 37752338 PMCID: PMC10522590 DOI: 10.1038/s41598-023-43214-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 09/21/2023] [Indexed: 09/28/2023] Open
Abstract
The Blood-Brain Barrier (BBB) is a highly-selective physiologic barrier responsible for maintaining cerebral homeostasis. Innovative in vitro models of the BBB are needed to provide useful insights into BBB function with CNS disorders like traumatic brain injury (TBI). TBI is a multidimensional and highly complex pathophysiological condition that requires intrinsic models to elucidate its mechanisms. Current models either lack fluidic shear stress, or neglect hemodynamic parameters important in recapitulating the human in vivo BBB phenotype. To address these limitations in the field, we developed a fluid dynamic novel platform which closely mimics these parameters. To validate our platform, Matrigel-coated Transwells were seeded with brain microvascular endothelial cells, both with and without co-cultured primary human astrocytes and bone-marrow mesenchymal stem cells. In this article we characterized BBB functional properties such as TEER and paracellular permeability. Our platform demonstrated physiologic relevant decreases in TEER in response to an ischemic environment, while directly measuring barrier fluid fluctuation. These recordings were followed with recovery, implying stability of the model. We also demonstrate that our dynamic platform is responsive to inflammatory and metabolic cues with resultant permeability coefficients. These results indicate that this novel dynamic platform will be a valuable tool for evaluating the recapitulating BBB function in vitro, screening potential novel therapeutics, and establishing a relevant paradigm to evaluate the pathophysiology of TBI.
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Affiliation(s)
- Christopher T Bolden
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
| | - Max A Skibber
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Scott D Olson
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Miriam Zamorano Rojas
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Samantha Milewicz
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Brijesh S Gill
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Charles S Cox
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
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3
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Schlotterose L, Beldjilali-Labro M, Hagel M, Yadid M, Flaxer C, Flaxer E, Barnea AR, Hattermann K, Shohami E, Leichtmann-Bardoogo Y, Maoz BM. Inducing Mechanical Stimuli to Tissues Grown on a Magnetic Gel Allows Deconvoluting the Forces Leading to Traumatic Brain Injury. Neurotrauma Rep 2023; 4:560-572. [PMID: 37636339 PMCID: PMC10457614 DOI: 10.1089/neur.2023.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Traumatic brain injury (TBI), which is characterized by damage to the brain resulting from a sudden traumatic event, is a major cause of death and disability worldwide. It has short- and long-term effects, including neuroinflammation, cognitive deficits, and depression. TBI consists of multiple steps that may sometimes have opposing effects or mechanisms, making it challenging to investigate and translate new knowledge into effective therapies. In order to better understand and address the underlying mechanisms of TBI, we have developed an in vitro platform that allows dynamic simulation of TBI conditions by applying external magnetic forces to induce acceleration and deceleration injury, which is often observed in human TBI. Endothelial and neuron-like cells were successfully grown on magnetic gels and applied to the platform. Both cell types showed an instant response to the TBI model, but the endothelial cells were able to recover quickly-in contrast to the neuron-like cells. In conclusion, the presented in vitro model mimics the mechanical processes of acceleration/deceleration injury involved in TBI and will be a valuable resource for further research on brain injury.
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Affiliation(s)
- Luise Schlotterose
- Institute of Anatomy, Kiel University, Kiel, Germany
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | | | - Mario Hagel
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Moran Yadid
- The Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Carina Flaxer
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Eli Flaxer
- AFEKA–Tel-Aviv Academic College of Engineering, Tel-Aviv, Israel
| | - A. Ronny Barnea
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | | | - Esther Shohami
- Institute for Drug Research, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Ben M. Maoz
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
- Institute for Drug Research, The Hebrew University of Jerusalem, Jerusalem, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
- The Center for Nanoscience and Nanotechnology, Tel Aviv University, Tel Aviv, Israel
- Sagol Center for Regenerative Medicine, Tel Aviv University, Tel Aviv, Israel
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4
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Tang Y, Liu Y, Zhou H, Lu H, Zhang Y, Hua J, Liao X. Esketamine is neuroprotective against traumatic brain injury through its modulation of autophagy and oxidative stress via AMPK/mTOR-dependent TFEB nuclear translocation. Exp Neurol 2023; 366:114436. [PMID: 37187276 DOI: 10.1016/j.expneurol.2023.114436] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 05/17/2023]
Abstract
Recent clinical studies highlight the neuroprotective effects of esketamine, but its benefits following traumatic brain injury (TBI) have not been defined. Here, we investigated the effects of esketamine following TBI and its associated neuroprotection mechanisms. In our study, controlled cortical impact injury on mice was utilized to induce the TBI model in vivo. TBI mice were randomized to receive vehicle or esketamine at 2 h post-injury for 7 consecutive days. Neurological deficits and brain water content in mice were detected, respectively. Cortical tissues surrounding focal trauma were obtained for Nissl staining, immunofluorescence, immunohistochemistry, and ELISA assay. In vitro, esketamine were added in culture medium after cortical neuronal cells induced by H2O2 (100μM). After exposed for 12h, neuronal cells were obtained for western blotting, immunofluorescence, ELISA and CO-IP assay. Following administration of 2-8 mg/kg esketamine, we observed that 8 mg/kg esketamine produced no additional recovery of neurological function and ability to alleviate brain edema in TBI mice model, so 4 mg/kg esketamine was selected for subsequent experiments. Additionally, esketamine can effectively reduce TBI-induced oxidative stress, the number of damaged neurons, and the number of TUNEL-positive cells in the cortex of TBI models. Meanwhile, the levels of Beclin 1, LC3 II, and the number of LC3-positive cells in injured cortex were also increased following esketamine exposure. Western blotting and immunofluorescence assays showed that esketamine accelerated the nuclear translocation of TFEB, increased the p-AMPKα level and decreased the p-mTOR level. Similar results including nuclear translocation of TFEB, the increases of autophagy-related markers, and influences of AMPK/mTOR pathway were observed in H2O2-induced cortical neuronal cells; however, BML-275 (AMPK inhibitor) can reverse these effects of esketamine. Furthermore, TFEB silencing not only decreased the Nrf2 level in H2O2-induced cortical neuronal cells, but also alleviated the oxidative stress. Importantly, CO-IP confirmed the interaction between TFEB and Nrf2 in cortical neuronal cells. These findings suggested that esketamine exerts the neuroprotective effects of esketamine in TBI mice model via enhancing autophagy and alleviating oxidative stress; its mechanism involves AMPK/mTOR-dependent TFEB nuclear translocation-induced autophagy and TFEB/Nrf2-induced antioxidant system.
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Affiliation(s)
- Yanbin Tang
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China
| | - Yufang Liu
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China
| | - Huanzhu Zhou
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China; School of Anesthesiology, Xuzhou Medical University, Xuzhou 221004, Jiangsu, China
| | - Haibo Lu
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China
| | - Yafei Zhang
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China
| | - Jun Hua
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China
| | - Xingzhi Liao
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China.
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5
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Pischiutta F, Cavaleiro H, Caruso E, Tribuzio F, Di Marzo N, Moro F, Kobeissy F, Wang KK, Salgado AJ, Zanier ER. A novel organotypic cortical slice culture model for traumatic brain injury: molecular changes induced by injury and mesenchymal stromal cell secretome treatment. Front Cell Neurosci 2023; 17:1217987. [PMID: 37534042 PMCID: PMC10390737 DOI: 10.3389/fncel.2023.1217987] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 06/23/2023] [Indexed: 08/04/2023] Open
Abstract
Traumatic brain injury (TBI) is a major worldwide neurological disorder with no neuroprotective treatment available. Three-dimensional (3D) in vitro models of brain contusion serving as a screening platform for drug testing are lacking. Here we developed a new in vitro model of brain contusion on organotypic cortical brain slices and tested its responsiveness to mesenchymal stromal cell (MSC) derived secretome. A focal TBI was induced on organotypic slices by an electromagnetic impactor. Compared to control condition, a temporal increase in cell death was observed after TBI by propidium iodide incorporation and lactate dehydrogenase release assays up to 48 h post-injury. TBI induced gross neuronal loss in the lesion core, with disruption of neuronal arborizations measured by microtubule-associated protein-2 (MAP-2) immunostaining and associated with MAP-2 gene down-regulation. Neuronal damage was confirmed by increased levels of neurofilament light chain (NfL), microtubule associated protein (Tau) and ubiquitin C-terminal hydrolase L1 (UCH-L1) released into the culture medium 48 h after TBI. We detected glial activation with microglia cells acquiring an amoeboid shape with less ramified morphology in the contusion core. MSC-secretome treatment, delivered 1 h post-injury, reduced cell death in the contusion core, decreased NfL release in the culture media, promoted neuronal reorganization and improved microglia survival/activation. Our 3D in vitro model of brain contusion recapitulates key features of TBI pathology. We showed protective effects of MSC-secretome, suggesting the model stands as a tractable medium/high throughput, ethically viable, and pathomimetic biological asset for testing new cell-based therapies.
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Affiliation(s)
- Francesca Pischiutta
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Helena Cavaleiro
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s–PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Enrico Caruso
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Tribuzio
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Noemi Di Marzo
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
- Centro Ricerca Tettamanti, Clinica Pediatrica, Università di Milano-Bicocca, Fondazione MBBM, Monza, Italy
| | - Federico Moro
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Firas Kobeissy
- Program for Neurotrauma, Neuroproteomics and Biomarkers Research, Departments of Emergency Medicine, Psychiatry, Neuroscience and Chemistry, University of Florida, Gainesville, FL, United States
- Department of Neurobiology, Center for Neurotrauma, Multiomics and Biomarkers (CNMB), Neuroscience Institute, Morehouse School of Medicine, Atlanta, GA, United States
| | - Kevin K. Wang
- Program for Neurotrauma, Neuroproteomics and Biomarkers Research, Departments of Emergency Medicine, Psychiatry, Neuroscience and Chemistry, University of Florida, Gainesville, FL, United States
- Department of Neurobiology, Center for Neurotrauma, Multiomics and Biomarkers (CNMB), Neuroscience Institute, Morehouse School of Medicine, Atlanta, GA, United States
| | - António J. Salgado
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s–PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Elisa R. Zanier
- Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
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6
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Zhao Q, Zhang J, Li H, Li H, Xie F. Models of traumatic brain injury-highlights and drawbacks. Front Neurol 2023; 14:1151660. [PMID: 37396767 PMCID: PMC10309005 DOI: 10.3389/fneur.2023.1151660] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/26/2023] [Indexed: 07/04/2023] Open
Abstract
Traumatic brain injury (TBI) is the leading cause for high morbidity and mortality rates in young adults, survivors may suffer from long-term physical, cognitive, and/or psychological disorders. Establishing better models of TBI would further our understanding of the pathophysiology of TBI and develop new potential treatments. A multitude of animal TBI models have been used to replicate the various aspects of human TBI. Although numerous experimental neuroprotective strategies were identified to be effective in animal models, a majority of strategies have failed in phase II or phase III clinical trials. This failure in clinical translation highlights the necessity of revisiting the current status of animal models of TBI and therapeutic strategies. In this review, we elucidate approaches for the generation of animal models and cell models of TBI and summarize their strengths and limitations with the aim of exploring clinically meaningful neuroprotective strategies.
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Affiliation(s)
- Qinghui Zhao
- Institute of Physical Culture, Huanghuai University, Zhumadian, China
| | - Jianhua Zhang
- Institute of Physical Culture, Huanghuai University, Zhumadian, China
| | - Huige Li
- Institute of Physical Culture, Huanghuai University, Zhumadian, China
| | - Hongru Li
- Zhumadian Central Hospital, Zhumadian, China
| | - Fei Xie
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
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7
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Zargari M, Meyer LJ, Riess ML, Li Z, Barajas MB. P188 Therapy in In Vitro Models of Traumatic Brain Injury. Int J Mol Sci 2023; 24:3334. [PMID: 36834743 PMCID: PMC9961452 DOI: 10.3390/ijms24043334] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/26/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Traumatic brain injury (TBI) is a significant cause of morbidity and mortality worldwide. Varied mechanisms of injury contribute to the heterogeneity of this patient population as demonstrated by the multiple published grading scales and diverse required criteria leading to diagnoses from mild to severe. TBI pathophysiology is classically separated into a primary injury that is characterized by local tissue destruction as a result of the initial blow, followed by a secondary phase of injury constituted by a score of incompletely understood cellular processes including reperfusion injury, disruption to the blood-brain barrier, excitotoxicity, and metabolic dysregulation. There are currently no effective pharmacological treatments in the wide-spread use for TBI, in large part due to challenges associated with the development of clinically representative in vitro and in vivo models. Poloxamer 188 (P188), a Food and Drug Administration-approved amphiphilic triblock copolymer embeds itself into the plasma membrane of damaged cells. P188 has been shown to have neuroprotective properties on various cell types. The objective of this review is to provide a summary of the current literature on in vitro models of TBI treated with P188.
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Affiliation(s)
- Michael Zargari
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | | | - Matthias L. Riess
- TVHS VA Medical Center, Anesthesiology, Nashville, TN 37212, USA
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Pharmacology, Vanderbilt University, Nashville, TN 37232, USA
| | - Zhu Li
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Matthew B. Barajas
- TVHS VA Medical Center, Anesthesiology, Nashville, TN 37212, USA
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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8
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Establishment and Application of a Novel In Vitro Model of Microglial Activation in Traumatic Brain Injury. J Neurosci 2023; 43:319-332. [PMID: 36446585 PMCID: PMC9838700 DOI: 10.1523/jneurosci.1539-22.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/08/2022] [Accepted: 11/17/2022] [Indexed: 12/03/2022] Open
Abstract
Mechanical impact-induced primary injury after traumatic brain injury (TBI) leads to acute microglial pro-inflammatory activation and consequently mediates neurodegeneration, which is a major secondary brain injury mechanism. However, the detailed pathologic cascades have not been fully elucidated, partially because of the pathologic complexity in animal TBI models. Although there are several in vitro TBI models, none of them closely mimic post-TBI microglial activation. In the present study, we aimed to establish an in vitro TBI model, specifically reconstituting the pro-inflammatory activation and associated neurodegeneration following TBI. We proposed three sets of experiments. First, we established a needle scratch injured neuron-induced microglial activation and neurodegeneration in vitro model of TBI. Second, we compared microglial pro-inflammatory cytokines profiles between the in vitro TBI model and TBI in male mice. Additionally, we validated the role of injured neurons-derived damage-associated molecular patterns in amplifying microglial pro-inflammatory pathways using the in vitro TBI model. Third, we applied the in vitro model for the first time to characterize the cellular metabolic profile of needle scratch injured-neuron-activated microglia, and define the role of metabolic reprogramming in mediating pro-inflammatory microglial activation and mediated neurodegeneration. Our results showed that we successfully established a novel in vitro TBI model, which closely mimics primary neuronal injury-triggered microglial pro-inflammatory activation and mediated neurodegeneration after TBI. This in vitro model provides an advanced and highly translational platform for dissecting interactions in the pathologic processes of neuronal injury-microglial activation-neuronal degeneration cascade, and elucidating the detailed underlying cellular and molecular insights after TBI.SIGNIFICANCE STATEMENT Microglial activation is a key component of acute neuroinflammation that leads to neurodegeneration and long-term neurologic outcome deficits after TBI. However, it is not feasible to truly dissect primary neuronal injury-induced microglia activation, and consequently mediated neurodegeneration in vivo Furthermore, there is currently lacking of in vitro TBI models closely mimicking the TBI primary injury-mediated microglial activation. In this study, we successfully established and validated a novel in vitro TBI model of microglial activation, and for the first time, characterized the cellular metabolic profile of microglia in this model. This novel microglial activation in vitro TBI model will help in elucidating microglial inflammatory activation and consequently associated neurodegeneration after TBI.
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9
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Schlotterose L, Beldjilali-Labro M, Schneider G, Vardi O, Hattermann K, Even U, Shohami E, Haustein HD, Leichtmann-Bardoogo Y, Maoz BM. Traumatic Brain Injury in a Well: A Modular Three-Dimensional Printed Tool for Inducing Traumatic Brain Injury In vitro. Neurotrauma Rep 2023; 4:255-266. [PMID: 37095852 PMCID: PMC10122253 DOI: 10.1089/neur.2022.0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Traumatic brain injury (TBI) is a major health problem that affects millions of persons worldwide every year among all age groups, mainly young children, and elderly persons. It is the leading cause of death for children under the age of 16 and is highly correlated with a variety of neuronal disorders, such as epilepsy, and neurodegenerative disease, such as Alzheimer's disease or amyotrophic lateral sclerosis. Over the past few decades, our comprehension of the molecular pathway of TBI has improved, yet despite being a major public health issue, there is currently no U.S. Food and Drug Administration-approved treatment for TBI, and a gap remains between these advances and their application to the clinical treatment of TBI. One of the major hurdles for pushing TBI research forward is the accessibility of TBI models and tools. Most of the TBI models require costume-made, complex, and expensive equipment, which often requires special knowledge to operate. In this study, we present a modular, three-dimensional printed TBI induction device, which induces, by the pulse of a pressure shock, a TBI-like injury on any standard cell-culture tool. Moreover, we demonstrate that our device can be used on multiple systems and cell types and can induce repetitive TBIs, which is very common in clinical TBI. Further, we demonstrate that our platform can recapitulate the hallmarks of TBI, which include cell death, decrease in neuronal functionality, axonal swelling (for neurons), and increase permeability (for endothelium). In addition, in view of the continued discussion on the need, benefits, and ethics of the use of animals in scientific research, this in vitro, high-throughput platform will make TBI research more accessible to other labs that prefer to avoid the use of animals yet are interested in this field. We believe that this will enable us to push the field forward and facilitate/accelerate the availability of novel treatments.
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Affiliation(s)
- Luise Schlotterose
- Institute of Anatomy, Kiel University, Kiel, Germany
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | | | - Gaya Schneider
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Vardi
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | | | - Uzi Even
- School of Chemistry, Tel Aviv University, Tel Aviv, Israel
| | - Esther Shohami
- Institute for Drug Research, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Herman D. Haustein
- School of Mechanical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | | | - Ben M. Maoz
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
- The Center for Nanoscience and Nanotechnology, Tel Aviv University, Tel Aviv, Israel
- Address correspondence to: Ben M. Maoz, PhD, Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, 69978, Israel.
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10
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Kundu S, Singh S. What Happens in TBI? A Wide Talk on Animal Models and Future Perspective. Curr Neuropharmacol 2023; 21:1139-1164. [PMID: 35794772 PMCID: PMC10286592 DOI: 10.2174/1570159x20666220706094248] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/05/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022] Open
Abstract
Traumatic brain injury (TBI) is a global healthcare concern and a leading cause of death. The most common causes of TBI include road accidents, sports injuries, violence in warzones, and falls. TBI induces neuronal cell death independent of age, gender, and genetic background. TBI survivor patients often experience long-term behavioral changes like cognitive and emotional changes. TBI affects social activity, reducing the quality and duration of life. Over the last 40 years, several rodent models have been developed to mimic different clinical outcomes of human TBI for a better understanding of pathophysiology and to check the efficacy of drugs used for TBI. However, promising neuroprotective approaches that have been used preclinically have been found to be less beneficial in clinical trials. So, there is an urgent need to find a suitable animal model for establishing a new therapeutic intervention useful for TBI. In this review, we have demonstrated the etiology of TBI and post- TBI social life alteration, and also discussed various preclinical TBI models of rodents, zebrafish, and drosophila.
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Affiliation(s)
- Satyabrata Kundu
- Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab, India
| | - Shamsher Singh
- Department of Pharmacology, ISF College of Pharmacy, Moga, Punjab, India
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11
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Chari D, Basit R, Wiseman J, Chowdhury F. Simulating traumatic brain injury in vitro: developing high throughput models to test biomaterial based therapies. Neural Regen Res 2023; 18:289-292. [PMID: 35900405 PMCID: PMC9396524 DOI: 10.4103/1673-5374.346465] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Traumatic brain injuries are serious clinical incidents associated with some of the poorest outcomes in neurological practice. Coupled with the limited regenerative capacity of the brain, this has significant implications for patients, carers, and healthcare systems, and the requirement for life-long care in some cases. Clinical treatment currently focuses on limiting the initial neural damage with long-term care/support from multidisciplinary teams. Therapies targeting neuroprotection and neural regeneration are not currently available but are the focus of intensive research. Biomaterial-based interventions are gaining popularity for a range of applications including biomolecule and drug delivery, and to function as cellular scaffolds. Experimental investigations into the development of such novel therapeutics for traumatic brain injury will be critically underpinned by the availability of appropriate high throughput, facile, ethically viable, and pathomimetic biological model systems. This represents a significant challenge for researchers given the pathological complexity of traumatic brain injury. Specifically, there is a concerted post-injury response mounted by multiple neural cell types which includes microglial activation and astroglial scarring with the expression of a range of growth inhibitory molecules and cytokines in the lesion environment. Here, we review common models used for the study of traumatic brain injury (ranging from live animal models to in vitro systems), focusing on penetrating traumatic brain injury models. We discuss their relative advantages and drawbacks for the developmental testing of biomaterial-based therapies.
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12
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Costantini E, Jarlapoodi S, Serra F, Aielli L, Khan H, Belwal T, Falasca K, Reale M. Neuroprotective Potential of Bacopa monnieri: Modulation of Inflammatory Signals. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2023; 22:441-451. [PMID: 35021981 DOI: 10.2174/1871527321666220111124047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/25/2021] [Accepted: 11/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND To date, much evidence has shown the increased interest in natural molecules and traditional herbal medicine as alternative bioactive compounds to fight many inflammatory conditions, both in relation to immunomodulation and in terms of their wound healing potential. Bacopa monnieri is a herb that is used in the Ayurvedic medicine tradition for its anti-inflammatory activity. OBJECTIVE In this study, we evaluate the anti-inflammatory and regenerative properties of the Bacopa monnieri extract (BME) in vitro model of neuroinflammation. METHODS Neuronal SH-SY5Y cells were stimulated with TNFα and IFNγ and used to evaluate the effect of BME on cell viability, cytotoxicity, cytokine gene expression, and healing rate. RESULTS Our results showed that BME protects against the Okadaic acid-induced cytotoxicity in SH-SY5Y cells. Moreover, in TNFα and IFNγ primed cells, BME reduces IL-1β, IL-6, COX-2, and iNOS, mitigates the mechanical trauma injury-induced damage, and accelerates the healing of wounds. CONCLUSION This study indicates that BME might become a promising candidate for the treatment of neuroinflammation.
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Affiliation(s)
- Erica Costantini
- Department of Medicine and Science of Aging, University "G.d'Annunzio", Via dei Vestini 66100 Chieti, Italy
| | - Srinivas Jarlapoodi
- Department of Innovative Technologies in Medicine and Dentistry, University "G.d'Annunzio", Via dei Vestini 66100 Chieti, Italy
| | - Federica Serra
- Department of Pharmacy, University "G.d'Annunzio", Via dei Vestini 66100 Chieti, Italy
| | - Lisa Aielli
- Department of Innovative Technologies in Medicine and Dentistry, University "G.d'Annunzio", Via dei Vestini 66100 Chieti, Italy
| | - Haroon Khan
- Department of Pharmacy, Abdul Wali Khan University, Mardan 23200, Pakistan
| | - Tarun Belwal
- College of Biosystems Engineering and Food Science, Zhejiang University, Hangzhou 310058, People's Republic of China
| | - Katia Falasca
- Department of Medicine and Science of Aging, University "G.d'Annunzio", Via dei Vestini 66100 Chieti, Italy
| | - Marcella Reale
- Department of Innovative Technologies in Medicine and Dentistry, University "G.d'Annunzio", Via dei Vestini 66100 Chieti, Italy
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13
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Modeling Central Nervous System Injury In Vitro: Current Status and Promising Future Strategies. Biomedicines 2022; 11:biomedicines11010094. [PMID: 36672601 PMCID: PMC9855387 DOI: 10.3390/biomedicines11010094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/19/2022] [Accepted: 12/25/2022] [Indexed: 12/31/2022] Open
Abstract
The central nervous system (CNS) injury, which occurs because of mechanical trauma or ischemia/hypoxia, is one of the main causes of mortality and morbidity in the modern society. Until know, despite the fact that numerous preclinical and clinical studies have been undertaken, no significant neuroprotective strategies have been discovered that could be used in the brain trauma or ischemia treatment. Although there are many potential explanations for the failure of those studies, it is clear that there are questions regarding the use of experimental models, both in vivo and in vitro, when studying CNS injury and searching new therapeutics. Due to some ethical issues with the use of live animals in biomedical research, implementation of experimental strategies that prioritize the use of cells and tissues in the in vitro environment has been encouraged. In this review, we examined some of the most commonly used in vitro models and the most frequently utilized cellular platforms in the research of traumatic brain injury and cerebral ischemia. We also proposed some future strategies that could improve the usefulness of these studies for better bench-to-bedside translational outcomes.
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Ayasreh S, Jurado I, López-León CF, Montalà-Flaquer M, Soriano J. Dynamic and Functional Alterations of Neuronal Networks In Vitro upon Physical Damage: A Proof of Concept. MICROMACHINES 2022; 13:2259. [PMID: 36557557 PMCID: PMC9782595 DOI: 10.3390/mi13122259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 06/17/2023]
Abstract
There is a growing technological interest in combining biological neuronal networks with electronic ones, specifically for biological computation, human-machine interfacing and robotic implants. A major challenge for the development of these technologies is the resilience of the biological networks to physical damage, for instance, when used in harsh environments. To tackle this question, here, we investigated the dynamic and functional alterations of rodent cortical networks grown in vitro that were physically damaged, either by sequentially removing groups of neurons that were central for information flow or by applying an incision that cut the network in half. In both cases, we observed a remarkable capacity of the neuronal cultures to cope with damage, maintaining their activity and even reestablishing lost communication pathways. We also observed-particularly for the cultures cut in half-that a reservoir of healthy neurons surrounding the damaged region could boost resilience by providing stimulation and a communication bridge across disconnected areas. Our results show the remarkable capacity of neuronal cultures to sustain and recover from damage, and may be inspirational for the development of future hybrid biological-electronic systems.
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Affiliation(s)
- Sàlem Ayasreh
- Departament de Física de la Matèria Condensada, Universitat de Barcelona, E-08028 Barcelona, Spain
- Universitat de Barcelona Institute of Complex Systems (UBICS), E-08028 Barcelona, Spain
| | - Imanol Jurado
- Departament de Física de la Matèria Condensada, Universitat de Barcelona, E-08028 Barcelona, Spain
- Universitat de Barcelona Institute of Complex Systems (UBICS), E-08028 Barcelona, Spain
| | - Clara F. López-León
- Departament de Física de la Matèria Condensada, Universitat de Barcelona, E-08028 Barcelona, Spain
- Universitat de Barcelona Institute of Complex Systems (UBICS), E-08028 Barcelona, Spain
| | - Marc Montalà-Flaquer
- Departament de Física de la Matèria Condensada, Universitat de Barcelona, E-08028 Barcelona, Spain
- Universitat de Barcelona Institute of Complex Systems (UBICS), E-08028 Barcelona, Spain
| | - Jordi Soriano
- Departament de Física de la Matèria Condensada, Universitat de Barcelona, E-08028 Barcelona, Spain
- Universitat de Barcelona Institute of Complex Systems (UBICS), E-08028 Barcelona, Spain
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15
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Rogers EA, Beauclair T, Thyen A, Shi R. Utilizing novel TBI-on-a-chip device to link physical impacts to neurodegeneration and decipher primary and secondary injury mechanisms. Sci Rep 2022; 12:11838. [PMID: 35821510 PMCID: PMC9276772 DOI: 10.1038/s41598-022-14937-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 06/15/2022] [Indexed: 11/17/2022] Open
Abstract
While clinical observations have confirmed a link between the development of neurodegenerative diseases and traumatic brain injuries (TBI), there are currently no treatments available and the underlying mechanisms remain elusive. In response, we have developed an in vitro pendulum trauma model capable of imparting rapid acceleration injuries to neuronal networks grown on microelectrode arrays within a clinically relevant range of g forces, with real-time electrophysiological and morphological monitoring. By coupling a primary physical insult with the quantification of post-impact levels of known biochemical pathological markers, we demonstrate the capability of our system to delineate and investigate the primary and secondary injury mechanisms leading to post-impact neurodegeneration. Specifically, impact experiments reveal significant, force-dependent increases in the pro-inflammatory, oxidative stress marker acrolein at 24 h post-impact. The elevation of acrolein was augmented by escalating g force exposures (30–200 g), increasing the number of rapidly repeated impacts (4–6 s interval, 3, 5 and 10×), and by exposing impacted cells to 40 mM ethanol, a known comorbidity of TBI. The elevated levels of acrolein following multiple impacts could be reduced by increasing time-intervals between repeated hits. In addition, we show that conditioned media from maximally-impacted cultures can cause cellular acrolein elevation when introduced to non-impact, control networks, further solidifying acrolein’s role as a diffusive-factor in post-TBI secondary injuries. Finally, morphological data reveals post-impact acrolein generation to be primarily confined to soma, with some emergence in cellular processes. In conclusion, this novel technology provides accurate, physical insults with a unique level of structural and temporal resolution, facilitating the investigation of post-TBI neurodegeneration.
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Affiliation(s)
- Edmond A Rogers
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA.,Department of Basic Medical Sciences, School of Veterinary Medicine, Purdue University, West Lafayette, IN, 47907, USA.,Center for Paralysis Research, Purdue University, West Lafayette, IN, 47907, USA
| | - Timothy Beauclair
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA.,Department of Basic Medical Sciences, School of Veterinary Medicine, Purdue University, West Lafayette, IN, 47907, USA.,Center for Paralysis Research, Purdue University, West Lafayette, IN, 47907, USA
| | - Andrew Thyen
- Indiana University School of Medicine, Indianapolis, IN, 46033, USA
| | - Riyi Shi
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, 47907, USA. .,Department of Basic Medical Sciences, School of Veterinary Medicine, Purdue University, West Lafayette, IN, 47907, USA. .,Center for Paralysis Research, Purdue University, West Lafayette, IN, 47907, USA.
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16
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Meyer LJ, Lotze FP, Riess ML. Simulated traumatic brain injury in in-vitro mouse neuronal and brain endothelial cell culture models. J Pharmacol Toxicol Methods 2022; 114:107159. [PMID: 35149185 PMCID: PMC11151826 DOI: 10.1016/j.vascn.2022.107159] [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: 09/13/2021] [Revised: 01/02/2022] [Accepted: 02/04/2022] [Indexed: 11/18/2022]
Abstract
Traumatic brain injury can lead to fatal outcomes such as disability and death. Every year, it affects many patients all over the world. Not only the primary ischemic event, but also the subsequent reperfusion can cause severe brain injury. This so-called ischemia/reperfusion injury combined with mechanical forces lead to cellular disruption. Hence, this paper describes a special in-vitro model, mimicking traumatic brain injury by combining both hypoxia/reoxygenation and compression to simulate ischemia/reperfusion injury as well as the mechanical effects that occur concurrently when suffering traumatic brain injury. Through this approach, stroke, concussion, and traumatic brain injury can be studied on different cell lines in a simplified way. We used two primary mouse brain cell cultures, namely neurons and endothelial cells. Our results show that for the different cell types, different timelines of hypoxia and compression need to be explored to achieve the optimal amount of cellular damage in order to effectively mimic traumatic brain injury. Thus, this model will be useful to test potential treatments of brain injury in future in-vitro studies.
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Affiliation(s)
- Luise J Meyer
- Department of Anesthesiology, Vanderbilt University Medical Center, 1161 21(st) Avenue South, Nashville, TN 37232, USA; Department of Anesthesiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
| | - Felicia P Lotze
- Department of Anesthesiology, Vanderbilt University Medical Center, 1161 21(st) Avenue South, Nashville, TN 37232, USA; Department of Anesthesiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany
| | - Matthias L Riess
- Department of Anesthesiology, Vanderbilt University Medical Center, 1161 21(st) Avenue South, Nashville, TN 37232, USA; Anesthesiology, TVHS VA Medical Center, 1310 24(th) Ave South, Nashville, TN 37212, USA; Department of Pharmacology, Vanderbilt University, 465 21(st) Avenue South, Nashville, TN 37232, USA.
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17
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Blast-induced injury responsive relative gene expression of traumatic brain injury biomarkers in human brain microvascular endothelial cells. Brain Res 2021; 1770:147642. [PMID: 34474000 DOI: 10.1016/j.brainres.2021.147642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/28/2021] [Accepted: 08/26/2021] [Indexed: 01/01/2023]
Abstract
Disruption of the blood-brain barrier (BBB) is a critical component of traumatic brain injury (TBI) progression. However, further research into the mechanism of BBB disruption and its specific role in TBI pathophysiology is necessary. To help make progress in elucidating TBI affected BBB pathophysiology, we report herein relative gene expression of eleven TBI biomarkers and other factors of neuronal function in human brain microvascular cells (HBMVEC), one of the main cell types in the BBB. Our in-vitro blast TBI model employs a custom acoustic shock tube to deliver injuries of varying intensities to HBMVECs in culture. Each of the investigated genes exhibit a significant change in expression as a response to TBI, which is dependent on both the injury intensity and time following the injury. This data suggests that cell signaling of HBMVECs could be essential to understanding the interaction of the BBB and TBI pathophysiology, warranting future investigation.
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18
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In vitro model of traumatic brain injury to screen neuro-regenerative biomaterials. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 128:112253. [PMID: 34474815 DOI: 10.1016/j.msec.2021.112253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/21/2021] [Accepted: 06/11/2021] [Indexed: 11/24/2022]
Abstract
Penetrating traumatic brain injury (pTBI) causes serious neurological deficits with no clinical regenerative therapies currently available. Tissue engineering strategies using biomaterial-based 'structural bridges' offer high potential to promote neural regeneration post-injury. This includes surgical grade materials which can be repurposed as biological scaffolds to overcome challenges associated with long approval processes and scaleup for human application. However, high throughput, pathomimetic models of pTBI are lacking for the developmental testing of such neuro-materials, representing a bottleneck in this rapidly emergent field. We have established a high throughput and facile culture model containing the major neural cell types which govern biomaterial handling in the central nervous system. We show that induction of traumatic injuries was feasible in the model, with post-injury implantation of a surgical grade biomaterial. Cellular imaging in lesions was achievable using standard epifluorescence microscopy methods. Key pathological features of pTBI were evident in vitro namely immune cell infiltration of lesions/biomaterial, with responses characteristic of cell scarring, namely hypertrophic astrocytes with GFAP upregulation. Based on our observations, we consider the high-throughput, inexpensive and facile pTBI model can be used to study biomaterial 'implantation' and evaluate neural cell-biomaterial responses. The model is highly versatile to test a range of laboratory and clinical grade materials for neural regeneration.
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19
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Shi W, Dong P, Kuss MA, Gu L, Kievit F, Kim HJ, Duan B. Design and Evaluation of an In Vitro Mild Traumatic Brain Injury Modeling System Using 3D Printed Mini Impact Device on the 3D Cultured Human iPSC Derived Neural Progenitor Cells. Adv Healthc Mater 2021; 10:e2100180. [PMID: 33890428 PMCID: PMC8222191 DOI: 10.1002/adhm.202100180] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/15/2021] [Indexed: 12/13/2022]
Abstract
Despite significant progress in understanding the disease mechanism of traumatic brain injury (TBI), promising preclinical therapeutics have seldom been translated into successful clinical outcomes, partially because the model animals have physiological and functional differences in the central nervous system (CNS) compared to humans. Human relevant models are thus urgently required. Here, an in vitro mild TBI (mTBI) modeling system is reported based on 3D cultured human induced pluripotent stem cells (iPSC) derived neural progenitor cells (iPSC-NPCs) to evaluate consequences of single and repetitive mTBI using a 3D printed mini weight-drop impact device. Computational simulation is performed to understand the single/cumulative effects of weight-drop impact on the NPC differentiated neurospheres. Experimental results reveal that neurospheres show reactive astrogliosis and glial scar formation after repetitive (10 hits) mild impacts, while no astrocyte activation is found after one or two mild impacts. A 3D co-culture model of human microglia cells with neurospheres is further developed. It is found that astrocyte response is promoted even after two mild impacts, possibly caused by the chronic neuroinflammation after microglia activation. The in vitro mTBI modeling system recapitulates several hallmarks of the brain impact injury and might serve as a good platform for future drug screening.
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Affiliation(s)
- Wen Shi
- Mary & Dick Holland Regenerative Medicine Program, University of Nebraska, Medical Center, Omaha, NE, 68198, USA
- Division of Cardiology, Department of Internal Medicine, University of Nebraska, Medical Center, Omaha, NE, 68198, USA
| | - Pengfei Dong
- Department of Biomedical and Chemical Engineering and Science, Florida Institute of Technology, Melbourne, FL, 32901, USA
| | - Mitchell A Kuss
- Mary & Dick Holland Regenerative Medicine Program, University of Nebraska, Medical Center, Omaha, NE, 68198, USA
- Division of Cardiology, Department of Internal Medicine, University of Nebraska, Medical Center, Omaha, NE, 68198, USA
| | - Linxia Gu
- Department of Biomedical and Chemical Engineering and Science, Florida Institute of Technology, Melbourne, FL, 32901, USA
| | - Forrest Kievit
- Department of Biological Systems Engineering, University of Nebraska-Lincoln, Lincoln, NE, 68583, USA
| | - Hyung Joon Kim
- Mary & Dick Holland Regenerative Medicine Program, University of Nebraska, Medical Center, Omaha, NE, 68198, USA
- Eppley Institute, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Bin Duan
- Mary & Dick Holland Regenerative Medicine Program, University of Nebraska, Medical Center, Omaha, NE, 68198, USA
- Division of Cardiology, Department of Internal Medicine, University of Nebraska, Medical Center, Omaha, NE, 68198, USA
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, 68198, USA
- Department of Mechanical Engineering, University of Nebraska-Lincoln, Lincoln, NE, 68588, USA
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20
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Meyer LJ, Riess ML. Evaluation of In Vitro Neuronal Protection by Postconditioning with Poloxamer 188 Following Simulated Traumatic Brain Injury. Life (Basel) 2021; 11:316. [PMID: 33917288 PMCID: PMC8067401 DOI: 10.3390/life11040316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/16/2021] [Accepted: 03/29/2021] [Indexed: 12/16/2022] Open
Abstract
Traumatic brain injury (TBI) leads to morbidity and mortality worldwide. Reperfusion after ischemia adds detrimental injury to cells. Ischemia/reperfusion (I/R) injures cells in a variety of ways including cell membrane disruption. Hence, methods to improve endogenous membrane resealing capacity are crucial. Poloxamer (P) 188, an amphiphilic triblock copolymer, was found to be effective against I/R and mechanical injury in various experimental settings. The aim of this study was to establish an in vitro mouse neuronal TBI model and, further, to investigate if postconditioning with P188 directly interacts with neurons after compression and simulated I/R injury, when administered at the start of reoxygenation. Cellular function was assessed by cell number/viability, mitochondrial viability, membrane damage by lactated dehydrogenase (LDH) release and FM1-43 incorporation as well as apoptosis-activation by Caspase 3. Five hours hypoxia ± compression with 2 h reoxygenation proved to be a suitable model for TBI. Compared to normoxic cells not exposed to compression, cell number and mitochondrial viability decreased, whereas membrane injury by LDH release/FM1-43 dye incorporation and Caspase 3 activity increased in cells exposed to hypoxic conditions with compression followed by reoxygenation. P188 did not protect neurons from simulated I/R and/or compression injury. Future research is indicated.
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Affiliation(s)
- Luise J. Meyer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA; Department of Anesthesiology, University Medicine Greifswald, 17475 Greifswald, Germany;
| | - Matthias L. Riess
- Anesthesiology, TVHS VA Medical Center, Nashville, TN 37212, USA; Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA; Department of Pharmacology, Vanderbilt University, Nashville, TN 37232, USA
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21
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Honkamäki L, Joki T, Grigoryev NA, Levon K, Ylä-Outinen L, Narkilahti S. Novel method to produce a layered 3D scaffold for human pluripotent stem cell-derived neuronal cells. J Neurosci Methods 2020; 350:109043. [PMID: 33345946 DOI: 10.1016/j.jneumeth.2020.109043] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Three-dimensional (3D) in vitro models have been developed into more in vivo resembling structures. In particular, there is a need for human-based models for neuronal tissue engineering (TE). To produce such a model with organized microenvironment for cells in central nervous system (CNS), a 3D layered scaffold composed of hydrogel and cell guiding fibers has been proposed. NEW METHOD Here, we describe a novel method for producing a layered 3D scaffold consisting of electrospun poly (L,D-lactide) fibers embedded into collagen 1 hydrogel to achieve better resemblance of cells' natural microenvironment for human pluripotent stem cell (hPSC)-derived neurons. The scaffold was constructed via a single layer-by-layer process using an electrospinning technique with a unique collector design. RESULTS The method enabled the production of layered 3D cell-containing scaffold in a single process. HPSC-derived neurons were found in all layers of the scaffold and exhibited a typical neuronal phenotype. The guiding fiber layers supported the directed cell growth and extension of the neurites inside the scaffold without additional functionalization. COMPARISON WITH EXISTING METHODS Previous methods have required several process steps to construct 3D layer-by-layer scaffolds. CONCLUSIONS We introduced a method to produce layered 3D scaffolds to mimic the cell guiding cues in CNS by alternating the soft hydrogel matrix and fibrous guidance cues. The produced scaffold successfully enabled the long-term culture of hPSC-derived neuronal cells. This layered 3D scaffold is a useful model for in vitro and in vivo neuronal TE applications.
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Affiliation(s)
- Laura Honkamäki
- NeuroGroup, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Tiina Joki
- NeuroGroup, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Nikita A Grigoryev
- Department of Chemical and Biomolecular Engineering, NYU Tandon School of Engineering, Brooklyn, NY, USA
| | - Kalle Levon
- Department of Chemical and Biomolecular Engineering, NYU Tandon School of Engineering, Brooklyn, NY, USA
| | - Laura Ylä-Outinen
- NeuroGroup, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Susanna Narkilahti
- NeuroGroup, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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22
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Nikolakopoulou P, Rauti R, Voulgaris D, Shlomy I, Maoz BM, Herland A. Recent progress in translational engineered in vitro models of the central nervous system. Brain 2020; 143:3181-3213. [PMID: 33020798 PMCID: PMC7719033 DOI: 10.1093/brain/awaa268] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 06/17/2020] [Accepted: 06/21/2020] [Indexed: 02/07/2023] Open
Abstract
The complexity of the human brain poses a substantial challenge for the development of models of the CNS. Current animal models lack many essential human characteristics (in addition to raising operational challenges and ethical concerns), and conventional in vitro models, in turn, are limited in their capacity to provide information regarding many functional and systemic responses. Indeed, these challenges may underlie the notoriously low success rates of CNS drug development efforts. During the past 5 years, there has been a leap in the complexity and functionality of in vitro systems of the CNS, which have the potential to overcome many of the limitations of traditional model systems. The availability of human-derived induced pluripotent stem cell technology has further increased the translational potential of these systems. Yet, the adoption of state-of-the-art in vitro platforms within the CNS research community is limited. This may be attributable to the high costs or the immaturity of the systems. Nevertheless, the costs of fabrication have decreased, and there are tremendous ongoing efforts to improve the quality of cell differentiation. Herein, we aim to raise awareness of the capabilities and accessibility of advanced in vitro CNS technologies. We provide an overview of some of the main recent developments (since 2015) in in vitro CNS models. In particular, we focus on engineered in vitro models based on cell culture systems combined with microfluidic platforms (e.g. 'organ-on-a-chip' systems). We delve into the fundamental principles underlying these systems and review several applications of these platforms for the study of the CNS in health and disease. Our discussion further addresses the challenges that hinder the implementation of advanced in vitro platforms in personalized medicine or in large-scale industrial settings, and outlines the existing differentiation protocols and industrial cell sources. We conclude by providing practical guidelines for laboratories that are considering adopting organ-on-a-chip technologies.
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Affiliation(s)
- Polyxeni Nikolakopoulou
- AIMES, Center for the Advancement of Integrated Medical and Engineering Sciences, Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Rossana Rauti
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Dimitrios Voulgaris
- Division of Micro and Nanosystems, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Iftach Shlomy
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Ben M Maoz
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
- The Center for Nanoscience and Nanotechnology, Tel Aviv University, Tel Aviv, Israel
| | - Anna Herland
- AIMES, Center for the Advancement of Integrated Medical and Engineering Sciences, Department of Neuroscience, Karolinska Institute, Stockholm, Sweden
- Division of Micro and Nanosystems, KTH Royal Institute of Technology, Stockholm, Sweden
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23
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Hamilton KA, Santhakumar V. Current ex Vivo and in Vitro Approaches to Uncovering Mechanisms of Neurological Dysfunction after Traumatic Brain Injury. CURRENT OPINION IN BIOMEDICAL ENGINEERING 2020; 14:18-24. [PMID: 32548365 PMCID: PMC7297186 DOI: 10.1016/j.cobme.2020.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Traumatic brain injury often leads to progressive alterations at the molecular to circuit levels resulting in epilepsy and memory impairments. Ex vivo and in vitro models have provided a powerful platform for investigating the multimodal alteration after trauma. Recent ex vivo analyses using voltage sensitive dye imaging, optogenetics, and glutamate uncaging have revealed circuit abnormalities following in vivo brain injury. In vitro injury models have enabled examination of early and progressive changes in activity while development of three-dimensional organoids derived from human induced pluripotent stem cells have opened novel avenues for injury research. Here, we highlight recent advances in ex vivo and in vitro systems, focusing on their potential for advancing mechanistic understandings, possible limitations, and implications for therapeutics.
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Affiliation(s)
- Kelly Andrew Hamilton
- Department of Molecular, Cell and Systems Biology, University of California Riverside, Riverside, CA, USA
| | - Vijayalakshmi Santhakumar
- Department of Molecular, Cell and Systems Biology, University of California Riverside, Riverside, CA, USA
- Department of Pharmacology, Physiology and Neuroscience, Rutgers New Jersey Medical School, Newark, NJ, USA
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Kempuraj D, Ahmed ME, Selvakumar GP, Thangavel R, Dhaliwal AS, Dubova I, Mentor S, Premkumar K, Saeed D, Zahoor H, Raikwar SP, Zaheer S, Iyer SS, Zaheer A. Brain Injury-Mediated Neuroinflammatory Response and Alzheimer's Disease. Neuroscientist 2020; 26:134-155. [PMID: 31092147 PMCID: PMC7274851 DOI: 10.1177/1073858419848293] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Traumatic brain injury (TBI) is a major health problem in the United States, which affects about 1.7 million people each year. Glial cells, T-cells, and mast cells perform specific protective functions in different regions of the brain for the recovery of cognitive and motor functions after central nervous system (CNS) injuries including TBI. Chronic neuroinflammatory responses resulting in neuronal death and the accompanying stress following brain injury predisposes or accelerates the onset and progression of Alzheimer's disease (AD) in high-risk individuals. About 5.7 million Americans are currently living with AD. Immediately following brain injury, mast cells respond by releasing prestored and preactivated mediators and recruit immune cells to the CNS. Blood-brain barrier (BBB), tight junction and adherens junction proteins, neurovascular and gliovascular microstructural rearrangements, and dysfunction associated with increased trafficking of inflammatory mediators and inflammatory cells from the periphery across the BBB leads to increase in the chronic neuroinflammatory reactions following brain injury. In this review, we advance the hypothesis that neuroinflammatory responses resulting from mast cell activation along with the accompanying risk factors such as age, gender, food habits, emotional status, stress, allergic tendency, chronic inflammatory diseases, and certain drugs can accelerate brain injury-associated neuroinflammation, neurodegeneration, and AD pathogenesis.
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Affiliation(s)
- Duraisamy Kempuraj
- Harry S. Truman Memorial Veterans Hospital, U.S. Department of Veterans Affairs’, Columbia, MO 65201, USA
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Mohammad Ejaz Ahmed
- Harry S. Truman Memorial Veterans Hospital, U.S. Department of Veterans Affairs’, Columbia, MO 65201, USA
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Govindhasamy Pushpavathi Selvakumar
- Harry S. Truman Memorial Veterans Hospital, U.S. Department of Veterans Affairs’, Columbia, MO 65201, USA
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Ramasamy Thangavel
- Harry S. Truman Memorial Veterans Hospital, U.S. Department of Veterans Affairs’, Columbia, MO 65201, USA
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Arshdeep S. Dhaliwal
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Iuliia Dubova
- Harry S. Truman Memorial Veterans Hospital, U.S. Department of Veterans Affairs’, Columbia, MO 65201, USA
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Shireen Mentor
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Keerthivaas Premkumar
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Daniyal Saeed
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Haris Zahoor
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Sudhanshu P. Raikwar
- Harry S. Truman Memorial Veterans Hospital, U.S. Department of Veterans Affairs’, Columbia, MO 65201, USA
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Smita Zaheer
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Shankar S. Iyer
- Harry S. Truman Memorial Veterans Hospital, U.S. Department of Veterans Affairs’, Columbia, MO 65201, USA
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
| | - Asgar Zaheer
- Harry S. Truman Memorial Veterans Hospital, U.S. Department of Veterans Affairs’, Columbia, MO 65201, USA
- Department of Neurology, and the Center for Translational Neuroscience, School of Medicine, University of Missouri, Columbia, MO 65212, USA
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Musafargani S, Mishra S, Gulyás M, Mahalakshmi P, Archunan G, Padmanabhan P, Gulyás B. Blood brain barrier: A tissue engineered microfluidic chip. J Neurosci Methods 2020; 331:108525. [DOI: 10.1016/j.jneumeth.2019.108525] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/18/2019] [Accepted: 11/18/2019] [Indexed: 12/18/2022]
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Simultaneous electrophysiological and morphological assessment of functional damage to neural networks in vitro after 30-300 g impacts. Sci Rep 2019; 9:14994. [PMID: 31628381 PMCID: PMC6802386 DOI: 10.1038/s41598-019-51541-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 09/26/2019] [Indexed: 11/08/2022] Open
Abstract
An enigma of mild traumatic brain injury are observations of substantial behavior and performance deficits in the absence of bleeding or other observable structural damage. Altered behavior and performance reflect changes in action potential (AP) patterns within neuronal networks, which could result from subtle subcellular responses that affect synaptic efficacy and AP production. The aim of this study was to investigate and quantify network activity changes after simulated concussions in vitro and therewith develop a platform for simultaneous and direct observations of morphological and electrophysiological changes in neural networks. We used spontaneously active networks grown on microelectrode arrays (MEAs) to allow long-term multisite monitoring with simultaneous optical observations before and after impacts delivered by a ballistic pendulum (30 to 300 g accelerations). The monitoring of AP waveshape templates for long periods before and after impact provided an internal control for cell death or loss of cell-electrode coupling in the observed set of neurons. Network activity patterns were linked in real-time to high power phase contrast microscopy. There was no overt loss of glial or neuronal adhesion, even at high-g impacts. All recording experiments showed repeatable spike production responses: a loss of activity with recovery to near reference in 1 hr, followed by a slow activity decay to a stable, level plateau approximately 30–40% below reference. The initial recovery occurred in two steps: a rapid return of activity to an average 24% below reference, forming a level plateau lasting from 5 to 20 min, followed by a climb to within 10% of reference where a second plateau was established for 1 to 2 hrs. Cross correlation profiles revealed changes in firing hierarchy as well as in Phase 1 in spontaneous network oscillations that were reduced by as much as 20% 6–8 min post impact with only a partial recovery at 30 min. We also observed that normally stable nuclei developed irregular rotational motion after impact in 27 out of 30 networks. The evolution of network activity deficits and recovery can be linked with microscopically observable changes in the very cells that are generating the activity. The repeatable electrophysiological impact response profiles and oscillation changes can provide a quantitative basis for systematic evaluations of pharmacological intervention strategies. Future expansion to include fluorescent microscopy should allow detailed investigations of damage mechanisms on the subcellular level.
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Rosas-Hernandez H, Burks SM, Cuevas E, Ali SF. Stretch-Induced Deformation as a Model to Study Dopaminergic Dysfunction in Traumatic Brain Injury. Neurochem Res 2019; 44:2546-2555. [DOI: 10.1007/s11064-019-02872-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/04/2019] [Accepted: 09/09/2019] [Indexed: 01/08/2023]
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Alves JL, Rato J, Silva V. Why Does Brain Trauma Research Fail? World Neurosurg 2019; 130:115-121. [PMID: 31284053 DOI: 10.1016/j.wneu.2019.06.212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) represents a major health care problem and a significant social and economic issue worldwide. Considering the generalized failure in introducing effective drugs and clinical protocols, there is an urgent need for efficient treatment modalities, able to improve devastating posttraumatic morbidity and mortality. In this work, the status of brain trauma research is analyzed in all its aspects, including basic and translational science and clinical trials. Implicit and explicit challenges to different lines of research are discussed and clinical trial structures and outcomes are scrutinized, along with possible explanations for systematic therapeutic failures and their implications for future development of drug and clinical trials. Despite significant advances in basic and clinical research in recent years, no specific therapeutic protocols for TBI have been shown to be effective. New potential therapeutic targets have been identified, following a better understanding of pathophysiologic mechanisms underlying TBI, although with disappointing results. Several reasons can be pinpointed at different levels, from inaccurate animal models of disease to faulty preclinical and clinical trials, with poor design and subjective outcome measures. Distinct strategies can be delineated to overcome specific shortcomings of research studies. Identifying and contextualizing the failures that have dominated TBI research is mandatory. This review analyzes current approaches and discusses possible strategies for improving outcomes.
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Affiliation(s)
- José Luís Alves
- Department of Neurosurgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Joana Rato
- Department of Neurosurgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Vitor Silva
- Department of Neurosurgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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