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Liu X, Manninen T, Capper AM, Jiang X, Ellison J, Kim Y, Gurler G, Xu D, Ferriero DM. Brain metabolism after therapeutic hypothermia for murine hypoxia-ischemia using hyperpolarized [1- 13C] pyruvate magnetic resonance spectroscopy. NMR IN BIOMEDICINE 2024:e5196. [PMID: 38853759 DOI: 10.1002/nbm.5196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/16/2024] [Accepted: 05/12/2024] [Indexed: 06/11/2024]
Abstract
Hypoxic-ischemic encephalopathy (HIE) is a common neurological syndrome in newborns with high mortality and morbidity. Therapeutic hypothermia (TH), which is standard of care for HIE, mitigates brain injury by suppressing anaerobic metabolism. However, more than 40% of HIE neonates have a poor outcome, even after TH. This study aims to provide metabolic biomarkers for predicting the outcomes of hypoxia-ischemia (HI) after TH using hyperpolarized [1-13C] pyruvate magnetic resonance spectroscopy. Postnatal day 10 (P10) mice with HI underwent TH at 1 h and were scanned at 6-8 h (P10), 24 h (P11), 7 days (P17), and 21 days (P31) post-HI on a 14.1-T NMR spectrometer. The metabolic images were collected, and the conversion rate from pyruvate to lactate and the ratio of lactate to pyruvate in the injured left hemisphere (kPL(L) and Lac/Pyr(L), respectively) were calculated at each timepoint. The outcomes of TH were determined by the assessments of brain injury on T2-weighted images and behavioral tests at later timepoint. kPL(L) and Lac/Pyr(L) over time between the good-outcome and poor-outcome groups and across timepoints within groups were analyzed. We found significant differences in temporal trends of kPL(L) and Lac/Pyr(L) between groups. In the good-outcome group, kPL(L) increased until P31 with a significantly higher value at P31 compared with that at P10, while the level of Lac/Pyr(L) at P31 was notably higher than those at all other timepoints. In the poor-outcome group, kPL(L) and Lac/Pyr(L) increased within 24 h. The kPL(L) value at P11 was considerably higher compared with P10. Discrete temporal changes of kPL(L) and Lac/Pyr(L) after TH between the good-outcome and poor-outcome groups were seen as early as 24 h after HI, reflecting various TH effects on brain anaerobic metabolism, which may provide insights for early screening for response to TH.
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Affiliation(s)
- Xiaodan Liu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Tiina Manninen
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Xiangning Jiang
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Jacob Ellison
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Joint UCSF/UC Berkeley Graduate Group in Bioengineering, San Francisco, California, USA
| | - Yaewon Kim
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Gokce Gurler
- Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Duan Xu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Joint UCSF/UC Berkeley Graduate Group in Bioengineering, San Francisco, California, USA
| | - Donna M Ferriero
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
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Hung SC, Tu YF, Hunter SE, Guimaraes C. MRI predictors of long-term outcomes of neonatal hypoxic ischaemic encephalopathy: a primer for radiologists. Br J Radiol 2024; 97:1067-1077. [PMID: 38407350 DOI: 10.1093/bjr/tqae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/12/2024] [Accepted: 02/22/2024] [Indexed: 02/27/2024] Open
Abstract
This review aims to serve as a foundational resource for general radiologists, enhancing their understanding of the role of Magnetic Resonance Imaging (MRI) in early prognostication for newborns diagnosed with hypoxic ischaemic encephalopathy (HIE). The article explores the application of MRI as a predictive instrument for determining long-term outcomes in newborns affected by HIE. With HIE constituting a leading cause of neonatal mortality and severe long-term neurodevelopmental impairments, early identification of prognostic indicators is crucial for timely intervention and optimal clinical management. We examine current literature and recent advancements to provide an in-depth overview of MRI predictors, encompassing brain injury patterns, injury scoring systems, spectroscopy, and diffusion imaging. The potential of these MRI biomarkers in predicting long-term neurodevelopmental outcomes and the probability of epilepsy is also discussed.
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Affiliation(s)
- Sheng-Che Hung
- Department of Radiology, School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC 27599, United States
| | - Yi-Fang Tu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Senyene E Hunter
- Department of Neurology, School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC 27599-7025, United States
| | - Carolina Guimaraes
- Department of Radiology, School of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC 27599, United States
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3
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Joshi M, Muneer J, Mbuagbaw L, Goswami I. Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review. PLoS One 2023; 18:e0291170. [PMID: 38060481 PMCID: PMC10703341 DOI: 10.1371/journal.pone.0291170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. OBJECTIVE This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. METHODS We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. RESULTS The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40-100% worldwide. TH alters most drugs' metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. CONCLUSIONS No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.
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Affiliation(s)
- Mahima Joshi
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Javed Muneer
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ipsita Goswami
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Tetarbe M, Wisnowski JL, Geyer E, Tamrazi B, Wood T, Mietzsch U, Blüml S, Wu TW. Cerebral Glucose Concentration in Neonatal Hypoxic-Ischemic Encephalopathy during Therapeutic Hypothermia. J Pediatr 2023; 261:113560. [PMID: 37321289 DOI: 10.1016/j.jpeds.2023.113560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/24/2023] [Accepted: 06/12/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To determine cerebral glucose concentration and its relationship with glucose infusion rate (GIR) and blood glucose concentration in neonatal encephalopathy during therapeutic hypothermia (TH). METHODS This was an observational study in which cerebral glucose during TH was quantified by magnetic resonance (MR) spectroscopy and compared with mean blood glucose at the time of scan. Clinical data (gestational age, birth weight, GIR, sedative use) that could affect glucose use were collected. The severity and pattern of brain injury on MR imaging were scored by a neuroradiologist. Student t test, Pearson correlation, repeated measures ANOVA, and multiple regression analysis were performed. RESULTS Three-hundred-sixty blood glucose values and 402 MR spectra from 54 infants (30 female infants; mean gestational age 38.6 ± 1.9 weeks) were analyzed. In total, 41 infants had normal-mild and 13 had moderate-severe injury. Median GIR and blood glucose during TH were 6.0 mg/kg/min (IQR 5-7) and 90 mg/dL (IQR 80-102), respectively. GIR did not correlate with blood or cerebral glucose. Cerebral glucose was significantly greater during than after TH (65.9 ± 22.9 vs 60.0 ± 25.2 mg/dL, P < .01), and there was a significant correlation between blood glucose and cerebral glucose during TH (basal ganglia: r = 0.42, thalamus: r = 0.42, cortical gray matter: r = 0.39, white matter: r = 0.39, all P < .01). There was no significant difference in cerebral glucose concentration in relation to injury severity or pattern. CONCLUSIONS During TH, cerebral glucose concentration is partly dependent on blood glucose concentration. Further studies to understand brain glucose use and optimal glucose concentrations during hypothermic neuroprotection are needed.
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Affiliation(s)
- Manas Tetarbe
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine of USC, Los Angeles, CA
| | - Jessica L Wisnowski
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA; Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Eduardo Geyer
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - Benita Tamrazi
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Thomas Wood
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Seattle Children's Hospital, Seattle, WA
| | - Stefan Blüml
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Tai-Wei Wu
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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Korf JM, McCullough LD, Caretti V. A narrative review on treatment strategies for neonatal hypoxic ischemic encephalopathy. Transl Pediatr 2023; 12:1552-1571. [PMID: 37692539 PMCID: PMC10485647 DOI: 10.21037/tp-23-253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Background and Objective Hypoxic-ischemic encephalopathy (HIE) is a leading cause of death and disability worldwide. Therapeutic hypothermia (TH) represents a significant achievement in the translation of scientific research to clinical application, but it is currently the only neuroprotective treatment for HIE. This review aims to revisit the use of TH for HIE and its longitudinal impact on patient outcomes to readers new to the field of HIE. We discuss how emerging therapies address the broader pathophysiology of injury progression in the neonatal brain days to years after HIE. Methods We included full articles and book chapters published in English on PubMed with references to "hypoxic ischemic encephalopathy", "birth asphyxia", "therapeutic hypothermia", or "neonatal encephalopathy". We limited our review to outcomes on term infants and to new therapeutics that are in the second phase of clinical trials. Key Content and Findings Despite the use of TH for HIE, mortality remains high. Analysis of longitudinal studies reveals a high incidence of ongoing disability even with the implementation of TH. New therapeutics addressing the secondary phase and the less understood tertiary phase of brain injury are in clinical trials as adjunctive treatments to TH to support additional neurological repair and regeneration. Conclusions TH successfully improves outcomes after HIE, and it continues to be optimized. Larger studies are needed to understand its use in mild cases of HIE and if certain factors, such as sex, affect long term outcomes. TH primarily acts in the initial phases of injury, while new pharmaceutical therapies target additional injury pathways into the tertiary phases of injury. This may allow for more effective approaches to treatment and improvement of long-term functional outcomes after HIE.
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Affiliation(s)
- Janelle M. Korf
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Louise D. McCullough
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
| | - Viola Caretti
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, USA
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
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6
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Li R, Lee JK, Govindan RB, Graham EM, Everett AD, Perin J, Vezina G, Tekes A, Chen MW, Northington F, Parkinson C, O’Kane A, McGowan M, Krein C, Al-Shargabi T, Chang T, Massaro AN. Plasma Biomarkers of Evolving Encephalopathy and Brain Injury in Neonates with Hypoxic-Ischemic Encephalopathy. J Pediatr 2023; 252:146-153.e2. [PMID: 35944723 PMCID: PMC9828943 DOI: 10.1016/j.jpeds.2022.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate the relationship between a panel of candidate plasma biomarkers and (1) death or severe brain injury on magnetic resonance imaging (MRI) and (2) dysfunctional cerebral pressure autoregulation as a measure of evolving encephalopathy. STUDY DESIGN Neonates with moderate-to-severe hypoxic-ischemic encephalopathy (HIE) at 2 level IV neonatal intensive care units were enrolled into this observational study. Patients were treated with therapeutic hypothermia (TH) and monitored with continuous blood pressure monitoring and near-infrared spectroscopy. Cerebral pressure autoregulation was measured by the hemoglobin volume phase (HVP) index; a higher HVP index indicates poorer autoregulation. Serial blood samples were collected during TH and assayed for Tau, glial fibrillary acidic protein, and neurogranin. MRIs were assessed using National Institutes of Child Health and Human Development scores. The relationships between the candidate biomarkers and (1) death or severe brain injury on MRI (defined as a National Institutes of Child Health and Human Development score of ≥ 2B) and (2) autoregulation were evaluated using bivariate and adjusted logistic regression models. RESULTS Sixty-two patients were included. Elevated Tau levels on days 2-3 of TH were associated with death or severe injury on MRI (aOR: 1.06, 95% CI: 1.03-1.09; aOR: 1.04, 95% CI: 1.01-1.06, respectively). Higher Tau was also associated with poorer autoregulation (higher HVP index) on the same day (P = .022). CONCLUSIONS Elevated plasma levels of Tau are associated with death or severe brain injury by MRI and dysfunctional cerebral autoregulation in neonates with HIE. Larger-scale validation of Tau as a biomarker of brain injury in neonates with HIE is warranted.
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Affiliation(s)
- Ruoying Li
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rathinaswamy B. Govindan
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Ernest M. Graham
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allen D. Everett
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gilbert Vezina
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Division of Diagnostic Imaging and Radiology, Children’s National Hospital, Washington, DC
| | - Aylin Tekes
- Department of Radiology, Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - May W. Chen
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Frances Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra O’Kane
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Meaghan McGowan
- Department of Neurology, Children’s National Hospital, Washington, DC
| | - Colleen Krein
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Tareq Al-Shargabi
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC
| | - Taeun Chang
- Department of Neurology, Children’s National Hospital, Washington, DC;,Department of Pediatrics, The George Washington University School of Medicine, Washington, DC
| | - An N. Massaro
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC;,Division of Neonatology, Children’s National Hospital, Washington, DC
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7
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Paz AA, González-Candia A. Potential pharmacological target of tight junctions to improve the BBB permeability in neonatal Hypoxic-Ischemic encephalopathy Diseases. Biochem Pharmacol 2023; 207:115356. [PMID: 36455671 DOI: 10.1016/j.bcp.2022.115356] [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: 09/09/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
Neonatal encephalopathy (NE) is a pathological condition that describes a neurocognitive malfunction in the newborn that arises from fetal, peripartum, or intrapartum events of multifactorial nature, having a poor prognosis and accounting for an incidence of 5-8 per 1000 live births. Neonatal hypoxic-ischemic encephalopathy (HIE) is one of the most studied paradigms of NE, caused by a scarce cerebral perfusion and oxygen supply during perinatal life. The cerebral hypoxic-ischemic insult promotes a loss of permeability of the blood-brain barrier (BBB), an essential structural intermediary of blood-brain communication. This permeability disruption is associated with an increase in inflammatory cytokines, an increase of adhesion molecules, and oxidative stress which disturb the tight junction (TJ) performance and enable transcytosis and paracellular leakage, ultimately leading to death from brain cells. In this context, TJs proteins are essential to preserving the barrier mechanical stability and signaling that modulates the brain-blood vessel multicellular domains, known as neurovascular units (NVU). Recent studies have proposed different strategies with neuroprotective effects that allow for maintaining or restoring the integrity and permeability of the BBB. This review identifies and discusses regulator mechanisms and novel aspects of TJs in the BBB disruption induced by cerebral hypoxic insults during the perinatal period, evaluating potential pharmacological strategies to safeguard BBB integrity.
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Affiliation(s)
- Adolfo A Paz
- Institute of Health Sciences, University O'Higgins, Rancagua, Chile
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8
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Chevin M, Chabrier S, Allard MJ, Sébire G. Necroptosis Blockade Potentiates the Neuroprotective Effect of Hypothermia in Neonatal Hypoxic-Ischemic Encephalopathy. Biomedicines 2022; 10:biomedicines10112913. [PMID: 36428481 PMCID: PMC9687213 DOI: 10.3390/biomedicines10112913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/08/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Abstract
Neonatal encephalopathy (NE) caused by hypoxia-ischemia (HI) affects around 1 per 1000 term newborns and is the leading cause of acquired brain injury and neurodisability. Despite the use of hypothermia (HT) as a standard of care, the incidence of NE and its devastating outcomes remains a major issue. Ongoing research surrounding add-on neuroprotective strategies against NE is important as HT effects are limited, leaving 50% of treated patients with neurological sequelae. Little is known about the interaction between necroptotic blockade and HT in neonatal HI. Using a preclinical Lewis rat model of term human NE induced by HI, we showed a neuroprotective effect of Necrostatin-1 (Nec-1: a compound blocking necroptosis) in combination with HT. The beneficial effect of Nec-1 added to HT against NE injuries was observed at the mechanistic level on both pMLKL and TNF-α, and at the anatomical level on brain volume loss visualized by magnetic resonance imaging (MRI). HT alone showed no effect on activated necroptotic effectors and did not preserve the brain MRI volume. This study opens new avenues of research to understand better the specific cell death mechanisms of brain injuries as well as the potential use of new therapeutics targeting the necroptosis pathway.
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Affiliation(s)
- Mathilde Chevin
- Department of Pediatrics, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC H4A 3J1, Canada
- Correspondence: ; Tel.: +1-(819)-640-3648
| | - Stéphane Chabrier
- Department of Pediatrics, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC H4A 3J1, Canada
- CHU Saint-Étienne, INSERM, Centre National de Référence de l’AVC de l’enfant, CIC1408, F-42055 Saint-Étienne, France
- INSERM, Université Saint-Étienne, Université Lyon, UMR1059 Sainbiose, F-42023 Saint-Étienne, France
| | - Marie-Julie Allard
- Department of Pediatrics, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC H4A 3J1, Canada
| | - Guillaume Sébire
- Department of Pediatrics, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC H4A 3J1, Canada
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9
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Spielman DM, Gu M, Hurd RE, Riemer RK, Okamura K, Hanley FL. Proton magnetic resonance spectroscopy assessment of neonatal brain metabolism during cardiopulmonary bypass surgery. NMR IN BIOMEDICINE 2022; 35:e4752. [PMID: 35483967 PMCID: PMC9484292 DOI: 10.1002/nbm.4752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 06/14/2023]
Abstract
Here, we report on the development and performance of a robust 3-T single-voxel proton magnetic resonance spectroscopy (1 H MRS) experimental protocol and data analysis pipeline for quantifying brain metabolism during cardiopulmonary bypass (CPB) surgery in a neonatal porcine model, with the overall goal of elucidating primary mechanisms of brain injury associated with these procedures. The specific aims were to assess which metabolic processes can be reliably interrogated by 1 H MRS on a 3-T clinical scanner and to provide an initial assessment of brain metabolism during deep hypothermia cardiac arrest (DHCA) surgery and recovery. Fourteen neonatal pigs underwent CPB surgery while placed in a 3-T MRI scanner for 18, 28, and 37°C DHCA studies under hyperglycemic, euglycemic, and hypoglycemic conditions. Total imaging times, including baseline measurements, circulatory arrest (CA), and recovery averaged 3 h/animal, during which 30-40 single-voxel 1 H MRS spectra (sLASER pulse sequence, TR/TE = 2000/30 ms, 64 or 128 averages) were acquired from a 2.2-cc right midbrain voxel. 1 H MRS at 3 T was able to reliably quantify (1) anaerobic metabolism via depletion of brain glucose and the associated build-up of lactate during CA, (2) phosphocreatine (PCr) to creatine (Cr) conversion during CA and subsequent recovery upon reperfusion, (3) a robust increase in the glutamine-to-glutamate (Gln/Glu) ratio during the post-CA recovery period, and (4) a broadening of the water peak during CA. In vivo 1 H MRS at 3 T can reliably quantify subtle metabolic brain changes previously deemed challenging to interrogate, including brain glucose concentrations even under hypoglycemic conditions, ATP usage via the conversion of PCr to Cr, and differential changes in Glu and Gln. Observed metabolic changes during CPB surgery of a neonatal porcine model provide new insights into possible mechanisms for prevention of neuronal injury.
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Affiliation(s)
- Daniel M. Spielman
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Meng Gu
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Ralph E. Hurd
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - R. Kirk Riemer
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Kenichi Okamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Frank L. Hanley
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, USA
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10
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Erlich-Malona N, Bartolini L, D’Abreu A, Roth J. Paroxysmal Hypothermia With Prominent Parkinsonian Features After Suprachiasmatic Tumor Resection. Neurohospitalist 2021; 12:285-289. [PMID: 35419139 PMCID: PMC8995609 DOI: 10.1177/19418744211056206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Paroxysmal hypothermia (PH) is a rare syndrome of stereotyped episodes of hypothermia, bradycardia, and altered mental status occurring in patients with hypothalamic lesions. Prior cases have mentioned bradykinesia, ataxia, and dysarthria, but parkinsonism has not been described as a specific feature of PH. We report two patients, an adult and a child, who developed PH after suprachiasmatic tumor resection, both with clinical presentations notable for prominent parkinsonian features despite no evidence of parkinsonism during the intervening months and years. We propose a diagnostic algorithm and scoring tool to aid in the clinical diagnosis of PH presenting as parkinsonism.
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Affiliation(s)
- Natalie Erlich-Malona
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Luca Bartolini
- Division of Pediatric Neurology, Hasbro Children’s Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Anelyssa D’Abreu
- Department of Neurology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Julie Roth
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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11
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Shibasaki J, Niwa T, Piedvache A, Tomiyasu M, Morisaki N, Fujii Y, Toyoshima K, Aida N. Comparison of Predictive Values of Magnetic Resonance Biomarkers Based on Scan Timing in Neonatal Encephalopathy Following Therapeutic Hypothermia. J Pediatr 2021; 239:101-109.e4. [PMID: 34391766 DOI: 10.1016/j.jpeds.2021.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/28/2021] [Accepted: 08/06/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the optimal quantitative magnetic resonance (MR) biomarker in neonatal encephalopathy following therapeutic hypothermia based on scan timing. STUDY DESIGN This retrospective study included 98 neonates (35-41 weeks of gestation) with neonatal encephalopathy, who underwent therapeutic hypothermia; diffusion-weighted imaging and proton MR spectroscopy were performed at 24-96 hours (n = 56) and 7-14 days (n = 92) after birth, respectively, to estimate apparent diffusion coefficient (ADC) values, N-acetylaspartate and N-acetylaspartylglutamate (tNAA), lactate, and choline concentrations, and lactate/tNAA, tNAA/choline ratios in the deep gray matter. Adverse outcomes included death or neurodevelopmental impairment at 18-22 months of age. We used receiver operating characteristic curves to examine the prognostic accuracy of each MR biomarker. RESULTS Deep gray matter tNAA concentrations showed the best prognostic value, with an area under the curve (AUC) of 0.97 and 1.00 at 24-96 hours and 7-14 days after birth, respectively. At 24-96 hours of age, ADC values, lactate concentrations, and lactate/tNAA ratios showed prognostic value with AUCs of 0.90, 0.95, and 0.97, respectively. At 7-14 days of age, the AUCs of ADC values, lactate, and lactate/tNAA ratios were 0.61, 0.67, and 0.80, respectively; these were lower than those at 24-96 hours of age. CONCLUSIONS During the first 2 weeks of life, the deep gray matter tNAA concentration was the most accurate quantitative MR biomarker. Although ADC values, lactate levels, and lactate/tNAA ratios also showed high prognostic value during 24-96 hours of life, only tNAA retained high prognostic value in the second week of life.
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Affiliation(s)
- Jun Shibasaki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tetsu Niwa
- Department of Radiology, Tokai University School of Medicine, Isehara, Japan; Department of Radiology, Kanagawa Children's Medical Center, Yokohama, Japan.
| | - Aurélie Piedvache
- Division of Lifecourse Epidemiology, Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Moyoko Tomiyasu
- Department of Radiology, Kanagawa Children's Medical Center, Yokohama, Japan; Department of Molecular Imaging and Theranostics, National Institute for Quantum and Radiological Science and Technology, Chiba, Japan
| | - Naho Morisaki
- Division of Lifecourse Epidemiology, Department of Social Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yuta Fujii
- Department of Radiology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Noriko Aida
- Department of Radiology, Kanagawa Children's Medical Center, Yokohama, Japan
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12
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Marlow N, Shankaran S, Rogers EE, Maitre NL, Smyser CD. Neurological and developmental outcomes following neonatal encephalopathy treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101274. [PMID: 34330680 DOI: 10.1016/j.siny.2021.101274] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In randomized trials, therapeutic hypothermia (TH) is associated with reduced prevalence of the composite outcome mortality or neurodevelopmental morbidity in infants with neonatal encephalopathy (NE). Following systematic review, the reduction in prevalence of both mortality and infant neuromorbidity is clear. Among three trials reporting school age outcomes, the effects of NE and TH suggest that such benefit persists into middle childhood, but none of the major trials were powered to detect differences in these outcomes. Cognitive, educational and behavioural outcomes are all adversely affected by NE in children without moderate or severe neuromorbidity. High-quality longitudinal studies of neurocognitive and educational outcomes following NE in the era of TH, including studies incorporating multimodal neuroimaging assessments, are required to characterise deficits more precisely so that robust interventional targets may be developed, and resource planning can occur. Understanding the impact of NE on families and important educational, social, and behavioural outcomes in childhood is critical to attempts to optimise outcomes through interventions.
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Affiliation(s)
| | | | | | - Nathalie L Maitre
- Nationwide Children's Hospital, Columbus, OH, USA; Vanderbilt University, Nashville, TN, USA
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13
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Wisnowski JL, Wintermark P, Bonifacio SL, Smyser CD, Barkovich AJ, Edwards AD, de Vries LS, Inder TE, Chau V. Neuroimaging in the term newborn with neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101304. [PMID: 34736808 PMCID: PMC9135955 DOI: 10.1016/j.siny.2021.101304] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neuroimaging is widely used to aid in the diagnosis and clinical management of neonates with neonatal encephalopathy (NE). Yet, despite widespread use clinically, there are few published guidelines on neuroimaging for neonates with NE. This review outlines the primary patterns of brain injury associated with hypoxic-ischemic injury in neonates with NE and their frequency, associated neuropathological features, and risk factors. In addition, it provides an overview of neuroimaging methods, including the most widely used scoring systems used to characterize brain injury in these neonates and their utility as predictive biomarkers. Last, recommendations for neuroimaging in neonates with NE are presented.
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Affiliation(s)
- Jessica L. Wisnowski
- Departments of Radiology and Pediatrics (Neonatology), Children’s Hospital Los Angeles, 4650 Sunset Blvd. MS #81, Los Angeles CA 90027, USA
| | - Pia Wintermark
- Department of Pediatrics (Neonatology), McGill University/Montreal Children's Hospital, Division of Newborn Medicine, Research Institute of the McGill University Health Centre, 1001 boul. Décarie, Site Glen Block E, EM0.3244, Montréal, QC H4A 3J1, Canada.
| | - Sonia L. Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics (Neonatology), Lucile Packard Children’s Hospital, Stanford University School of Medicine, 750 Welch Road, Suite 315, Palo Alto, CA 94304, USA
| | - Christopher D. Smyser
- Departments of Neurology, Radiology, and Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8111, St Louis, MO 63110-1093, USA
| | - A. James Barkovich
- Department of Radiology, UCSF Benioff Children’s Hospital, University of California San Francisco, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA
| | - A. David Edwards
- Evelina London Children’s Hospital, Centre for Developing Brain, King’s College London, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Linda S. de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht University, Lundlaan 6, 3584 EA, Utrecht, the Netherlands
| | - Terrie E. Inder
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Vann Chau
- Department of Pediatrics (Neurology), The Hospital for Sick Children, University of Toronto, 555 University Avenue, Room 6513, Toronto, ON M5G 1X8, Canada.
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14
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Liddle LJ, Kalisvaart ACJ, Abrahart AH, Almekhlafi M, Demchuk A, Colbourne F. Targeting focal ischemic and hemorrhagic stroke neuroprotection: Current prospects for local hypothermia. J Neurochem 2021; 160:128-144. [PMID: 34496050 DOI: 10.1111/jnc.15508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/01/2021] [Accepted: 09/05/2021] [Indexed: 01/17/2023]
Abstract
Therapeutic hypothermia (TH) has applications dating back millennia. In modern history, however, TH saw its importation into medical practice where investigations have demonstrated that TH is efficacious in ischemic insults, notably cardiac arrest and hypoxic-ischemic encephalopathy. As well, studies have been undertaken to investigate whether TH can provide benefit in focal stroke (i.e., focal ischemia and intracerebral hemorrhage). However, clinical studies have encountered various challenges with induction and maintenance of post-stroke TH. Most clinical studies have attempted to use body-wide cooling protocols, commonly hindered by side effects that can worsen post-stroke outcomes. Some of the complications and difficulties with systemic TH can be circumvented by using local hypothermia (LH) methods. Additional advantages include the potential for lower target temperatures to be achieved and faster TH induction rates with LH. This systematic review summarizes the body of clinical and preclinical LH focal stroke studies and raises key points to consider for future LH research. We conclude with an overview of LH neuroprotective mechanisms and a comparison of LH mechanisms with those observed with systemic TH. Overall, whereas many LH studies have been conducted preclinically in the context of focal ischemia, insufficient work has been done in intracerebral hemorrhage. Furthermore, key translational studies have yet to be done in either stroke subtype (e.g., varied models and time-to-treat, studies considering aged animals or animals with co-morbidities). Few clinical LH investigations have been performed and the optimal LH parameters to achieve neuroprotection are unknown.
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Affiliation(s)
- Lane J Liddle
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
| | | | - Ashley H Abrahart
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Frederick Colbourne
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada.,Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
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15
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Perioperative GABA Blood Concentrations in Infants with Cyanotic and Non-Cyanotic Congenital Heart Diseases. Diagnostics (Basel) 2021; 11:diagnostics11071149. [PMID: 34202425 PMCID: PMC8304774 DOI: 10.3390/diagnostics11071149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 11/17/2022] Open
Abstract
Perioperative stress detection in children with congenital heart disease (CHD), particularly in the brain, is still limited. Among biomarkers, γ-amino-aminobutyric acid (GABA) assessment in biological fluids appears to be promising for its regulatory action on the cardiovascular and cerebral systems. We aimed to investigate cyanotic (C) or non-cyanotic (N) CHD children for GABA blood level changes in the perioperative period. We conducted an observational study in 68 CHD infants (C: n = 33; N: n = 35) who underwent perioperative clinical, standard laboratory and monitoring parameter recordings and GABA assessment. Blood samples were drawn at five predetermined time-points before, during and after surgery. No significant perioperative differences were observed between groups in clinical and laboratory parameters. In C, perioperative GABA levels were significantly lower than N. Arterial oxygen saturation and blood concentration significantly differed between C and N children and correlated at cardiopulmonary by-pass (CPB) time-point with GABA levels. The present data showing higher hypoxia/hyperoxia-mediated GABA concentrations in C children suggest that they are more prone to perioperative cardiovascular and brain stress/damage. The findings suggest the usefulness of further investigations to detect the “optimal” oxygen concentration target in order to avoid the side effects associated with re-oxygenation during CPB.
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16
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Li K, Zheng Y, Wang X. Self-Regulation of Cerebral Metabolism and Its Neuroprotective Effect After Hypoxic-Ischemic Injury: Evidence From 1H-MRS. Front Neuroanat 2021; 15:672412. [PMID: 34220456 PMCID: PMC8247914 DOI: 10.3389/fnana.2021.672412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/24/2021] [Indexed: 12/27/2022] Open
Abstract
1H-MRS technology can be used to non-invasively detect the content of cerebral metabolites, to assess the severity of hypoxic-ischemic (HI) injury, and to predict the recovery of compromised neurological function. However, changes to the cerebral self-regulation process after HI are still unclear. This study investigated the changes in cerebral metabolites and the potential relationship with the number of neurons and neural stem/progenitor cells (NSPC) using 1H-MRS, and finally clarifies the self-regulation of cerebral metabolism and neuroprotection after HI injury. Newborn Yorkshire pigs (28 males, 1.0–1.5 kg) aged 3–5 days were used for the HI model in this study. The pigs were randomly divided into the HI group (n = 24) and the control group (n = 4), then the experimental group was subdivided according to different recovery time after HI into the following groups: 0–2 h (n = 4), 2–6 h (n = 4), 6–12 h (n = 4), 12–24 h (n = 4), 24–48 h (n = 4), and 48–72 h (n = 4). Following the HI timepoints, 1H-MRS scans were performed and processed using LCModel software, and brain tissue was immunohistochemically stained for Nestin and NeuN. Immunofluorescence staining of creatine phosphokinase-BB (CK-BB), N-acetylaspartylglutamate synthetase (NAAGS), glutamate carboxypeptidase II (GCP-II), glutamate-cysteine ligase catalytic subunit (GCLC), glutathione synthase (GS), and excitatory amino acid carrier 1 (EAAC1) was then performed. The 1H-MRS results showed that cerebral N-acetylaspartylglutamate (NAAG), glutathione (GSH), and creatine (Cr) content reached their peaks at 12–24 h, which was consistent with the recovery time of hippocampal NSPCs and neurons, indicating a potential neuroprotective effect of NAAG, GSH, and Cr after HI injury.
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Affiliation(s)
- Kexin Li
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yang Zheng
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiaoming Wang
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
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17
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Wisnowski JL, Bluml S, Panigrahy A, Mathur AM, Berman J, Chen PSK, Dix J, Flynn T, Fricke S, Friedman SD, Head HW, Ho CY, Kline-Fath B, Oveson M, Patterson R, Pruthi S, Rollins N, Ramos YM, Rampton J, Rusin J, Shaw DW, Smith M, Tkach J, Vasanawala S, Vossough A, Whitehead MT, Xu D, Yeom K, Comstock B, Heagerty PJ, Juul SE, Wu YW, McKinstry RC. Integrating neuroimaging biomarkers into the multicentre, high-dose erythropoietin for asphyxia and encephalopathy (HEAL) trial: rationale, protocol and harmonisation. BMJ Open 2021; 11:e043852. [PMID: 33888528 PMCID: PMC8070884 DOI: 10.1136/bmjopen-2020-043852] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION MRI and MR spectroscopy (MRS) provide early biomarkers of brain injury and treatment response in neonates with hypoxic-ischaemic encephalopathy). Still, there are challenges to incorporating neuroimaging biomarkers into multisite randomised controlled trials. In this paper, we provide the rationale for incorporating MRI and MRS biomarkers into the multisite, phase III high-dose erythropoietin for asphyxia and encephalopathy (HEAL) Trial, the MRI/S protocol and describe the strategies used for harmonisation across multiple MRI platforms. METHODS AND ANALYSIS Neonates with moderate or severe encephalopathy enrolled in the multisite HEAL trial undergo MRI and MRS between 96 and 144 hours of age using standardised neuroimaging protocols. MRI and MRS data are processed centrally and used to determine a brain injury score and quantitative measures of lactate and n-acetylaspartate. Harmonisation is achieved through standardisation-thereby reducing intrasite and intersite variance, real-time quality assurance monitoring and phantom scans. ETHICS AND DISSEMINATION IRB approval was obtained at each participating site and written consent obtained from parents prior to participation in HEAL. Additional oversight is provided by an National Institutes of Health-appointed data safety monitoring board and medical monitor. TRIAL REGISTRATION NUMBER NCT02811263; Pre-result.
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Affiliation(s)
- Jessica L Wisnowski
- Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
- Pediatrics, Children's Hospital Los Angeles Division of Neonatology, Los Angeles, California, USA
| | - Stefan Bluml
- Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Ashok Panigrahy
- Radiology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amit M Mathur
- Pediatrics, Division of Neonatal-Perinatal Medicine, SSM Health Cardinal Glennon Children's Hospital, Saint Louis, Missouri, USA
- Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University, Saint Louis, Missouri, USA
| | - Jeffrey Berman
- Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - James Dix
- Radiology, Methodist Children's Hospital, San Antonio, Texas, USA
| | - Trevor Flynn
- Radiology, University of California San Francisco, San Francisco, California, USA
| | - Stanley Fricke
- Radiology, Children's National Medical Center, Washington, District of Columbia, USA
- Radiology, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Seth D Friedman
- Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Hayden W Head
- Radiology, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Chang Y Ho
- Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Beth Kline-Fath
- Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael Oveson
- Radiology, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Richard Patterson
- Radiology, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - Sumit Pruthi
- Radiology, Vanderbilt University, Nashville, Tennessee, USA
| | - Nancy Rollins
- Radiology, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Yanerys M Ramos
- Radiology, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
| | - John Rampton
- Radiology, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Jerome Rusin
- Radiology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Dennis W Shaw
- Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Mark Smith
- Radiology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jean Tkach
- Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Arastoo Vossough
- Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew T Whitehead
- Radiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Duan Xu
- Radiology, University of California San Francisco, San Francisco, California, USA
| | - Kristen Yeom
- Radiology, Stanford University, Stanford, California, USA
| | - Bryan Comstock
- Biostatistics, University of Washington, Seattle, Washington, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sandra E Juul
- Pediatrics, Division of Neonatology, University of Washington, Seattle, Washington, USA
| | - Yvonne W Wu
- Neurology, University of California San Francisco, San Francisco, California, USA
| | - Robert C McKinstry
- Radiology, St. Louis Children's Hospital and Washington University, Saint Louis, Missouri, USA
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18
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Park YJ, Borlongan CV, Dezawa M. Cell-based treatment for perinatal hypoxic-ischemic encephalopathy. Brain Circ 2021; 7:13-17. [PMID: 34084971 PMCID: PMC8057102 DOI: 10.4103/bc.bc_7_21] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/03/2021] [Accepted: 01/20/2021] [Indexed: 12/03/2022] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) is a major cause of acute neonatal brain injury and can lead to disabling long-term neurological complications. Treatment for HIE is limited to supportive care and hypothermia within 6 h injury which is reserved for full-term infants. Preclinical studies suggest the potential for cell-based therapies as effective treatments for HIE. Some clinical trials using umbilical cord blood cells, placenta-derived stem cells, mesenchymal stem cells (MSCs), and others have yielded promising results though more studies are needed to optimize protocols and multi-center trials are needed to prove safety and efficacy. To date, the therapeutic effects of most cell-based therapies are hypothesized to stem from the bystander effect of donor cells. Transplantation of stem cells attenuate the aberrant inflammation cascade following HIE and provide a more ideal environment for endogenous neurogenesis and repair. Recently, a subset of MSCs, the multilineage-differentiating stress-enduring (Muse) cells have shown to treat HIE and other models of neurologic diseases by replacing dead or ischemic cells and have reached clinical trials. In this review, we examine the different cell sources used in clinical trials and evaluate the underlying mechanism behind their therapeutic effects. Three databases–PubMed, Web of Science, and ClinicalTrials.gov–were used to review preclinical and clinical experimental treatments for HIE.
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Affiliation(s)
- You Jeong Park
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Cesario V Borlongan
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Mari Dezawa
- Department of Stem Cell Biology and Histology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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19
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Mitochondrial Dysfunction and Permeability Transition in Neonatal Brain and Lung Injuries. Cells 2021; 10:cells10030569. [PMID: 33807810 PMCID: PMC7999701 DOI: 10.3390/cells10030569] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/27/2021] [Accepted: 03/01/2021] [Indexed: 01/16/2023] Open
Abstract
This review discusses the potential mechanistic role of abnormally elevated mitochondrial proton leak and mitochondrial bioenergetic dysfunction in the pathogenesis of neonatal brain and lung injuries associated with premature birth. Providing supporting evidence, we hypothesized that mitochondrial dysfunction contributes to postnatal alveolar developmental arrest in bronchopulmonary dysplasia (BPD) and cerebral myelination failure in diffuse white matter injury (WMI). This review also analyzes data on mitochondrial dysfunction triggered by activation of mitochondrial permeability transition pore(s) (mPTP) during the evolution of perinatal hypoxic-ischemic encephalopathy. While the still cryptic molecular identity of mPTP continues to be a subject for extensive basic science research efforts, the translational significance of mitochondrial proton leak received less scientific attention, especially in diseases of the developing organs. This review is focused on the potential mechanistic relevance of mPTP and mitochondrial dysfunction to neonatal diseases driven by developmental failure of organ maturation or by acute ischemia-reperfusion insult during development.
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20
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How to Improve the Antioxidant Defense in Asphyxiated Newborns-Lessons from Animal Models. Antioxidants (Basel) 2020; 9:antiox9090898. [PMID: 32967335 PMCID: PMC7554981 DOI: 10.3390/antiox9090898] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/12/2020] [Accepted: 09/15/2020] [Indexed: 02/07/2023] Open
Abstract
Oxygen free radicals have been implicated in brain damage after neonatal asphyxia. In the early phase of asphyxia/reoxygenation, changes in antioxidant enzyme activity play a pivotal role in switching on and off the cascade of events that can kill the neurons. Hypoxia/ischemia (H/I) forces the brain to activate endogenous mechanisms (e.g., antioxidant enzymes) to compensate for the lost or broken neural circuits. It is important to evaluate therapies to enhance the self-protective capacity of the brain. In animal models, decreased body temperature during neonatal asphyxia has been shown to increase cerebral antioxidant capacity. However, in preterm or severely asphyxiated newborns this therapy, rather than beneficial seems to be harmful. Thus, seeking new therapeutic approaches to prevent anoxia-induced complications is crucial. Pharmacotherapy with deferoxamine (DFO) is commonly recognized as a beneficial regimen for H/I insult. DFO, via iron chelation, reduces oxidative stress. It also assures an optimal antioxidant protection minimizing depletion of the antioxidant enzymes as well as low molecular antioxidants. In the present review, some aspects of recently acquired insight into the therapeutic effects of hypothermia and DFO in promoting neuronal survival after H/I are discussed.
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21
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Abstract
Cerebrovascular autoregulation is the ability to maintain stable cerebral blood flow within a range of cerebral perfusion pressures. When cerebral perfusion pressure is outside the limits of effective autoregulation, the brain is subjected to hypoperfusion or hyperperfusion, which may cause vascular injury, hemorrhage, and/or hypoxic white matter injury. Infants born preterm, after fetal growth restriction, with congenital heart disease, or with hypoxic-ischemic encephalopathy are susceptible to a failure of cerebral autoregulation. Bedside assessment of cerebrovascular autoregulation would offer the opportunity to prevent brain injury. Clinicians need to know which patient populations and circumstances are associated with impaired/absent cerebral autoregulation.
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Affiliation(s)
- Elisabeth M W Kooi
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, PO Box 30001, Groningen 9700 RB, The Netherlands.
| | - Anne E Richter
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, PO Box 30001, Groningen 9700 RB, The Netherlands
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22
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Derivation of a metabolic signature associated with bacterial meningitis in infants. Pediatr Res 2020; 88:184-191. [PMID: 32120377 PMCID: PMC7390682 DOI: 10.1038/s41390-020-0816-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/03/2020] [Accepted: 02/09/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diagnosis of bacterial meningitis (BM) is challenging in newborn infants. Presently, biomarkers of BM have limited diagnostic accuracy. Analysis of cerebrospinal fluid (CSF) metabolites may be a useful diagnostic tool in BM. METHODS In a nested case-control study, we examined >400 metabolites in CSF of uninfected infants and infants with culture-confirmed BM using gas and liquid chromatography mass spectrometry. Preterm and full-term infants in a Level III or IV Neonatal Intensive Care Unit were prospectively enrolled when evaluated for serious bacterial infection. RESULTS Over 200 CSF metabolites significantly differed in uninfected infants and infants with BM. Using machine learning, we found that as few as 6 metabolites distinguished infants with BM from uninfected infants in this pilot cohort. Further analysis demonstrated three metabolites associated with Group B Streptococcal meningitis. CONCLUSIONS We report the first comprehensive metabolic analysis of CSF in infants with BM. In our pilot cohort, we derived a metabolic signature that predicted the presence or absence of BM, irrespective of gestational age, postnatal age, sex, race and ethnicity, presence of neurosurgical hardware, white blood cell count in CSF, and red blood cell contamination in CSF. Metabolic analysis may aid diagnosis of BM and facilitate clinical decision-making in infants. IMPACT In a pilot cohort, metabolites in cerebrospinal fluid distinguished infants with bacterial meningitis from uninfected infants.We report the first comprehensive metabolic analysis of cerebrospinal fluid in infants with bacterial meningitis.Our findings may be used to improve diagnosis of bacterial meningitis and to offer mechanistic insights into the pathophysiology of bacterial meningitis in infants.
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Di Salvo ML, Hargett SL, Jnah A, Newberry D. System Specific Effects of Therapeutic Hypothermia with Neonatal Encephalopathy: Pearls for Clinicians. Neonatal Netw 2020; 39:205-214. [PMID: 32675316 DOI: 10.1891/0730-0832.39.4.205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 06/11/2023]
Abstract
Neonatal encephalopathy (NE) is defined as a condition of impaired neurological function often caused by a peripartum event that impairs gas exchange resulting in hypoxia, hypercapnia, cerebral ischemia, and metabolic acidosis. NE is a significant cause of neonatal morbidity and mortality. Therapeutic hypothermia (TH) is the standard of care for the treatment of moderate and severe NE and has significantly improved long-term outcomes for affected infants. There are extensive systemic physiologic effects associated with TH that clinicians need to be aware of to optimize care for these infants. There is a paucity of literature that comprehensively identifies causal relationships between the physiologic and biochemical effects of TH. This can leave neonatal clinicians devoid of a comprehensive understanding of the medical management of NE. Therefore, this article seeks to help fill this gap, improve clinician knowledge base, and ultimately improve the care of infants undergoing TH.
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Abstract
Perinatal brain injury is a major cause of neurological disability in both premature and term infants. In this review, we summarize the evidence behind some established neuroprotective practices such as administration of antenatal steroids, intrapartum magnesium for preterm delivery, and therapeutic hypothermia. In addition, we examine emerging practices such as delayed cord clamping, postnatal magnesium administration, recombinant erythropoietin, and non-steroidal anti-inflammatory agents and finally inform the reader about novel interventions, some of which are currently in trials, such as xenon, melatonin, topiramate, allopurinol, creatine, and autologous cord cell therapy.
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Affiliation(s)
- Samata Singhi
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA.,Department of Pediatric Neurology, Johns Hopkins Medicine, Baltimore, MD, 21287, USA
| | - Michael Johnston
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA
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25
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Liu QT, Zhong XY. [Application of metabolomics in neonatal clinical practice]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:942-948. [PMID: 31506158 PMCID: PMC7390243 DOI: 10.7499/j.issn.1008-8830.2019.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/08/2019] [Indexed: 06/10/2023]
Abstract
Metabolomics is an emerging and popular subject in the post-genome era, and a large number of studies have been noted on the application of metabolomics in health evaluation, growth and development evaluation, disease diagnosis, and therapeutic efficacy evaluation. As a special period of life, the neonatal period is characterized by rapid cell renewing, consumption of a lot of energy and materials, and changes in metabolic pathways, all of which affect the level of metabolites. However, there is still no reference standard for metabolic level and profile in neonates. This article reviews the current status of metabolic research on neonatal growth and development and common diseases and related clinical application of metabolomics, so as to provide new ideas for nutrition guidance and evaluation, selection of therapeutic regimens, and new drug research in neonates.
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Affiliation(s)
- Qiu-Tong Liu
- Department of Neonatology, Chongqing Health Center for Children and Women, Chongqing 400000, China.
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Chen S, Liu X, Mei Y, Li C, Ren D, Zhong M, Xu Y. Early identification of neonatal mild hypoxic-ischemic encephalopathy by amide proton transfer magnetic resonance imaging: A pilot study. Eur J Radiol 2019; 119:108620. [PMID: 31422164 DOI: 10.1016/j.ejrad.2019.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 07/13/2019] [Accepted: 07/16/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE This study aimed to evaluate the amide proton transfer (APT) values in neonates with mild hypoxic-ischemic encephalopathy (HIE) using APT imaging. METHOD A total of 30 full-term neonates with mild HIE (16 males and 14 females; mean postnatal age 4.2 days, age range 2-7 days) and 12 normal neonates (six males and six females; mean postnatal age 3.3 days, age range 2-5 days) underwent conventional magnetic resonance imaging and APT imaging. APT measurements were performed in multiple regions of interest (ROIs) in the brain. APT values were statistically analyzed to assess for significant differences between the mild HIE and normal neonates in different regions of the brain, and correlation with neonatal gestational age. RESULTS In 30 neonates with mild HIE, 10% (3/30) of the HIE patients had normal conventional MRI. There were significant differences in APT values of the HIE group in bilateral caudate, bilateral thalamus, bilateral centrum semiovale and left globus pallidus/putamen (p < 0.05), and no statistical difference was observed in right globus pallidus/putamen (p = 0.051) and brainstem (p = 0.073) between the two groups. Furthermore, APT values in bilateral caudate, bilateral globus pallidus/putamen, bilateral thalamus, and brainstem regions (p < 0.05) exhibited positive linear correlations with gestational age in the control group, except for bilateral centrum semiovale (right: Pearson's r = 0.554, p = 0.062; left: Pearson's r = 0.561, p = 0.058). In the mild HIE groups, no significant correlation with gestational age was found in all regions. CONCLUSIONS APT imaging is a feasible and useful technique with diagnostic capability for neonatal HIE.
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Affiliation(s)
- Sijin Chen
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China; Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University Guangzhou 510515, China
| | - Xilong Liu
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yingjie Mei
- Philips Healthcare, Guangzhou, Guangdong 510055, China
| | - Caixia Li
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Daokun Ren
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Mei Zhong
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University Guangzhou 510515, China
| | - Yikai Xu
- Department of Medical Imaging Center, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.
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Lucke AM, Shetty AN, Hagan JL, Walton A, Stafford TD, Chu ZD, Rhee CJ, Kaiser JR, Sanz Cortes M. Early proton magnetic resonance spectroscopy during and after therapeutic hypothermia in perinatal hypoxic-ischemic encephalopathy. Pediatr Radiol 2019; 49:941-950. [PMID: 30918993 DOI: 10.1007/s00247-019-04383-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/04/2019] [Accepted: 03/08/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy (HIE) remains a significant cause of mortality and neurodevelopmental impairment despite treatment with therapeutic hypothermia. Magnetic resonance H1-spectroscopy measures concentrations of cerebral metabolites to detect derangements in aerobic metabolism. OBJECTIVE We assessed MR spectroscopy in neonates with HIE within 18-24 h of initiating therapeutic hypothermia and at 5-6 days post therapeutic hypothermia. MATERIALS AND METHODS Eleven neonates with HIE underwent MR spectroscopy of the basal ganglia and white matter. We compared metabolite concentrations during therapeutic hypothermia and post-therapeutic hypothermia and between moderate and severe HIE. RESULTS During therapeutic hypothermia, neonates with severe HIE had decreased basal ganglia N-acetylaspartate (NAA; 0.62±0.08 vs. 0.72±0.05; P=0.02), NAA + N-acetylaspartylglutamate (NAAG; 0.66±0.11 vs. 0.77±0.06; P=0.05), glycerophosphorylcholine + phosphatidylcholine (GPC+PCh; 0.28±0.05 vs. 0.38±0.06; P=0.02) and decreased white matter GPC+PCh (0.35±0.13 vs. 0.48±0.04; P=0.02) compared to neonates with moderate HIE. For all subjects, basal ganglia NAA decreased (-0.08±0.07; P=0.01), whereas white matter GPC+PCh increased (0.03±0.04; P=0.04) from therapeutic hypothermia MRI to post-therapeutic-hypothermia MRI. All metabolite values are expressed in mmol/L. CONCLUSION Decreased NAA and GPC+PCh were associated with greater HIE severity and could distinguish neonates who might benefit most from targeted additional neuroprotective therapies.
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Affiliation(s)
- Ashley M Lucke
- Fetal Medicine Institute, Children's National Health System, 111 Michigan Ave. NW, Washington, DC, 20010, USA.
- Department of Pediatrics (Neonatology), Baylor College of Medicine, Houston, TX, USA.
| | - Anil N Shetty
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital Pavilion for Women, Houston, TX, USA
| | - Joseph L Hagan
- Department of Pediatrics (Neonatology), Baylor College of Medicine, Houston, TX, USA
| | - Allison Walton
- Department of Pediatrics (Neonatology), Baylor College of Medicine, Houston, TX, USA
| | - Tiffany D Stafford
- Department of Pediatrics (Neonatology), Baylor College of Medicine, Houston, TX, USA
| | - Zili D Chu
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Christopher J Rhee
- Department of Pediatrics (Neonatology), Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey R Kaiser
- Departments of Pediatrics (Neonatal-Perinatal Medicine) and Obstetrics and Gynecology, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital Pavilion for Women, Houston, TX, USA
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28
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Jackson TC, Kochanek PM. A New Vision for Therapeutic Hypothermia in the Era of Targeted Temperature Management: A Speculative Synthesis. Ther Hypothermia Temp Manag 2019; 9:13-47. [PMID: 30802174 PMCID: PMC6434603 DOI: 10.1089/ther.2019.0001] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Three decades of animal studies have reproducibly shown that hypothermia is profoundly cerebroprotective during or after a central nervous system (CNS) insult. The success of hypothermia in preclinical acute brain injury has not only fostered continued interest in research on the classic secondary injury mechanisms that are prevented or blunted by hypothermia but has also sparked a surge of new interest in elucidating beneficial signaling molecules that are increased by cooling. Ironically, while research into cold-induced neuroprotection is enjoying newfound interest in chronic neurodegenerative disease, conversely, the scope of the utility of therapeutic hypothermia (TH) across the field of acute brain injury is somewhat controversial and remains to be fully defined. This has led to the era of Targeted Temperature Management, which emphasizes a wider range of temperatures (33–36°C) showing benefit in acute brain injury. In this comprehensive review, we focus on our current understandings of the novel neuroprotective mechanisms activated by TH, and discuss the critical importance of developmental age germane to its clinical efficacy. We review emerging data on four cold stress hormones and three cold shock proteins that have generated new interest in hypothermia in the field of CNS injury, to create a framework for new frontiers in TH research. We make the case that further elucidation of novel cold responsive pathways might lead to major breakthroughs in the treatment of acute brain injury, chronic neurological diseases, and have broad potential implications for medicines of the distant future, including scenarios such as the prevention of adverse effects of long-duration spaceflight, among others. Finally, we introduce several new phrases that readily summarize the essence of the major concepts outlined by this review—namely, Ultramild Hypothermia, the “Responsivity of Cold Stress Pathways,” and “Hypothermia in a Syringe.”
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Affiliation(s)
- Travis C Jackson
- 1 John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania.,2 Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Patrick M Kochanek
- 1 John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania.,2 Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
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29
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Cerebral oxygen metabolism during and after therapeutic hypothermia in neonatal hypoxic-ischemic encephalopathy: a feasibility study using magnetic resonance imaging. Pediatr Radiol 2019; 49:224-233. [PMID: 30402807 DOI: 10.1007/s00247-018-4283-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/09/2018] [Accepted: 10/05/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Therapeutic hypothermia is the standard-of-care treatment for infants diagnosed with moderate-to-severe hypoxic-ischemic encephalopathy (HIE). MRI for assessing brain injury is usually performed after hypothermia because of logistical challenges in bringing acutely sick infants receiving hypothermia from the neonatal intensive care unit (NICU) to the MRI suite. Perhaps examining and comparing early cerebral oxygen metabolism disturbances to those after rewarming will lead to a better understanding of the mechanisms of brain injury in HIE and the effects of therapeutic hypothermia. OBJECTIVE The objectives were to assess the feasibility of performing a novel T2-relaxation under spin tagging (TRUST) MRI technique to measure venous oxygen saturation very early in the time course of treatment, 18-24 h after the initiation of therapeutic hypothermia, to provide a framework to measure neonatal cerebral oxygen metabolism noninvasively, and to compare parameters between early and post-hypothermia MRIs. MATERIALS AND METHODS Early (18-24 h after initiating hypothermia) MRIs were performed during hypothermia treatment in nine infants with HIE (six with moderate and three with severe HIE). Six infants subsequently had an MRI after hypothermia. Mean values of cerebral blood flow, oxygen extraction fraction, and cerebral metabolic rate of oxygen from MRIs during hypothermia were compared between infants with moderate and severe HIE; and in those with moderate HIE, we compared cerebral oxygen metabolism parameters between MRIs performed during and after hypothermia. RESULTS During the initial hypothermia MRI at 23.5±5.2 h after birth, infants with severe HIE had lower oxygen extraction fraction (P=0.04) and cerebral metabolic rate of oxygen (P=0.03) and a trend toward lower cerebral blood flow (P=0.33) compared to infants with moderate HIE. In infants with moderate HIE, cerebral blood flow decreased and oxygen extraction fraction increased between MRIs during and after hypothermia (although not significantly); cerebral metabolic rate of oxygen (P=0.93) was not different. CONCLUSION Early MRIs were technically feasible while maintaining hypothermic goal temperatures in infants with HIE. Cerebral oxygen metabolism early during hypothermia is more disturbed in severe HIE. In infants with moderate HIE, cerebral blood flow decreased and oxygen extraction fraction increased between early and post-hypothermia scans. A comparison of cerebral oxygen metabolism parameters between early and post-hypothermia MRIs might improve our understanding of the evolution of HIE and the benefits of hypothermia. This approach could guide the use of adjunctive neuroprotective strategies in affected infants.
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Gertsvolf N, Votava-Smith JK, Ceschin R, Del Castillo S, Lee V, Lai HA, Bluml S, Paquette L, Panigrahy A. Association between Subcortical Morphology and Cerebral White Matter Energy Metabolism in Neonates with Congenital Heart Disease. Sci Rep 2018; 8:14057. [PMID: 30232359 PMCID: PMC6145929 DOI: 10.1038/s41598-018-32288-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 09/05/2018] [Indexed: 12/11/2022] Open
Abstract
Complex congenital heart disease (CHD) is associated with neurodevelopmental impairment, the mechanism of which is unknown. Cerebral cortical dysmaturation in CHD is linked to white matter abnormalities, including developmental vulnerability of the subplate, in relation to oxygen delivery and metabolism deficits. In this study, we report associations between subcortical morphology and white matter metabolism in neonates with CHD using quantitative magnetic resonance imaging (MRI) and spectroscopy (MRS). Multi-modal brain imaging was performed in three groups of neonates close to term-equivalent age: (1) term CHD (n = 56); (2) preterm CHD (n = 37) and (3) preterm control group (n = 22). Thalamic volume and cerebellar transverse diameter were obtained in relation to cerebral metrics and white matter metabolism. Short echo single-voxel MRS of parietal and frontal white matter was used to quantitate metabolites related to brain maturation (n-acetyl aspartate [NAA], choline, myo-inositol), neurotransmitter (glutamate), and energy metabolism (glutamine, citrate, creatine and lactate). Multi-variate regression was performed to delineate associations between subcortical morphological measurements and white matter metabolism controlling for age and white matter injury. Reduced thalamic volume, most pronounced in the preterm control group, was associated with increased citrate levels in all three group in the parietal white matter. In contrast, reduced cerebellar volume, most pronounced in the preterm CHD group, was associated with reduced glutamine in parietal grey matter in both CHD groups. Single ventricle anatomy, aortic arch obstruction, and cyanotic lesion were predictive of the relationship between reduced subcortical morphometry and reduced GLX (particularly glutamine) in both CHD cohorts (frontal white matter and parietal grey matter). Subcortical morphological associations with brain metabolism were also distinct within each of the three groups, suggesting these relationships in the CHD groups were not directly related to prematurity or white matter injury alone. Taken together, these findings suggest that subplate vulnerability in CHD is likely relevant to understanding the mechanism of both cortical and subcortical dysmaturation in CHD infants. Future work is needed to link this potential pattern of encephalopathy of CHD (including the constellation of grey matter, white matter and brain metabolism deficits) to not only abnormal fetal substrate delivery and oxygen conformance, but also regional deficits in cerebral energy metabolism.
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Affiliation(s)
- Nina Gertsvolf
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jodie K Votava-Smith
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Rafael Ceschin
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, USA
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Sylvia Del Castillo
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Anesthesiology, Critical Care Medicine Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Vince Lee
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Hollie A Lai
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Stefan Bluml
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Lisa Paquette
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, USA.
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, USA.
- Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA.
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31
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Zou R, Xiong T, Zhang L, Li S, Zhao F, Tong Y, Qu Y, Mu D. Proton Magnetic Resonance Spectroscopy Biomarkers in Neonates With Hypoxic-Ischemic Encephalopathy: A Systematic Review and Meta-Analysis. Front Neurol 2018; 9:732. [PMID: 30233483 PMCID: PMC6127251 DOI: 10.3389/fneur.2018.00732] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 08/10/2018] [Indexed: 01/15/2023] Open
Abstract
Background: Hypoxic-ischemic encephalopathy (HIE) is a major contributor to child mortality and morbidity. Reliable prognostication for HIE is of key importance. Proton magnetic resonance spectroscopy (1H-MRS) is a quantitative, non-invasive method that has been demonstrated to be a suitable complementary tool for prediction. The aim of this study was to investigate the prognostic capability of 1H-MRS in the era of therapeutic hypothermia (TH). Methods: Databases, namely MEDLINE, Embase, Web of Science, and the Cochrane library (Cochrane Center Register of Controlled Trials), were searched for studies published before July 17, 2017. Study selection and data extraction were performed by two independent reviewers. The mean difference (MD) or standardized MD (SMD) and 95% confidence interval (CI) were calculated using random-effects models. Subgroup analyses were conducted based on the use of TH. Results: Among the 1,150 relevant studies, seven were included for meta-analysis, but only two small studies were conducted under TH. For 1H-MRS measurement, three peak area ratios revealed predictive values for adverse outcomes in TH subgroup and the combined results (with and without TH): N-acetylaspartate (NAA)/creatine in basal ganglia/thalamus (BG/T) in TH (MD −0.31, 95%CI −0.55 to −0.07) and combined results (MD −0.37, 95% CI −0.49 to −0.25); NAA/choline in BG/T in TH (MD −0.89, 95%CI −1.43 to −0.35) and combined results (MD −0.25, 95%CI −0.42 to −0.07); and myo-inositol/choline in cerebral cortex in TH (MD −1.94, 95%CI −3.69 to −0.19) and combined results (MD −1.64, 95%CI −2.64 to −0.64). Moreover, NAA relative concentration is associated with adverse outcomes: in TH (MD −0.04, 95%CI −0.06 to −0.02) and combined results (MD −0.06, 95%CI −0.11 to −0.01) in white matter; in TH (MD −0.04, 95%CI −0.07 to −0.01) and combined results (MD −0.05, 95%CI −0.07 to −0.02) in gray matter. Conclusions: NAA may be a potential marker in outcome prediction for all HIE subjects. It seems that MDs for the ratios including NAA are larger than for its relative concentration, and therefore are more likely to be measurable in a clinical context. Larger prospective multicenter studies with a standardized protocol for both measurement protocols and analysis methods are required in future studies.
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Affiliation(s)
- Rong Zou
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Tao Xiong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Li Zhang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Shiping Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Fengyan Zhao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Yu Tong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Yi Qu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
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32
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Zou R, Tang J, Bao S, Wu T, Huang JL, Qu Y, Mu DZ. [Current status of the application of 1H-magnetic resonance spectroscopy in neonates with hypoxic-ischemic encephalopathy]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:449-455. [PMID: 29972117 PMCID: PMC7389943 DOI: 10.7499/j.issn.1008-8830.2018.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 03/27/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate the current status of the application of 1H-magnetic resonance spectroscopy (1H-MRS) in neonates with hypoxic-ischemic encephalopathy (HIE), and to describe the trend of research in the field. METHODS PubMed, EMBASE, and Web of Science were searched for English articles published up to January 10, 2018, with the combination of key words and MeSH terms. The articles were screened according to inclusion and exclusion criteria. Excel 2016, Bicomb 2.0, and VOSviewer1.6.6 were used to analyze the key words, to perform a cluster analysis of hot words, and to plot the knowledge map. RESULTS A total of 66 articles were included, and 27 high-frequency key words were extracted. The results showed that 1H-MRS was mainly used in four directions of the clinical practice and scientific research on HIE. In clinical practice, 1H-MRS attracted wide attention as a clinical examination for HIE and a tool for prognostic evaluation; in scientific research, 1H-MRS was used in animal experiments and studies associated with mild hypothermia therapy. CONCLUSIONS As an auxiliary means of magnetic resonance imaging, 1H-MRS plays an important role in investigating the pathogenesis of neonatal HIE, improving existing therapies, and evaluating the prognosis of neonates with HIE.
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Affiliation(s)
- Rong Zou
- Department of Pediatrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu 610041, China.
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33
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Wu TW, Tamrazi B, Hsu KH, Ho E, Reitman AJ, Borzage M, Blüml S, Wisnowski JL. Cerebral Lactate Concentration in Neonatal Hypoxic-Ischemic Encephalopathy: In Relation to Time, Characteristic of Injury, and Serum Lactate Concentration. Front Neurol 2018; 9:293. [PMID: 29867713 PMCID: PMC5958276 DOI: 10.3389/fneur.2018.00293] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/16/2018] [Indexed: 01/25/2023] Open
Abstract
Background Cerebral lactate concentration can remain detectable in neonatal hypoxic-ischemic encephalopathy (HIE) after hemodynamic stability. The temporal resolution of regional cerebral lactate concentration in relation to the severity or area of injury is unclear. Furthermore, the interplay between serum and cerebral lactate in neonatal HIE has not been well defined. The study aims to describe cerebral lactate concentration in neonatal HIE in relation to time, injury, and serum lactate. Design/methods Fifty-two newborns with HIE undergoing therapeutic hypothermia (TH) were enrolled. Magnetic resonance imaging and spectroscopy (MRI + MR spectroscopy) were performed during and after TH at 54.6 ± 15.0 and 156 ± 57.6 h of life, respectively. Severity and predominant pattern of injury was scored radiographically. Single-voxel 1H MR spectra were acquired using short-echo (35 ms) PRESS sequence localized to the basal ganglia (BG), thalamus (Thal), gray matter (GM), and white matter. Cerebral lactate concentration was quantified by LCModel software. Serum and cerebral lactate concentrations were plotted based on age at time of measurement. Multiple comparisons of regional cerebral lactate concentration based on severity and predominant pattern of injury were performed. Spearman's Rho was computed to determine correlation between serum lactate and cerebral lactate concentration at the respective regions of interest. Results Overall, serum lactate concentration decreased over time. Cerebral lactate concentration remained low for less severe injury and decreased over time for more severe injury. Cerebral lactate remained detectable even after TH. During TH, there was a significant higher concentration of cerebral lactate at the areas of injury and also when injury was more severe. However, these differences were no longer observed after TH. There was a weak correlation between serum lactate and cerebral lactate concentration at the BG (rs = 0.3, p = 0.04) and Thal (rs = 0.35, p = 0.02). However, in infants with moderate-severe brain injury, a very strong correlation exists between serum lactate and cerebral lactate concentration at the BG (rs = 0.7, p = 0.03), Thal (rs = 0.9 p = 0.001), and GM (rs = 0.6, p = 0.04) regions. Conclusion Cerebral lactate is most significantly different between regions and severity of injury during TH. There is a moderate correlation between serum and cerebral lactate concentration measured in the deep gray nuclei during TH. Differences in injury and altered regional cerebral metabolism may account for these differences.
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Affiliation(s)
- Tai-Wei Wu
- Department of Pediatrics, Keck School of Medicine, Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, United States
| | - Benita Tamrazi
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Kai-Hsiang Hsu
- Department of Pediatrics, Keck School of Medicine, Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, United States.,Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan
| | - Eugenia Ho
- Department of Neurology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Aaron J Reitman
- Division of Neonatology, Department of Pediatrics, LAC + USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Matthew Borzage
- Department of Pediatrics, Keck School of Medicine, Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, United States
| | - Stefan Blüml
- Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States.,Rudi Schulte Research Institute, Santa Barbara, CA, United States
| | - Jessica L Wisnowski
- Department of Pediatrics, Keck School of Medicine, Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, United States.,Department of Radiology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States.,Rudi Schulte Research Institute, Santa Barbara, CA, United States
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Doman SE, Girish A, Nemeth CL, Drummond GT, Carr P, Garcia MS, Johnston MV, Kannan S, Fatemi A, Zhang J, Wilson MA. Early Detection of Hypothermic Neuroprotection Using T2-Weighted Magnetic Resonance Imaging in a Mouse Model of Hypoxic Ischemic Encephalopathy. Front Neurol 2018; 9:304. [PMID: 29867720 PMCID: PMC5951924 DOI: 10.3389/fneur.2018.00304] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/18/2018] [Indexed: 01/08/2023] Open
Abstract
Perinatal hypoxic-ischemic encephalopathy (HIE) can lead to neurodevelopmental disorders, including cerebral palsy. Standard care for neonatal HIE includes therapeutic hypothermia, which provides partial neuroprotection; magnetic resonance imaging (MRI) is often used to assess injury and predict outcome after HIE. Immature rodent models of HIE are used to evaluate mechanisms of injury and to examine the efficacy and mechanisms of neuroprotective interventions such as hypothermia. In this study, we first confirmed that, in the CD1 mouse model of perinatal HIE used for our research, MRI obtained 3 h after hypoxic ischemia (HI) could reliably assess initial brain injury and predict histopathological outcome. Mice were subjected to HI (unilateral carotid ligation followed by exposure to hypoxia) on postnatal day 7 and were imaged with T2-weighted MRI and diffusion-weighted MRI (DWI), 3 h after HI. Clearly defined regions of increased signal were comparable in T2 MRI and DWI, and we found a strong correlation between T2 MRI injury scores 3 h after HI and histopathological brain injury 7 days after HI, validating this method for evaluating initial injury in this model of HIE. The more efficient, higher resolution T2 MRI was used to score initial brain injury in subsequent studies. In mice treated with hypothermia, we found a significant reduction in T2 MRI injury scores 3 h after HI, compared to normothermic littermates. Early hypothermic neuroprotection was maintained 7 days after HI, in both T2 MRI injury scores and histopathology. In the normothermic group, T2 MRI injury scores 3 h after HI were comparable to those obtained 7 days after HI. However, in the hypothermic group, brain injury was significantly less 7 days after HI than at 3 h. Thus, early neuroprotective effects of hypothermia were enhanced by 7 days, which may reflect the additional 3 h of hypothermia after imaging or effects on later mechanisms of injury, such as delayed cell death and inflammation. Our results demonstrate that hypothermia has early neuroprotective effects in this model. These findings suggest that hypothermia has an impact on early mechanisms of excitotoxic injury and support initiation of hypothermic intervention as soon as possible after diagnosis of HIE.
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Affiliation(s)
- Sydney E Doman
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, United States
| | - Akanksha Girish
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, United States
| | - Christina L Nemeth
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, United States
| | - Gabrielle T Drummond
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, United States
| | - Patrice Carr
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, United States
| | - Maxine S Garcia
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, United States
| | - Michael V Johnston
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, United States.,Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sujatha Kannan
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, United States.,Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ali Fatemi
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, United States.,Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jiangyang Zhang
- Department of Radiology, New York University School of Medicine, New York, NY, United States
| | - Mary Ann Wilson
- Hugo W. Moser Research Institute at Kennedy Krieger, Baltimore, MD, United States.,Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Neuroscience, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Groenendaal F. The prognostic value of proton magnetic resonance spectroscopy in term newborns treated with therapeutic hypothermia following asphyxia. Magn Reson Imaging 2018; 48:139-140. [DOI: 10.1016/j.mri.2018.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/27/2018] [Indexed: 10/18/2022]
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The Applicability of Amide Proton Transfer Imaging in the Nervous System: Focus on Hypoxic-Ischemic Encephalopathy in the Neonate. Cell Mol Neurobiol 2017; 38:797-807. [DOI: 10.1007/s10571-017-0552-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 09/16/2017] [Indexed: 12/29/2022]
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Harriman T, Bradshaw WT, Blake SM. The Use of Whole Body Cooling in the Treatment of Hypoxic-Ischemic Encephalopathy. Neonatal Netw 2017; 36:273-279. [PMID: 28847350 DOI: 10.1891/0730-0832.36.5.273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Hypoxic-ischemic encephalopathy (HIE) is a major cause of morbidity and mortality in neonates. Hypoxic-ischemic encephalopathy occurs as a result of a perinatal hypoxic-ischemic event just prior to or during delivery. Therapeutic hypothermia using whole body cooling is the current treatment of choice to reduce brain injury and improve long-term neurodevelopmental outcomes for neonates with HIE. All English language articles published since 2005 in PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were analyzed for existing evidence-based methods for whole body cooling. Whole body cooling is effective in the treatment of HIE in term and near-term neonates. Further research is needed to investigate the use of adjunctive therapies in conjunction with whole body cooling for improved neuroprotection.
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Nemeth CL, Drummond GT, Mishra MK, Zhang F, Carr P, Garcia MS, Doman S, Fatemi A, Johnston MV, Kannan RM, Kannan S, Wilson MA. Uptake of dendrimer-drug by different cell types in the hippocampus after hypoxic-ischemic insult in neonatal mice: Effects of injury, microglial activation and hypothermia. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2017; 13:2359-2369. [PMID: 28669854 DOI: 10.1016/j.nano.2017.06.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 05/15/2017] [Accepted: 06/22/2017] [Indexed: 12/13/2022]
Abstract
Perinatal hypoxic-ischemic encephalopathy (HIE) can result in neurodevelopmental disability, including cerebral palsy. The only treatment, hypothermia, provides incomplete neuroprotection. Hydroxyl polyamidoamine (PAMAM) dendrimers are being explored for targeted delivery of therapy for HIE. Understanding the biodistribution of dendrimer-conjugated drugs into microglia, neurons and astrocytes after brain injury is essential for optimizing drug delivery. We conjugated N-acetyl-L-cysteine to Cy5-labeled PAMAM dendrimer (Cy5-D-NAC) and used a mouse model of perinatal HIE to study effects of timing of administration, hypothermia, brain injury, and microglial activation on uptake. Dendrimer conjugation delivered therapy most effectively to activated microglia but also targeted some astrocytes and injured neurons. Cy5-D-NAC uptake was correlated with brain injury in all cell types and with activated morphology in microglia. Uptake was not inhibited by hypothermia, except in CD68+ microglia. Thus, dendrimer-conjugated drug delivery can target microglia, astrocytes and neurons and can be used in combination with hypothermia for treatment of HIE.
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Affiliation(s)
- Christina L Nemeth
- Hugo W. Moser Research Institute at Kennedy Krieger, 707 N Broadway, Baltimore, MD 21205, USA; Department of Neurology, The Johns Hopkins University School of Medicine, 1800 Orleans St., Baltimore, MD 21287, USA
| | - Gabrielle T Drummond
- Hugo W. Moser Research Institute at Kennedy Krieger, 707 N Broadway, Baltimore, MD 21205, USA
| | - Manoj K Mishra
- Center for Nanomedicine at the Wilmer Eye Institute, The Johns Hopkins University School of Medicine, 400 N Broadway, Baltimore, MD 21287, USA
| | - Fan Zhang
- Center for Nanomedicine at the Wilmer Eye Institute, The Johns Hopkins University School of Medicine, 400 N Broadway, Baltimore, MD 21287, USA
| | - Patrice Carr
- Hugo W. Moser Research Institute at Kennedy Krieger, 707 N Broadway, Baltimore, MD 21205, USA
| | - Maxine S Garcia
- Hugo W. Moser Research Institute at Kennedy Krieger, 707 N Broadway, Baltimore, MD 21205, USA
| | - Sydney Doman
- Hugo W. Moser Research Institute at Kennedy Krieger, 707 N Broadway, Baltimore, MD 21205, USA
| | - Ali Fatemi
- Hugo W. Moser Research Institute at Kennedy Krieger, 707 N Broadway, Baltimore, MD 21205, USA; Department of Neurology, The Johns Hopkins University School of Medicine, 1800 Orleans St., Baltimore, MD 21287, USA
| | - Michael V Johnston
- Hugo W. Moser Research Institute at Kennedy Krieger, 707 N Broadway, Baltimore, MD 21205, USA; Department of Neurology, The Johns Hopkins University School of Medicine, 1800 Orleans St., Baltimore, MD 21287, USA
| | - Rangaramanujam M Kannan
- Hugo W. Moser Research Institute at Kennedy Krieger, 707 N Broadway, Baltimore, MD 21205, USA; Center for Nanomedicine at the Wilmer Eye Institute, The Johns Hopkins University School of Medicine, 400 N Broadway, Baltimore, MD 21287, USA
| | - Sujatha Kannan
- Hugo W. Moser Research Institute at Kennedy Krieger, 707 N Broadway, Baltimore, MD 21205, USA; Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 6318D, Baltimore, MD 21287, USA.
| | - Mary Ann Wilson
- Hugo W. Moser Research Institute at Kennedy Krieger, 707 N Broadway, Baltimore, MD 21205, USA; Department of Neurology, The Johns Hopkins University School of Medicine, 1800 Orleans St., Baltimore, MD 21287, USA; Department of Neuroscience, The Johns Hopkins University School of Medicine, 725 N. Wolfe St., Baltimore, MD 21205, USA.
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Harbison AL, Votava-Smith JK, del Castillo S, Kumar SR, Lee V, Schmithorst V, Lai HA, O'Neil S, Bluml S, Paquette L, Panigrahy A. Clinical Factors Associated with Cerebral Metabolism in Term Neonates with Congenital Heart Disease. J Pediatr 2017; 183:67-73.e1. [PMID: 28109537 PMCID: PMC5368020 DOI: 10.1016/j.jpeds.2016.12.061] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 11/15/2016] [Accepted: 12/20/2016] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine associations between patient and clinical factors with postnatal brain metabolism in term neonates with congenital heart disease (CHD) via the use of quantitative magnetic resonance spectroscopy. STUDY DESIGN Neonates with CHD were enrolled prospectively to undergo pre- and postoperative 3T brain magnetic resonance imaging. Short-echo single-voxel magnetic resonance spectroscopy of parietal white matter was used to quantify metabolites related to brain maturation (n-acetyl aspartate, choline, myo- inositol), neurotransmitters (glutamate and gamma-aminobutyric acid), energy metabolism (glutamine, citrate, glucose, and phosphocreatine), and injury/apoptosis (lactate and lipids). Multivariable regression was performed to search for associations between (1) patient-specific/prenatal/preoperative factors with concurrent brain metabolism and (2) intraoperative and postoperative factors with postoperative brain metabolism. RESULTS A total of 83 magnetic resonance images were obtained on 55 subjects. No patient-specific, prenatal, or preoperative factors associated with concurrent metabolic brain dysmaturation or elevated lactate could be identified. Chromosome 22q11 microdeletion and age at surgery were predictive of altered concurrent white matter phosphocreatine (P < .0055). The only significant intraoperative association found was increased deep hypothermic circulatory arrest time with reduced postoperative white matter glutamate and gamma-aminobutyric acid (P < .0072). Multiple postoperative factors, including increased number of extracorporeal membrane oxygenation days (P < .0067), intensive care unit, length of stay (P < .0047), seizures in the intensive care unit (P < .0009), and home antiepileptic use (P < .0002), were associated with reduced postoperative white matter n-acetyl aspartate. CONCLUSION Multiple postoperative factors were found to be associated with altered brain metabolism in term infants with CHD, but not patient-specific, preoperative, or intraoperative factors.
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Affiliation(s)
- Anna Lonyai Harbison
- Division of Cardiology, Department of Pediatrics, Critical Care Medicine, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Jodie K. Votava-Smith
- Division of Cardiology, Department of Pediatrics, Critical Care Medicine, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Sylvia del Castillo
- Department of Anesthesiology, Critical Care Medicine, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - S. Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, Children’s Hospital of Los Angeles/University of Southern California, Los Angeles, CA
| | - Vince Lee
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Vincent Schmithorst
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC and University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Hollie A. Lai
- Division of Radiology, Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Sharon O'Neil
- Division of Neurology, Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Stefan Bluml
- Division of Radiology, Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Lisa Paquette
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center and University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Filippi L, Fiorini P, Catarzi S, Berti E, Padrini L, Landucci E, Donzelli G, Bartalena L, Fiorentini E, Boldrini A, Giampietri M, Scaramuzzo RT, la Marca G, Della Bona ML, Fiori S, Tinelli F, Bancale A, Guzzetta A, Cioni G, Pisano T, Falchi M, Guerrini R. Safety and efficacy of topiramate in neonates with hypoxic ischemic encephalopathy treated with hypothermia (NeoNATI): a feasibility study. J Matern Fetal Neonatal Med 2017; 31:973-980. [PMID: 28274169 DOI: 10.1080/14767058.2017.1304536] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate the feasibility of a study based on treatment with topiramate (TPM) added to moderate hypothermia in newborns with hypoxic ischemic encephalopathy (HIE). MATERIALS AND METHODS Multicenter randomized controlled trial. Term newborns with precocious metabolic, clinical and electroencephalographic (EEG) signs of HIE were selected according to their amplified integrated EEG pattern and randomized to receive either TPM (10 mg/kg once a day for the first three days of life) plus moderate hypothermia or hypothermia alone. Safety was assessed by monitoring cardiorespiratory parameters and blood samples collected to check renal, liver, metabolic balance and TPM pharmacokinetics. Efficacy was evaluated by the combined frequency of mortality and severe neurological disability as primary outcome. Incidence of magnetic resonance injury, epilepsy, blindness, hearing loss, neurodevelopment at 18-24 months of life was assessed as secondary outcomes. RESULTS Forty-four asphyxiated newborns were enrolled in the study. Twenty one newborns (10 with moderate and 11 with severe HIE) were allocated to hypothermia plus TPM and 23 (12 moderate and 11 severe HIE) to hypothermia. No statistically or clinically significant differences were observed for safety, primary or secondary outcomes. However, a reduction in the prevalence of epilepsy was observed in newborns co-treated with TPM. CONCLUSIONS Results of this pilot trial suggest that administration of TPM in newborns with HIE is safe but does not reduce the combined frequency of mortality and severe neurological disability. The role of TPM co-treatment in preventing subsequent epilepsy deserves further studies.
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Affiliation(s)
- Luca Filippi
- a Neonatal Intensive Care Unit, Medical Surgical Feto-Neonatal Department , "A. Meyer" University Children's Hospital , Florence , Italy
| | - Patrizio Fiorini
- a Neonatal Intensive Care Unit, Medical Surgical Feto-Neonatal Department , "A. Meyer" University Children's Hospital , Florence , Italy
| | - Serena Catarzi
- a Neonatal Intensive Care Unit, Medical Surgical Feto-Neonatal Department , "A. Meyer" University Children's Hospital , Florence , Italy
| | - Elettra Berti
- a Neonatal Intensive Care Unit, Medical Surgical Feto-Neonatal Department , "A. Meyer" University Children's Hospital , Florence , Italy
| | - Letizia Padrini
- a Neonatal Intensive Care Unit, Medical Surgical Feto-Neonatal Department , "A. Meyer" University Children's Hospital , Florence , Italy
| | - Elisa Landucci
- b Department of Health Sciences, Section of Clinical Pharmacology and Oncology , University of Florence , Florence , Italy
| | | | - Laura Bartalena
- d Neonatal Unit, Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Erika Fiorentini
- d Neonatal Unit, Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Antonio Boldrini
- d Neonatal Unit, Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Matteo Giampietri
- d Neonatal Unit, Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Rosa Teresa Scaramuzzo
- d Neonatal Unit, Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Giancarlo la Marca
- e Laboratory for Diseases of the Nervous System and Metabolism , "A. Meyer" University Children's Hospital , Florence , Italy
| | - Maria Luisa Della Bona
- e Laboratory for Diseases of the Nervous System and Metabolism , "A. Meyer" University Children's Hospital , Florence , Italy
| | - Simona Fiori
- f Department of Developmental Neuroscience , Stella Maris Scientific Institute , Pisa , Italy
| | - Francesca Tinelli
- f Department of Developmental Neuroscience , Stella Maris Scientific Institute , Pisa , Italy
| | - Ada Bancale
- f Department of Developmental Neuroscience , Stella Maris Scientific Institute , Pisa , Italy
| | - Andrea Guzzetta
- f Department of Developmental Neuroscience , Stella Maris Scientific Institute , Pisa , Italy
| | - Giovanni Cioni
- f Department of Developmental Neuroscience , Stella Maris Scientific Institute , Pisa , Italy
| | - Tiziana Pisano
- g Pediatric Neurology Unit and Laboratories , "A. Meyer" Children's Hospital, University of Florence , Florence , Italy
| | - Melania Falchi
- g Pediatric Neurology Unit and Laboratories , "A. Meyer" Children's Hospital, University of Florence , Florence , Italy
| | - Renzo Guerrini
- g Pediatric Neurology Unit and Laboratories , "A. Meyer" Children's Hospital, University of Florence , Florence , Italy
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Alderliesten T, de Vries LS, Staats L, van Haastert IC, Weeke L, Benders MJNL, Koopman-Esseboom C, Groenendaal F. MRI and spectroscopy in (near) term neonates with perinatal asphyxia and therapeutic hypothermia. Arch Dis Child Fetal Neonatal Ed 2017; 102:F147-F152. [PMID: 27553589 DOI: 10.1136/archdischild-2016-310514] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 07/20/2016] [Accepted: 07/24/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Previous studies have demonstrated the association of abnormalities on diffusion-weighted MRI (DW-MRI) and proton magnetic resonance spectroscopy (1H-MRS) in infants with perinatal asphyxia. The use of therapeutic hypothermia might change this association. AIM To study the association between DW-MRI and 1H-MRS and outcome after perinatal asphyxia and therapeutic hypothermia in infants with a gestational age of ≥36 weeks. PATIENTS AND METHODS Infants with perinatal asphyxia and therapeutic hypothermia (n=88) were included when an MR examination was performed within 7 days after birth. Apparent diffusion coefficient (ADC) values of the basal ganglia and thalamus were calculated, as were lactate/N-acetylaspartate (LAC/NAA) and N-acetylaspartate/choline (NAA/Cho) ratios. Death or an abnormal neurodevelopment at ≥24 months was considered an adverse outcome. Receiver operating characteristic analysis was performed to determine cut-off levels. RESULTS Of the 88 infants, 22 died and 7 had an adverse neurodevelopmental outcome. In infants with an adverse outcome, ADC values of the basal ganglia and thalamus were significantly lower, and Lac/NAA ratios were significantly higher than in infants with a normal outcome. Areas under the curve of ADC of the basal ganglia, thalami and Lac/NAA ratio were 0.89, 0.88 and 0.87, respectively. NAA/Cho ratios were in this cohort not associated with outcome. CONCLUSIONS During and after therapeutic hypothermia, low ADC values and high Lac/NAA ratios of the basal ganglia and thalamus are associated with an adverse outcome in infants with perinatal asphyxia.
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Affiliation(s)
- Thomas Alderliesten
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Liza Staats
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ingrid C van Haastert
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lauren Weeke
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Corine Koopman-Esseboom
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
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The Impact of Venoarterial and Venovenous Extracorporeal Membrane Oxygenation on Cerebral Metabolism in the Newborn Brain. PLoS One 2016; 11:e0168578. [PMID: 28033354 PMCID: PMC5199081 DOI: 10.1371/journal.pone.0168578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 12/02/2016] [Indexed: 12/13/2022] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is an effective therapy for supporting infants with reversible cardiopulmonary failure. Still, survivors are at risk for long-term neurodevelopmental impairments, the cause of which is not fully understood. Objective To elucidate the effects of ECMO on the newborn brain. We hypothesized that the cerebral metabolic profile of neonates who received ECMO would differ from neonates who did not receive ECMO. To address this, we used magnetic resonance spectroscopy (1H-MRS) to investigate the effects of venoarterial and venovenous ECMO on cerebral metabolism. Methods 41 neonates treated with ECMO were contrasted to 38 age-matched neonates. Results All 1H-MRS data were acquired from standardized grey matter and white matter regions of interest using a short-echo (TE = 35 milliseconds), point-resolved spectroscopy sequence (PRESS) and quantitated using LCModel. Metabolite concentrations (mmol/kg) were compared across groups using multivariate analysis of covariance. Elevated creatine (p = 0.002) and choline (p = 0.005) concentrations were observed in the grey matter among neonates treated with ECMO relative to the reference group. Likewise, choline concentrations were elevated in the white matter (p = 0.003) while glutamate was reduced (p = 0.03). Contrasts between ECMO groups revealed lower osmolite concentrations (e.g. myoinositol) among the venovenous ECMO group. Conclusion Neonates who underwent ECMO were found to have an abnormal cerebral metabolic profile, with the pattern of abnormalities suggestive of an underlying inflammatory process. Additionally, neonates who underwent venovenous ECMO had low cerebral osmolite concentrations as seen in vasogenic edema.
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Glucose and Intermediary Metabolism and Astrocyte–Neuron Interactions Following Neonatal Hypoxia–Ischemia in Rat. Neurochem Res 2016; 42:115-132. [DOI: 10.1007/s11064-016-2149-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 12/09/2016] [Accepted: 12/10/2016] [Indexed: 11/27/2022]
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