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Chen X, An H, Wu D, Ji X. Research progress of selective brain cooling methods in the prehospital care for stroke patients: A narrative review. Brain Circ 2023; 9:16-20. [PMID: 37151794 PMCID: PMC10158655 DOI: 10.4103/bc.bc_88_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/14/2023] [Accepted: 01/29/2023] [Indexed: 05/09/2023] Open
Abstract
Over the past four decades, therapeutic hypothermia (TH) has long been suggested as a promising neuroprotective treatment of acute ischemic stroke (AIS). Much attention has focus on keeping the hypothermic benefits and removing side effects of systemic hypothermia. In the past few years, the advent of intravenous thrombolysis and endovascular thrombectomy has taken us into a reperfusion era of AIS treatment. With recent research emphasizing ways to plus neuroprotective treatments to reperfusion therapy, the spotlight is now shifting toward the study of how selective brain hypothermia can offset the drawbacks of systemic hypothermia and be applied in prehospital condition. This mini-review summarizes current brain cooling methods that can be used for inducing selective hypothermia in prehospital care. It will guide the future development of selective cooling methods, extend the application of TH in prehospital care, and provide insights into the prospects of selective hypothermia in AIS.
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Affiliation(s)
- Xi Chen
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Hong An
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
- Address for correspondence: Dr. Xunming Ji, Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing 100053, China. E-mail:
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Hong JM, Choi ES, Park SY. Selective Brain Cooling: A New Horizon of Neuroprotection. Front Neurol 2022; 13:873165. [PMID: 35795804 PMCID: PMC9251464 DOI: 10.3389/fneur.2022.873165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/23/2022] [Indexed: 11/17/2022] Open
Abstract
Therapeutic hypothermia (TH), which prevents irreversible neuronal necrosis and ischemic brain damage, has been proven effective for preventing ischemia-reperfusion injury in post-cardiac arrest syndrome and neonatal encephalopathy in both animal studies and clinical trials. However, lowering the whole-body temperature below 34°C can lead to severe systemic complications such as cardiac, hematologic, immunologic, and metabolic side effects. Although the brain accounts for only 2% of the total body weight, it consumes 20% of the body's total energy at rest and requires a continuous supply of glucose and oxygen to maintain function and structural integrity. As such, theoretically, temperature-controlled selective brain cooling (SBC) may be more beneficial for brain ischemia than systemic pan-ischemia. Various SBC methods have been introduced to selectively cool the brain while minimizing systemic TH-related complications. However, technical setbacks of conventional SBCs, such as insufficient cooling power and relatively expensive coolant and/or irritating effects on skin or mucosal interfaces, limit its application to various clinical settings. This review aimed to integrate current literature on SBC modalities with promising therapeutic potential. Further, future directions were discussed by exploring studies on interesting coping skills in response to environmental or stress-induced hyperthermia among wild animals, including mammals and birds.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
- *Correspondence: Ji Man Hong
| | - Eun Sil Choi
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - So Young Park
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
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3
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Ghozy S, Reda A, Varney J, Elhawary AS, Shah J, Murry K, Sobeeh MG, Nayak SS, Azzam AY, Brinjikji W, Kadirvel R, Kallmes DF. Neuroprotection in Acute Ischemic Stroke: A Battle Against the Biology of Nature. Front Neurol 2022; 13:870141. [PMID: 35711268 PMCID: PMC9195142 DOI: 10.3389/fneur.2022.870141] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/21/2022] [Indexed: 12/22/2022] Open
Abstract
Stroke is the second most common cause of global death following coronary artery disease. Time is crucial in managing stroke to reduce the rapidly progressing insult of the ischemic penumbra and the serious neurologic deficits that might follow it. Strokes are mainly either hemorrhagic or ischemic, with ischemic being the most common of all types of strokes. Thrombolytic therapy with recombinant tissue plasminogen activator and endovascular thrombectomy are the main types of management of acute ischemic stroke (AIS). In addition, there is a vital need for neuroprotection in the setting of AIS. Neuroprotective agents are important to investigate as they may reduce mortality, lessen disability, and improve quality of life after AIS. In our review, we will discuss the main types of management and the different modalities of neuroprotection, their mechanisms of action, and evidence of their effectiveness after ischemic stroke.
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Affiliation(s)
- Sherief Ghozy
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, United States.,Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC Program), Oxford University, Oxford, United Kingdom
| | - Abdullah Reda
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Joseph Varney
- School of Medicine, American University of the Caribbean, Philipsburg, Sint Maarten
| | | | - Jaffer Shah
- Medical Research Center, Kateb University, Kabul, Afghanistan
| | | | - Mohamed Gomaa Sobeeh
- Faculty of Physical Therapy, Sinai University, Cairo, Egypt.,Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Sandeep S Nayak
- Department of Internal Medicine, NYC Health + Hospitals/Metropolitan, New York, NY, United States
| | - Ahmed Y Azzam
- Faculty of Medicine, October 6 University, Giza, Egypt
| | - Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic Rochester, Rochester, MN, United States
| | | | - David F Kallmes
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, United States
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Choi JH, Poli S, Chen M, Nguyen TN, Saver JL, Matouk C, Pile-Spellman J. Selective Brain Hypothermia in Acute Ischemic Stroke: Reperfusion Without Reperfusion Injury. Front Neurol 2020; 11:594289. [PMID: 33281733 PMCID: PMC7691595 DOI: 10.3389/fneur.2020.594289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/15/2020] [Indexed: 01/19/2023] Open
Abstract
In acute ischemic stroke, early recanalization of the occluded artery is crucial for best outcome to be achieved. Recanalization aims at restoring blood flow to the ischemic tissue (reperfusion) and is achieved with pharmacological thrombolytic drugs, endovascular thrombectomy (EVT) devices, or both. The introduction of modern endovascular devices has led to tremendous anatomical and clinical success with rates of substantial reperfusion exceeding 80% and proven clinical benefit in patients with anterior circulation large vessel occlusions (LVOs). However, not every successful reperfusion procedure leads to the desired clinical outcome. In fact, the rate of non-disabled outcome at 3 months with current EVT treatment is ~1 out of 4. A constraint upon better outcomes is that reperfusion, though resolving ischemic stress, may not restore the anatomic structures and metabolic functions of ischemic tissue to their baseline states. In fact, ischemia triggers a complex cascade of destructive mechanisms that can sometimes be exacerbated rather than alleviated by reperfusion therapy. Such reperfusion injury may cause infarct progression, intracranial hemorrhage, and unfavorable outcome. Therapeutic hypothermia has been shown to have a favorable impact on the molecular elaboration of ischemic injury, but systemic hypothermia is limited by slow speed of attaining target temperatures and clinical complications. A novel approach is endovascular delivery of hypothermia to cool the affected brain tissue selectively and rapidly with tight local temperature control, features not available with systemic hypothermia devices. In this perspective article, we discuss the possible benefits of adjunctive selective endovascular brain hypothermia during interventional stroke treatment.
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Affiliation(s)
- Jae H. Choi
- Neurovascular Center, Neurological Surgery, P.C., Lake Success, NY, United States
- Hybernia Medical, LLC, New Rochelle, NY, United States
| | - Sven Poli
- Department of Neurology & Stroke, Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Michael Chen
- Stroke Center, Department of Neurosurgery, Rush University Medical Center, Chicago, IL, United States
| | - Thanh N. Nguyen
- Interventional Neurology/Neuroradiology, Boston University School of Medicine, Boston, MA, United States
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Charles Matouk
- Neurovascular Surgery, Department of Neurosurgery, Yale University-New Haven Hospital, New Haven, CT, United States
| | - John Pile-Spellman
- Neurovascular Center, Neurological Surgery, P.C., Lake Success, NY, United States
- Hybernia Medical, LLC, New Rochelle, NY, United States
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Wu D, Chen J, Hussain M, Wu L, Shi J, Wu C, Ma Y, Zhang M, Yang Q, Fu Y, Duan Y, Ma C, Yan F, Zhu Z, He X, Yao T, Song M, Zhi X, Wang C, Cai L, Li C, Li S, Zhang Y, Ding Y, Ji X. Selective intra-arterial brain cooling improves long-term outcomes in a non-human primate model of embolic stroke: Efficacy depending on reperfusion status. J Cereb Blood Flow Metab 2020; 40:1415-1426. [PMID: 32126876 PMCID: PMC7308521 DOI: 10.1177/0271678x20903697] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Nearly all stroke neuroprotection modalities, including selective intra-arterial cooling (SI-AC), have failed to be translated from bench to bed side. Potentially overlooked reasons may be biological gaps, inadequate attention to reperfusion states and mismatched attention to neurological benefits. To advance stroke translation, we describe a novel thrombus-based stroke model in adult rhesus macaques. Intra-arterial thrombolysis with tissue plasminogen activator leads to three clinically relevant outcomes - complete, partial, and no recanalization based on digital subtraction angiography. We also find reperfusion as a prerequisite for SI-AC-induced benefits, in which models with complete or partial reperfusion exhibit significantly reduced infarct volumes, mitigated neurological deficits, improved upper limb motor dysfunction in both acute and chronic stages; however, no further neuroprotection is observed in those without reperfusion. In summary, we discover reperfusion as a crucial regulator of SI-AC-induced neuroprotection and provide insights of long-term functional benefits in behavior and imaging levels. Our findings could be important not only for the translational prerequisite and potential molecular targets, but also for this thrombus-thrombolysis model in monkeys as a powerful tool for further translational stroke studies.
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Affiliation(s)
- Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mohammed Hussain
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Longfei Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China
| | - Jingfei Shi
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China
| | - Yanhui Ma
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mo Zhang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qi Yang
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongjuan Fu
- Department of Pathology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yunxia Duan
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Cui Ma
- Interdisciplinary Innovation Institute of Medicine and Engineering, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Feng Yan
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zixin Zhu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaoduo He
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianqi Yao
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ming Song
- Interdisciplinary Innovation Institute of Medicine and Engineering, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Xinglong Zhi
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chunxiu Wang
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lipeng Cai
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shengli Li
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongbiao Zhang
- Brainnetome Center, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Yuchuan Ding
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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Tang YN, Zhang GF, Chen HL, Sun XP, Qin WW, Shi F, Sun LX, Xu XN, Wang MS. Selective brain hypothermia-induced neuroprotection against focal cerebral ischemia/reperfusion injury is associated with Fis1 inhibition. Neural Regen Res 2020; 15:903-911. [PMID: 31719256 PMCID: PMC6990783 DOI: 10.4103/1673-5374.268973] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Selective brain hypothermia is considered an effective treatment for neuronal injury after stroke, and avoids the complications of general hypothermia. However, the mechanisms by which selective brain hypothermia affects mitochondrial fission remain unknown. In this study, we investigated the effect of selective brain hypothermia on the expression of fission 1 (Fis1) protein, a key factor in the mitochondrial fission system, during focal cerebral ischemia/reperfusion injury. Sprague-Dawley rats were divided into four groups. In the sham group, the carotid arteries were exposed only. In the other three groups, middle cerebral artery occlusion was performed using the intraluminal filament technique. After 2 hours of occlusion, the filament was slowly removed to allow blood reperfusion in the ischemia/reperfusion group. Saline, at 4°C and 37°C, were perfused through the carotid artery in the hypothermia and normothermia groups, respectively, followed by restoration of blood flow. Neurological function was assessed with the Zea Longa 5-point scoring method. Cerebral infarct volume was assessed by 2,3,5-triphenyltetrazolium chloride staining, and apoptosis was assessed by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling staining. Fis1 and cytosolic cytochrome c levels were assessed by western blot assay. Fis1 mRNA expression was assessed by quantitative reverse transcription-polymerase chain reaction. Mitochondrial ultrastructure was evaluated by transmission electron microscopy. Compared with the sham group, apoptosis, Fis1 protein and mRNA expression and cytosolic cytochrome c levels in the cortical ischemic penumbra and cerebral infarct volume were increased after reperfusion in the other three groups. These changes caused by cerebral ischemia/reperfusion were inhibited in the hypothermia group compared with the normothermia group. These findings show that selective brain hypothermia inhibits Fis1 expression and reduces apoptosis, thereby ameliorating focal cerebral ischemia/reperfusion injury in rats. Experiments were authorized by the Ethics Committee of Qingdao Municipal Hospital of China (approval No. 2019008).
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Affiliation(s)
- Ya-Nan Tang
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Gao-Feng Zhang
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Huai-Long Chen
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xiao-Peng Sun
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Wei-Wei Qin
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Fei Shi
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Li-Xin Sun
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xiao-Na Xu
- Department of Central Laboratory, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Ming-Shan Wang
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
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Assis FR, Narasimhan B, Ziai W, Tandri H. From systemic to selective brain cooling - Methods in review. Brain Circ 2019; 5:179-186. [PMID: 31950093 PMCID: PMC6950511 DOI: 10.4103/bc.bc_23_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/28/2019] [Accepted: 11/05/2019] [Indexed: 01/14/2023] Open
Abstract
Therapeutic hypothermia (TH) remains one of the few proven neuroprotective modalities available in clinical practice today. Although targeting lower temperatures during TH seems to benefit ischemic brain cells, systemic side effects associated with global hypothermia limit its clinical applicability. Therefore, the ability to selectively reduce the temperature of the brain while minimally impacting core temperature allows for maximizing neurological benefit over systemic complications. In that scenario, selective brain cooling (SBC) has emerged as a promising modality of TH. In this report, we reviewed the general concepts of TH, from systemic to selective brain hypothermia, and explored the different cooling strategies and respective evidence, including preclinical and clinical data. SBC has been investigated in different animal models with promising results, wherein organ-specific, rapid, and deep target brain temperature managements stand out as major advantages over systemic TH. Nevertheless, procedure-related complications and adverse events still remain a concern, limiting clinical translation. Different invasive and noninvasive methods for SBC have been clinically investigated with variable results, and although adverse effects were still reported in some studies, therapies rendered overall safe profiles. Further study is needed to define the optimal technique, timing of initiation, rate and length of cooling as well as target temperature and rewarming protocols for different indications.
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Affiliation(s)
- Fabrizio R Assis
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bharat Narasimhan
- Department of Internal Medicine, Mount Sinai St. Lukes-Roosevelt, New York, NY, USA
| | - Wendy Ziai
- Division of Anesthesia and Neurocritical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harikrishna Tandri
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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