Surgically-induced brain injury: where are we now?

Mesenchymal stem cell-loaded hydrogel to inhibit inflammatory reaction in surgical brain injury via mitochondria transfer

Neurosurgical procedures are the key therapeutic interventions for the cerebral hemorrhage and brain tumors. However, neurosurgical procedures inevitably cause surgical brain injury (SBI), which will induce hemorrhage and inflammation. Gelatin Sponges are still the primary hemostatic materials used in clinical, but their anti-inflammatory efficacy is poor. Herein, we developed a cross-linked gelatin hydrogel (GelMA) to load mesenchymal stem cells (MSC) and directly implant them to the SBI site. Upon contacting the SBI site, the GelMA showed better clotting performance than Gelatin Sponges. Moreover, the MSC can reduce oxidative stress and enhance mitochondrial fusion via mitochondria transfer, resulting in ameliorating mitochondrial damage and reducing inflammation. Thus, the GelMA containing MSC can effectively reduce brain edema and inflammation and improve neurological function in SBI mouse models. In addition, GelMA exhibits excellent hemocompatibility and low cytotoxicity. It also enhances the proliferation of MSCs and decelerates the rapid depletion of MSCs. Therefore, MSC-loaded GelMA exhibits excellent hemostatic and anti-inflammatory effects, making it a potential new-generation biomaterial for SBI.

Up-regulation of BMAL1 by epigallocatechin-3-gallate improves neurological damage in SBI rats

Brain Muscle ARNT-Like Protein 1 (BMAL1) suppresses oxidative stress in brain injury during surgery. Epigallocatechin-3-gallate (EGCG), a monomer in green tea, has been identified as an antioxidant and a potential agonist for BMAL1. In this work, the mechanism by which BMAL1 is regulated was investigated, as well as the therapeutic effect of EGCG on surgically injured rats. The pathological environment after brain injury during surgery was simulated by excising the right frontal lobe of rats. Rats received an intraperitoneal injection of EGCG immediately after surgery. Neurological scores and cerebral edema were recorded after surgery. Fluoro-Jade C staining, TUNEL staining, western blot, and lipid peroxidation analyses were conducted 3 days later. Here we show that the endogenous BMAL1 level decreased after brain injury. Postoperative administration of EGCG up-regulated the content of BMAL1 around the cerebral cortex, reduced the oxidative stress level, reduced neuronal apoptosis and the number of degenerated neurons, alleviated cerebral edema, and improved neurological scores in rats. This suggests that BMAL1 is an effective target for treating surgical brain injury, as well as that EGCG may be a promising agent for alleviating postoperative brain injury.

Evaluation of risk factors for postoperative neurologic intensive care admission after brain tumor craniotomy: A single-center longitudinal study

Background and Aims

Perioperative variable parameters can be significant risk factors for postoperative intensive care unit (ICU) admission after elective craniotomy for intracranial neoplasm, as assessed by various scoring systems such as Cranio Score. This observational study evaluates the relationship between these factors and early postoperative neurological complications necessitating ICU admission.

Material and Methods

In total, 119 patients, aged 18 years and above, of either sex, American Society of Anesthesiologists (ASA) grades I-III, scheduled for elective craniotomy and tumor excision were included. The primary objective was to evaluate the relationship between perioperative risk factors and the incidence of early postoperative complications as a means of validation of the Cranio Score. The secondary outcomes studied were 30-day postoperative morbidity/mortality and the association with patient-related risk factors.

Results

Forty-five of 119 patients (37.82%) required postoperative ICU care with the mean duration of ICU stay being 1.92 ± 4.91 days. Tumor location (frontal/infratemporal region), preoperative deglutition disorder, Glasgow Coma Scale (GCS) less than 15, motor deficit, cerebellar deficit, midline shift >3 mm, mass effect, tumor size, use of blood products, lateral position, inotropic support, elevated systolic/mean arterial pressures, and duration of anesthesia/surgery were associated with a higher incidence of ICU care. Maximum (P = 0.035, AOR = 1.130) and minimum systolic arterial pressures (P = 0.022, Adjusted Odds Ratio (AOR) = 0.861) were the only independent risk factors. Cranio Score was found to be an accurate predictor of complications at a cut-off point of >10.52%. The preoperative motor deficit was the only independent risk factor associated with 30-day morbidity (AOR = 4.66).

Conclusion

Perioperative hemodynamic effects are an independent predictor of postoperative ICU requirement. Further Cranio Score is shown to be a good scoring system for postoperative complications.

Intracerebellar injection of monocytic immature myeloid cells prevents the adverse effects caused by stereotactic surgery in a model of cerebellar neurodegeneration

BACKGROUND

Myeloid-derived suppressor cells (MDSCs) constitute a recently discovered bone-marrow-derived cell type useful for dealing with neuroinflammatory disorders. However, these cells are only formed during inflammatory conditions from immature myeloid cells (IMCs) that acquire immunosuppressive activity, thus being commonly gathered from diseased animals. Then, to obtain a more clinically feasible source, we characterized IMCs directly derived from healthy bone marrow and proved their potential immunosuppressive activity under pathological conditions in vitro. We then explored their neuroprotective potential in a model of human cerebellar ataxia, the Purkinje Cell Degeneration (PCD) mouse, as it displays a well-defined neurodegenerative and neuroinflammatory process that can be also aggravated by invasive surgeries.

METHODS

IMCs were obtained from healthy bone marrow and co-cultured with activated T cells. The proliferation and apoptotic rate of the later were analyzed with Tag-it Violet. For in vivo studies, IMCs were transplanted by stereotactic surgery into the cerebellum of PCD mice. We also used sham-operated animals as controls of the surgical effects, as well as their untreated counterparts. Motor behavior of mice was assessed by rotarod test. The Purkinje cell density was measured by immunohistochemistry and cell death assessed with the TUNEL technique. We also analyzed the microglial phenotype by immunofluorescence and the expression pattern of inflammation-related genes by qPCR. Parametric tests were applied depending on the specific experiment: one or two way ANOVA and Student's T test.

RESULTS

IMCs were proven to effectively acquire immunosuppressive activity under pathological conditions in vitro, thus acting as MDSCs. Concerning in vivo studios, sham-operated PCD mice suffered detrimental effects in motor coordination, Purkinje cell survival and microglial activation. After intracranial administration of IMCs into the cerebellum of PCD mice, no special benefits were detected in the transplanted animals when compared to untreated mice. Nonetheless, this transplant almost completely prevented the impairments caused by the surgery in PCD mice, probably by the modulation of the inflammatory patterns.

CONCLUSIONS

Our work comprise two main translational findings: (1) IMCs can be directly used as they behave as MDSCs under pathological conditions, thus avoiding their gathering from diseased subjects; (2) IMCs are promising adjuvants when performing neurosurgery.

Early Postoperative Magnetic Resonance Imaging Findings Related to Electrocauterization for Cerebellar Reduction During Chiari Decompression Surgery

BACKGROUND

Cerebellar tonsillar reduction or resection can be performed as part of the surgical management of Chiari type 1 malformation when it is accompanied by symptomatic brainstem compression or syringomyelia. The purpose of this study is to characterize the early postoperative magnetic resonance imaging (MRI) findings in patients with Chiari type 1 malformations who undergo cerebellar tonsillar reduction via electrocautery.

METHODS

The extent of cytotoxic edema and microhemorrhages demonstrated on MRI scans obtained within 9 days following surgery was assessed and correlated with neurological symptoms.

RESULTS

Cytotoxic edema was found on all postoperative MRI examinations included in this series, with superimposed hemorrhage in 12 of 16 patients (75%) and was primarily located along the margins of the cauterized inferior cerebellum. Cytotoxic edema was present beyond the margins of the cauterized cerebellar tonsils in 5 of 16 patients (31%) and was associated with new focal neurological deficits in 4 of 5 patients (80%).

CONCLUSION

Cytotoxic edema and hemorrhages along the cerebellar tonsil cautery margins can be expected findings in early postoperative MRI in patients who undergo Chiari decompression accompanied by tonsillar reduction. However, the presence of cytotoxic edema beyond these regions can be associated with new focal neurological symptoms.

Surgery for spontaneous supratentorial intracerebral haemorrhage

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the efficacy and safety of surgery plus standard medical management, compared to standard medical management alone, in people with spontaneous supratentorial ICH, and to assess whether the effect of surgery differs according to the surgical technique.

Injury programs shape glioblastoma

Glioblastoma is the most common and aggressive primary brain cancer in adults and is almost universally fatal due to its stark therapeutic resistance. During the past decade, although survival has not substantially improved, major advances have been made in our understanding of the underlying biology. It has become clear that these devastating tumors recapitulate features of neurodevelopmental hierarchies which are influenced by the microenvironment. Emerging evidence also highlights a prominent role for injury responses in steering cellular phenotypes and contributing to tumor heterogeneity. This review highlights how the interplay between injury and neurodevelopmental programs impacts on tumor growth, invasion, and treatment resistance, and discusses potential therapeutic considerations in view of these findings.

Case studies in neuroscience: reversible signatures of edema following electric and piezoelectric craniotomy drilling in macaques

In vivo electrophysiology requires direct access to brain tissue, necessitating the development and refinement of surgical procedures and techniques that promote the health and well-being of animal subjects. Here, we report a series of findings noted on structural magnetic resonance imaging (MRI) scans in monkeys with MRI-compatible implants following small craniotomies that provide access for intracranial electrophysiology. We found distinct brain regions exhibiting hyperintensities in T2-weighted scans that were prominent underneath the sites at which craniotomies had been performed. We interpreted these hyperintensities as edema of the neural tissue and found that they were predominantly present following electric and piezoelectric drilling, but not when manual, hand-operated drills were used. Furthermore, the anomalies subsided within 2-3 wk following surgery. Our report highlights the utility of MRI-compatible implants that promote clinical examination of the animal's brain, sometimes revealing findings that may go unnoticed when incompatible implants are used. We show replicable differences in outcome when using electric versus mechanical devices, both ubiquitous in the field. If electric drills are used, our report cautions against electrophysiological recordings from tissue directly underneath the craniotomy for the first 2-3 wk following the procedure due to putative edema.NEW & NOTEWORTHY Close examination of structural MRI in eight nonhuman primates following craniotomy surgeries for intracranial electrophysiology highlights a prevalence of hyperintensities on T2-weighted scans following surgeries conducted using electric and piezoelectric drills, but not when using mechanical, hand-operated drills. We interpret these anomalies as edema of neural tissue that resolved 2-3 wk postsurgery. This finding is especially of interest as electrophysiological recordings from compromised tissue may directly influence the integrity of collected data immediately following surgery.

A rare complication after vestibular schwannoma surgery: Neurogenic pulmonary edema

Background:

In our center, large vestibular schwannoma (VS) is typically managed by a planned partial resection through the translabyrinthine route. Here, we report on a rare complication of VS surgery and severe neurogenic pulmonary edema.

Case Description:

A 33-year-old male was referred to our skull-base center with a large VS. A planned partial resection was performed. The surgery was without complications and the patient showed good recovery without facial nerve dysfunction. In the evening of the 2nd day after surgery, the patient showed rapid neurological deterioration, accompanied by cardiac arrest. After the patient was resuscitated, a computed tomography (CT) was made, which showed generalized (infra- and supratentorial) brain edema and hematoma in the resection cavity. Despite rapid removal of the hematoma, there was no change in the neurological situation. The next CT scan showed a further increase of brain edema and the patient died eventually. Autopsy revealed generalized lung edema, brain edema, and Hashimoto’s thyroiditis. The pathologist diagnosed neurogenic lung edema.

Conclusion:

Neurogenic lung edema can occur on the 2nd day after surgery and induce rapid deterioration of the patient with massive brain edema.

Clinical Outcomes and Complications of Preoperative Embolization for Intracranial Giant Meningioma Tumorectomy: A Retrospective, Observational, Matched Cohort Study

Objective

The potential benefits of preoperative embolization for intracranial meningiomas are still under debate. We aimed to investigate whether preoperative embolization can improve surgical and functional outcomes, based on controlling patient- and tumor-related confounding factors.

Methods

We reviewed all meningioma cases in our department from January 2016 to May 2021. Cases in the nonembolization cohort were matched to the embolization cohort by 1:1 ratio propensity score matching, through controlling patient- and tumor-related confounds. Surgical outcomes, complications, and functional outcomes were retrospectively compared between these two groups.

Results

Sixty-six cases in each group were included in our study after being matched. We did not find any significant differences of estimated blood loss (600.00 (400) vs. 500.00 (500.00) ml, p = 0.31), decrease of HGB level (30.81 ± 15.82 vs. 26.59 ± 12.90 g/L, p = 0.09), gross total resection rate (74.24% vs. 77.27%, p = 0.68), surgical time (302.50 (136) vs. 300.00 (72) min, p = 0.48), blood transfusion rates (53.03% vs. 42.42%, p = 0.35), blood transfusion volume [650.00 (657.50) vs. 535.00 (875.00) ml, p = 0.63] between the embolization group and nonembolization group. The number of patients who experience postsurgery complications were significantly higher in the nonembolization group (39.39% vs. 21.21%, p = 0.02). Patients in the nonembolization group were more likely to have a higher rate of mRS decline postsurgery (31.82% vs. 15.15%, p = 0.04).

Conclusion

Our study showed significant lower rates of surgical complications and long-term disabilities of meningioma patients treated with preoperative embolization. There were no significant differences in estimated blood loss, surgical time, and blood transfusion volume between embolization and nonembolization groups.

Downregulation of TREM2/NF-кB signaling may damage the blood-brain barrier and aggravate neuronal apoptosis in experimental rats with surgically injured brain

Surgical brain injury (SBI) is unavoidable in neurosurgery, and could aggravate secondary brain injury. Post-brain injury, multiple inflammatory factors are released, resulting in neuroinflammation and cell apoptosis, with subsequent brain edema and nerve function injury. TREM2, an immune protein mainly expressed in microglia, is an important link for nerve cells to participate in the inflammatory response. TREM2 and nuclear factor кB (NF-кB) are indeed closely associated with the release of inflammatory cytokines following brain injury. This work aimed to determine the inflammatory function of TREM2 in SBI, and to investigate whether TREM2 regulates interleukin-1 beta (IL-1β), IL-6 and tumor necrosis factor-α (TNF-α) release through the NF-кB p65 signaling pathway. We established a rat model of SBI, and performed Western blotting (WB), immunofluorescence (IF) and enzyme-linked immunosorbent assay (ELISA) for further analysis. Next, brain edema and neurological score analyses were performed. Finally, whether TREM2 regulating NF-кB p65 signaling affects blood-brain barrier (BBB) permeability and nerve cell apoptosis was examined. We found that post-SBI, TREM2 was upregulated, and inflammation and brain injury were aggravated. After TREM2 downregulation, NF-кB p65 production, inflammation and brain injury were enhanced, suggesting that TREM2 may play a protective role by inhibiting NF-кB p65 production after SBI. Overall, these findings suggest that TREM2 in SBI may have protective effects on postoperative nerve and BBB damage, possibly in part via the NF-κB p65 pathway.

The importance of axonal directions in the brainstem injury during neurosurgical interventions

Brainstem, which connects the distal part of the brain and the spinal cord, contains main motor and sensory nerves and facilitates communication between the cerebrum, cerebellum, and spinal cord. Due to the complicated anatomy and neurostructure of brainstem, surgical interventions to resect brainstem tumors are particularly challenging, and new approaches to reduce the risk of surgical brain injury are of utmost importance. Although previous studies have investigated the structural anisotropy of brain white matter, the effect of axonal fibers on the mechanical properties of white matter has not yet been fully understood. The current study aims to compare the effect of axonal orientation on changes in material properties of brainstem under large deformations and failure through a novel approach. Using diffusion tensor imaging (DTI) on ex-vivo bovine brains, we determined the orientation of axons in brainstem. We extracted brainstem samples in two orthogonal directions, parallel and perpendicular to the axons, and subjected to uniaxial tension to reach the failure at loading rates of 50 mm/min and 150 mm/min. The results showed that the tearing energy and failure strain of samples with axons parallel to the force direction were approximately 1.5 times higher than the samples with axons perpendicular to the force direction. The results also revealed that as the sample's initial length increases, its failure strain decreases. These results emphasize the importance of the axon orientation in the mechanical properties of brainstem, and suggest that considering the directional-dependent behavior for this tissue could help to propose new surgical interventions for reducing the risk of injury during tumor resection.

Real-Time Intraoperative Pressure Monitoring to Avoid Surgically Induced Localized Brain Injury Using a Miniaturized Piezoresistive Pressure Sensor

Neurosurgical procedures often cause damage to the brain tissue at the periphery from surgical manipulations. Especially during retraction, a large amount of pressure could be applied on the brain surface, which can damage it, leading to brain herniation, which can be fatal for patients. To resolve this issue, we have developed a pressure sensor that can be used to monitor the applied pressure during surgery for intraoperative care. This device was tested on a rodent model to create a superficial surgically induced damage profile for three different applied pressures (30, 50, and 70 mmHg) and compared to a standard intracranial pressure monitoring system. Magnetic resonance imaging has been performed after surgical procedures to detect the herniation caused by applied pressure. To evaluate the damage to brain cells and tissue rupture, histological analysis was performed using hematoxylin and eosin staining. A scoring system was developed to understand the severity of the surgically induced brain injury, which will help neurosurgeons to limit the pressure to an optimum point without causing damage.