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Ali M, Ascanio LC, Smith C, Odland I, Murtaza-Ali M, Vasan V, Downes M, Schuldt BR, Lin A, Dullea J, Schupper AJ, Hardigan T, Asghar N, Mocco J, Kellner CP. Early and effective intracerebral hemorrhage evacuation is associated with a lower 1-year residual cavity volume and better functional outcomes. J Neurointerv Surg 2024; 16:994-1004. [PMID: 37620128 DOI: 10.1136/jnis-2023-020787] [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: 07/10/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND We explored the clinical significance of the residual hematoma cavity 1 year after minimally invasive intracerebral hemorrhage (ICH) evacuation. METHODS Patients presenting with spontaneous supratentorial ICH were evaluated for minimally invasive surgical evacuation. Inclusion criteria included age ≥18 years, preoperative hematoma volume (Hv) ≥15 mL, presenting National Institutes of Health Stroke Scale score ≥6, and premorbid modified Rankin Scale (mRS) score ≤3. Patients with longitudinal CT scans at least 3 months after evacuation were included in the study. Remnant cavity volumes (Cv) after evacuation were computed using semi-automatic volumetric segmentation software. Relative cavity volume (rCv) was defined as the ratio of the preoperative Hv to the remnant Cv. RESULTS 108 patients with a total of 484 head CT scans were included in the study. The median postoperative Cv was 2.4 (IQR 0.0-11) mL, or just 6% (0-33%) of the preoperative Hv. The median residual Cv on the final head CT scan a median of 13 months (range 11-27 months) after surgery had increased to 9.4 (IQR 3.1-18) mL, or 25% (10-60%) of the preoperative Hv. rCv on the final head CT scan was negatively associated with measures of operative success including evacuation percentage, postoperative Hv ≤15 mL, and decreased time from ictus to evacuation. rCv on the final head CT scan was also associated with a worse 6-month functional outcome (β per mRS point 17.6%, P<0.0001; area under the receiver operating characteristic curve 0.91). CONCLUSION After minimally invasive ICH evacuation the hematoma lesion decompresses significantly, with a residual Cv just 6% of the original lesion, but then gradually increases in size over time. Early and high percentage ICH evacuation may reduce the remnant Cv over time which, in turn, is associated with improved functional outcomes.
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Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luis C Ascanio
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Braxton Riley Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anthony Lin
- Department of Pathology, Weill Cornell Medical College, New York, New York, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nek Asghar
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Du Y, Wang J, Zhang J, Li N, Li G, Liu X, Lin Y, Wang D, Kang K, Bian L, Zhao X. Intracerebral hemorrhage-induced brain injury in mice: The role of peroxiredoxin 2-Toll-like receptor 4 inflammatory axis. CNS Neurosci Ther 2024; 30:e14681. [PMID: 38516845 PMCID: PMC10958402 DOI: 10.1111/cns.14681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Peroxiredoxin 2 (Prx2), an intracellular protein that regulates redox reactions, released from red blood cells is involved in inflammatory brain injury after intracerebral hemorrhage (ICH). Toll-like receptor 4 (TLR4) may be crucial in this process. This study investigated the role of the Prx2-TLR4 inflammatory axis in brain injury following experimental ICH in mice. METHODS First, C57BL/6 mice received an intracaudate injection of autologous arterial blood or saline and their brains were harvested on day 1 to measure Prx2 levels. Second, mice received an intracaudate injection of either recombinant mouse Prx2 or saline. Third, the mice were co-injected with autologous arterial blood and conoidin A, a Prx2 inhibitor, or vehicle. Fourth, the mice received a Prx2 injection and were treated with TAK-242, a TLR4 antagonist, or saline (intraperitoneally). Behavioral tests, magnetic resonance imaging, western blot, immunohistochemistry/immunofluorescence staining, and RNA sequencing (RNA-seq) were performed. RESULTS Brain Prx2 levels were elevated after autologous arterial blood injection. Intracaudate injection of Prx2 caused brain swelling, microglial activation, neutrophil infiltration, neuronal death, and neurological deficits. Co-injection of conoidin A attenuated autologous arterial blood-induced brain injury. TLR4 was expressed on the surface of microglia/macrophages and neutrophils and participated in Prx2-induced inflammation. TAK-242 treatment attenuated Prx2-induced inflammation and neurological deficits. CONCLUSIONS Prx2 can cause brain injury following ICH through the TLR4 pathway, revealing the Prx2-TLR4 inflammatory axis as a potential therapeutic target.
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Affiliation(s)
- Yang Du
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
| | - Jinjin Wang
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
| | - Jia Zhang
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
| | - Ning Li
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
| | - Guangshuo Li
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
| | - Xinmin Liu
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
| | - Yijun Lin
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
| | - Dandan Wang
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
| | - Kaijiang Kang
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
| | - Liheng Bian
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
| | - Xingquan Zhao
- Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesCapital Medical UniversityBeijingChina
- Laboratory for Clinical MedicineCapital Medical UniversityBeijingChina
- Research Unit of Artificial Intelligence in Cerebrovascular DiseaseChinese Academy of Medical SciencesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
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3
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Bao D, Ni S, Chang B, Zhang W, Zhang H, Niu C. Short-term outcomes of robot-assisted minimally invasive surgery for brainstem hemorrhage: A case-control study. Heliyon 2024; 10:e25912. [PMID: 38384554 PMCID: PMC10878924 DOI: 10.1016/j.heliyon.2024.e25912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 01/09/2024] [Accepted: 02/05/2024] [Indexed: 02/23/2024] Open
Abstract
Objective This work focused on investigating if robot-assisted minimally invasive surgery improved middle term vital outcome for primary brainstem hemorrhage (PBSH). Methods This work obtained clinical data from patients with PBSH admitted from July 2019 to August 2021. All cases were classified as surgical or conservative treatment group. The general information, Glasgow coma scale (GCS) score, Glasgow outcome score (GOS), along with survival time in patients 60 days after robot-assisted surgery were recorded and analyzed. Results A prospective analysis was performed on 82 cases meeting eligibility criteria, including 36 from surgical group whereas 46 from the conservative group. Sixty days after onset, the death rate was found to be 19.44% and 50.00% of surgical and conservative groups, separately (cases versus controls, P < 0.05). Furthermore, postoperative GOS and GCS scores of surgical group were significantly higher, and hydrocephalus was lower compared with conservative group. Central fever incidence did not exhibit any significant difference between two groups. Conclusion Robot-assisted PBSH drainage may improve survivorship and reduce the occurrence of hydrocephalus.
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Affiliation(s)
- Dejun Bao
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No. 17 Lujiang Road, Hefei, 230001, Anhui Province, China
- Anhui Province Key Laboratory of Brain Function and Brain Disease, No. 17 Lujiang Road, Hefei, 230001, Anhui Province, China
| | - Shengyuan Ni
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No. 17 Lujiang Road, Hefei, 230001, Anhui Province, China
- Anhui Province Key Laboratory of Brain Function and Brain Disease, No. 17 Lujiang Road, Hefei, 230001, Anhui Province, China
| | - Bowen Chang
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No. 17 Lujiang Road, Hefei, 230001, Anhui Province, China
- Anhui Province Key Laboratory of Brain Function and Brain Disease, No. 17 Lujiang Road, Hefei, 230001, Anhui Province, China
| | - Wang Zhang
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No. 17 Lujiang Road, Hefei, 230001, Anhui Province, China
| | - Hong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No. 17 Lujiang Road, Hefei, 230001, Anhui Province, China
| | - Chaoshi Niu
- Department of Neurosurgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No. 17 Lujiang Road, Hefei, 230001, Anhui Province, China
- Anhui Province Key Laboratory of Brain Function and Brain Disease, No. 17 Lujiang Road, Hefei, 230001, Anhui Province, China
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Kirby C, Barrington J, Sondag L, Loan JJ, Schreuder FH, McColl BW, Klijn CJ, Al-Shahi Salman R, Samarasekera N. Association between circulating inflammatory biomarkers and functional outcome or perihaematomal oedema after ICH: a systematic review & meta-analysis. Wellcome Open Res 2023; 8:239. [PMID: 38037559 PMCID: PMC10687391 DOI: 10.12688/wellcomeopenres.19187.2] [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] [Accepted: 11/16/2023] [Indexed: 12/02/2023] Open
Abstract
Background Currently, there are no specific medical treatments for intracerebral haemorrhage (ICH), but the inflammatory response may provide a potential route to treatment. Given the known effects of acute brain injury on peripheral immunity, we hypothesised that inflammatory biomarkers in peripheral blood may be associated with clinical outcome following ICH, as well as perihaematomal oedema (PHO), which is an imaging marker of the neuroinflammatory response. Methods We searched OVID Medline and EMBASE on 07 April 2021 for studies of humans with ICH measuring an inflammatory biomarker in peripheral blood and PHO or clinical outcome. Risk of bias was assessed both by using a scale comprising features of the Newcastle-Ottawa Assessment Scale, STROBE-ME and REMARK guidelines, and for studies included in meta-analysis, also by the QUIPS tool.We used random effects meta-analysis to pool standardised mean differences (SMD) if ≥1 study quantified the association between identical biomarkers and measures of PHO or functional outcome. Results Of 8,615 publications, 16 examined associations between 21 inflammatory biomarkers and PHO (n=1,299 participants), and 93 studies examined associations between ≥1 biomarker and clinical outcome (n=17,702 participants). Overall, 20 studies of nine biomarkers (n=3,199) met criteria for meta-analysis of associations between inflammatory biomarkers and clinical outcome. Death or dependency (modified Rankin Scale (mRS) 3‒6) 90 days after ICH was associated with higher levels of fibrinogen (SMD 0.32; 95%CI [0.04, 0.61]; p=0.025), and high mobility group box protein 1 (HMGB1) (SMD 1.67; 95%CI [0.05, 3.30]; p=0.04). Higher WBC was associated with death or dependency at 90 days (pooled SMD 0.27; 95% CI [0.11, 0.44]; p=0.001; but the association was no longer significant when the analysis was restricted to studies with a low risk of bias (pooled SMD 0.22; 95% CI -0.04-0.48). Higher CRP seemed to be associated with death or dependency at 90 days (pooled SMD 0.80; 95% CI [0.44, 1.17]; p<0.0001) but this association was no longer significant when adjusted OR were pooled (OR 0.99 (95% CI 0.98-1.01)). Conclusions Higher circulating levels of, fibrinogen and HMGB1 are associated with poorer outcomes after ICH. This study highlights the clinical importance of the inflammatory response to ICH and identifies additional research needs in determining if these associations are mediated via PHO and are potential therapeutic targets. Registration PROSPERO ( CRD42019132628; 28/05/2019).
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Affiliation(s)
- Caoimhe Kirby
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
- Centre for Discovery Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
- UK Dementia Research Institute, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Jack Barrington
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
- Centre for Discovery Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
- UK Dementia Research Institute, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Lotte Sondag
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud Universiteit, Nijmegen, Gelderland, The Netherlands
| | - James J.M. Loan
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
- Centre for Discovery Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
- UK Dementia Research Institute, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Floris H.B.M. Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud Universiteit, Nijmegen, Gelderland, The Netherlands
| | - Barry W. McColl
- Centre for Discovery Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
- UK Dementia Research Institute, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Catharina J.M. Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud Universiteit, Nijmegen, Gelderland, The Netherlands
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Neshika Samarasekera
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
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5
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Marto JP, Carvalho AS, G. Mollet I, Mendonça M, Salavisa M, Meira B, Fernandes M, Serrazina F, Cabral G, Ventura R, Sobral‐Pinho A, Beck HC, Vieira HLA, Viana‐Baptista M, Matthiesen R. Proteomics to Identify New Blood Biomarkers for Diagnosing Patients With Acute Stroke. J Am Heart Assoc 2023; 12:e030021. [PMID: 37947097 PMCID: PMC10727303 DOI: 10.1161/jaha.123.030021] [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: 03/15/2023] [Accepted: 10/11/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Blood biomarkers are a potential tool for early stroke diagnosis. We aimed to perform a pilot and exploratory study on untargeted blood biomarkers in patients with suspected stroke by using mass spectrometry analysis. METHODS AND RESULTS This was a prospective observational study of consecutive patients with suspected stroke admitted within 6 hours of last being seen well. Blood samples were collected at admission. Patients were divided into 3 groups: ischemic stroke (IS), intracerebral hemorrhage (ICH), and stroke mimics. Quantitative analysis from mass spectrometry data was performed using a supervised approach. Biomarker-based prediction models were developed to differentiate IS from ICH and ICH+stroke mimics. Models were built aiming to minimize misidentification of patients with ICH as having IS. We included 90 patients, one-third within each subgroup. The median age was 71 years (interquartile range, 57-81 years), and 49 participants (54.4%) were women. In quantitative analysis, C3 (complement component 3), ICAM-2 (intercellular adhesion molecule 2), PLGLA (plasminogen like A), STXBP5 (syntaxin-binding protein 5), and IGHV3-64 (immunoglobulin heavy variable 3-64) were the 5 most significantly dysregulated proteins for both comparisons. Biomarker-based models showed 88% sensitivity and 89% negative predictive value for differentiating IS from ICH, and 75% sensitivity and 95% negative predictive value for differentiating IS from ICH+stroke mimics. ICAM-2, STXBP5, PLGLA, C3, and IGHV3-64 displayed the highest importance score in our models, being the most informative for identifying patients with stroke. CONCLUSIONS In this proof-of-concept and exploratory study, our biomarker-based prediction models, including ICAM-2, STXBP5, PLGLA, C3, and IGHV3-64, showed 75% to 88% sensitivity for identifying patients with IS, while aiming to minimize misclassification of ICH. Although our methodology provided an internal validation, these results still need validation in other cohorts and with different measurement techniques.
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Affiliation(s)
- João Pedro Marto
- Department of NeurologyHospital de Egas Moniz, Centro Hospitalar Lisboa OcidentalLisbonPortugal
- Centro Clínico Académico de Lisboa (CCAL), NOVA Medical School (MNS)LisbonPortugal
| | - Ana Sofia Carvalho
- iNOVA4Health, NOVA Medical SchoolUniversidade NOVA de LisboaLisbonPortugal
| | - Inês G. Mollet
- iNOVA4Health, NOVA Medical SchoolUniversidade NOVA de LisboaLisbonPortugal
- UCIBIO, Applied Molecular Biosciences Unit, NOVA School of Science and TechnologyUniversidade NOVA de LisboaCaparicaPortugal
- i4HB—Institute for Health and Bioeconomy, NOVA School of Science and TechnologyUniversidade NOVA de LisboaCaparicaPortugal
| | - Marcelo Mendonça
- iNOVA4Health, NOVA Medical SchoolUniversidade NOVA de LisboaLisbonPortugal
- Champalimaud Research and Clinical CentreChampalimaud FoundationLisbonPortugal
| | - Manuel Salavisa
- Department of NeurologyHospital de Egas Moniz, Centro Hospitalar Lisboa OcidentalLisbonPortugal
| | - Bruna Meira
- Department of NeurologyHospital de Egas Moniz, Centro Hospitalar Lisboa OcidentalLisbonPortugal
| | - Marco Fernandes
- Department of NeurologyHospital de Egas Moniz, Centro Hospitalar Lisboa OcidentalLisbonPortugal
| | - Filipa Serrazina
- Department of NeurologyHospital de Egas Moniz, Centro Hospitalar Lisboa OcidentalLisbonPortugal
| | - Gonçalo Cabral
- Department of NeurologyHospital de Egas Moniz, Centro Hospitalar Lisboa OcidentalLisbonPortugal
| | - Rita Ventura
- Department of NeurologyHospital de Egas Moniz, Centro Hospitalar Lisboa OcidentalLisbonPortugal
| | - André Sobral‐Pinho
- Department of NeurologyHospital de Egas Moniz, Centro Hospitalar Lisboa OcidentalLisbonPortugal
| | - Hans C. Beck
- Department of Clinical BiochemistryOdense University HospitalOdenseDenmark
| | - Helena L. A. Vieira
- iNOVA4Health, NOVA Medical SchoolUniversidade NOVA de LisboaLisbonPortugal
- UCIBIO, Applied Molecular Biosciences Unit, NOVA School of Science and TechnologyUniversidade NOVA de LisboaCaparicaPortugal
- i4HB—Institute for Health and Bioeconomy, NOVA School of Science and TechnologyUniversidade NOVA de LisboaCaparicaPortugal
| | - Miguel Viana‐Baptista
- Department of NeurologyHospital de Egas Moniz, Centro Hospitalar Lisboa OcidentalLisbonPortugal
- Centro Clínico Académico de Lisboa (CCAL), NOVA Medical School (MNS)LisbonPortugal
| | - Rune Matthiesen
- iNOVA4Health, NOVA Medical SchoolUniversidade NOVA de LisboaLisbonPortugal
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Sun S, Li Z, Xiao Q, Tan S, Hu B, Jin H. An updated review on prediction and preventive treatment of post-stroke depression. Expert Rev Neurother 2023; 23:721-739. [PMID: 37427452 DOI: 10.1080/14737175.2023.2234081] [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: 04/17/2023] [Accepted: 07/04/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION Post-stroke depression (PSD), one of the most common complications following stroke, affects approximately one-third of stroke patients and is significantly associated with increased disability and mortality as well as decreased quality of life, which makes it an important public health concern. Treatment of PSD significantly ameliorates depressive symptoms and improves the prognosis of stroke. AREAS COVERED The authors discuss the critical aspects of the clinical application of prediction and preventive treatment of PSD. Then, the authors update the biological factors associated with the onset of PSD. Furthermore, they summarize the recent progress in pharmacological preventive treatment in clinical trials and propose potential treatment targets. The authors also discuss the current roadblocks in the preventive treatment of PSD. Finally, the authors put postulate potential directions for future studies so as to discover accurate predictors and provide individualized preventive treatment. EXPERT OPINION Sorting out high-risk PSD patients using reliable predictors will greatly assist PSD management. Indeed, some predictors not only predict the incidence of PSD but also predict prognosis, which indicates that they might also aid the development of an individualized treatment scheme. Preventive application of antidepressants may also be considered.
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Affiliation(s)
- Shuai Sun
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhifang Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Qinghui Xiao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Senwei Tan
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Huijuan Jin
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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7
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Jia P, Wang J, Ren X, He J, Wang S, Xing Y, Chen D, Zhang X, Zhou S, Liu X, Yu S, Li Z, Jiang C, Zang W, Chen X, Wang J. An enriched environment improves long-term functional outcomes in mice after intracerebral hemorrhage by mechanisms that involve the Nrf2/BDNF/glutaminase pathway. J Cereb Blood Flow Metab 2023; 43:694-711. [PMID: 36635875 PMCID: PMC10108193 DOI: 10.1177/0271678x221135419] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 01/14/2023]
Abstract
Post-stroke depression exacerbates neurologic deficits and quality of life. Depression after ischemic stroke is known to some extent. However, depression after intracerebral hemorrhage (ICH) is relatively unknown. Increasing evidence shows that exposure to an enriched environment (EE) after cerebral ischemia/reperfusion injury has neuroprotective effects in animal models, but its impact after ICH is unknown. In this study, we investigated the effect of EE on long-term functional outcomes in mice subjected to collagenase-induced striatal ICH. Mice were subjected to ICH with the standard environment (SE) or ICH with EE for 6 h/day (8:00 am-2:00 pm). Depressive, anxiety-like behaviors and cognitive tests were evaluated on day 28 with the sucrose preference test, tail suspension test, forced swim test, light-dark transition experiment, morris water maze, and novel object recognition test. Exposure to EE improved neurologic function, attenuated depressive and anxiety-like behaviors, and promoted spatial learning and memory. These changes were associated with increased expression of transcription factor Nrf2 and brain-derived neurotrophic factor (BDNF) and inhibited glutaminase activity in the perihematomal tissue. However, EE did not change the above behavioral outcomes in Nrf2-/- mice on day 28. Furthermore, exposure to EE did not increase BDNF expression compared to exposure to SE in Nrf2-/- mice on day 28 after ICH. These findings indicate that EE improves long-term outcomes in sensorimotor, emotional, and cognitive behavior after ICH and that the underlying mechanism involves the Nrf2/BDNF/glutaminase pathway.
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Affiliation(s)
- Peijun Jia
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
- School of Life Sciences,
Zhengzhou University, Zhengzhou, China
| | - Junmin Wang
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Xiuhua Ren
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Jinxin He
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Shaoshuai Wang
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Yinpei Xing
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Danyang Chen
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Xinling Zhang
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Siqi Zhou
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Xi Liu
- Department of Neurology,
The First Affiliated Hospital of Zhengzhou University, Zhengzhou,
China
| | - Shangchen Yu
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Zefu Li
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Chao Jiang
- Department of Neurology,
The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou,
China
| | - Weidong Zang
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Xuemei Chen
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
| | - Jian Wang
- Department of Anatomy,
School of Basic Medical Sciences, , Zhengzhou
University, Zhengzhou, China
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Zhang S, Chen T, Han B, Zhu W. A Retrospective Study of Puncture and Drainage for Primary Brainstem Hemorrhage With the Assistance of a Surgical Robot. Neurologist 2023; 28:73-79. [PMID: 35593907 DOI: 10.1097/nrl.0000000000000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Whether primary brainstem hemorrhage (PBH) should be treated with a conservative treatment or with surgical intervention (such as craniotomy, puncture, and drainage) is still controversial. The aim of this study was to assess the feasibility and safety of puncture and drainage for PBH with the assistance of a surgical robot. PATIENTS AND METHODS A total of 53 patients diagnosed with PBH were included in this study. They were divided into surgical and nonsurgical groups. All patients in the surgical group underwent puncture and drainage of PBH assisted with surgical robots at Beijing Jingmei General Hospital from June 2017 to January 2021. We evaluated this technology with radiographic and clinical results. RESULTS Postoperative computed tomography showed that all the drainage catheters had been pushed to the target point, which had been designated before the operation. After the operation, the hematoma was reduced by an average of 3.7 mL. None of the patients experienced serious surgery-related complications. Clinical follow-up revealed that 2 patients could not be followed-up, 8 died, and the rest were in disability or in a vegetative state. CONCLUSIONS It may be safe, feasible, and effective to complete the puncture and drainage of PBH with the assistance of a surgical robot. This technique has fewer complications than the traditional puncture method and has high accuracy. It may be more suitable for patients with a hematoma volume of 5 to 10 mL in PBH. The amount of hematoma volume >10 mL may be associated with poor postoperative prognosis. However, high-quality cohorts or case-control studies are needed to verify the effect in this study.
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Affiliation(s)
- Shuai Zhang
- Department of Neurosurgery, Beijing Jingmei Group General Hospital
| | - Tao Chen
- Department of Neurosurgery, Huicheng Brain Research Institute, Beijing, P.R. China
| | - Bing Han
- Department of Neurosurgery, Huicheng Brain Research Institute, Beijing, P.R. China
| | - Weisheng Zhu
- Department of Neurosurgery, Beijing Jingmei Group General Hospital
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Yu T, Liu H, Liu Y, Jiang J. Inflammatory response biomarkers nomogram for predicting pneumonia in patients with spontaneous intracerebral hemorrhage. Front Neurol 2023; 13:1084616. [PMID: 36712440 PMCID: PMC9879054 DOI: 10.3389/fneur.2022.1084616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 12/01/2022] [Indexed: 01/13/2023] Open
Abstract
Objectives Inflammatory response biomarkers are promising prognostic factors to improve the prognosis of stroke-associated pneumonia (SAP) after ischemic stroke. This study aimed to investigate the prognostic significance of inflammatory response biomarkers on admission in SAP after spontaneous intracerebral hemorrhage (SICH) and establish a corresponding nomogram. Methods The data of 378 patients with SICH receiving conservative treatment from January 2019 to December 2021 at Taizhou People's Hospital were selected. All eligible patients were randomized into the training (70%, 265) and validation cohorts (30%, 113). In the training cohort, multivariate logistic regression analysis was used to establish an optimal nomogram, including inflammatory response biomarkers and clinical risk factors. The area under the receiver operating characteristic (ROC) curve (AUC), calibration curve, and decision curve analysis (DCA) were used to evaluate the nomogram's discrimination, calibration, and performance, respectively. Moreover, this model was further validated in a validation cohort. Results A logistic regression analysis showed that intraventricular hemorrhage (IVH), hypertension, dysphagia, Glasgow Coma Scale (GCS), National Institute of Health Stroke Scale (NIHSS), systemic inflammation response index (SIRI), and platelet/lymphocyte ratio (PLR) were correlated with SAP after SICH (P < 0.05). The nomogram was composed of all these statistically significant factors. The inflammatory marker-based nomogram showed strong prognostic power compared with the conventional factors, with an AUC of 0.886 (95% CI: 0.841-0.921) and 0.848 (95% CI: 0.799-0.899). The calibration curves demonstrated good homogeneity between the predicted risks and the observed outcomes. In addition, the model has a significant net benefit for SAP, according to DCA. Also, internal validation demonstrated the reliability of the prediction nomogram. The length of hospital stay was shorter in the non-SAP group than in the SAP group. At the 3-month follow-up, clinical outcomes were worse in the SAP group (P < 0.001). Conclusion SIRI and PLR at admission can be utilized as prognostic inflammatory biomarkers in patients with SICH in the upper brain treated with SAP. A nomogram covering SIRI and PLR can more accurately predict SAP in patients' supratentorial SICH. SAP can influence the length of hospital stay and the clinical outcome.
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Affiliation(s)
- Tingting Yu
- Graduate School of Dalian Medical University, Dalian, China,Department of Neurology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China,Department of Neurology, Taizhou People's Hospital, Taizhou, China
| | - Haimei Liu
- Graduate School of Dalian Medical University, Dalian, China,Department of Neurology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China,Department of Neurology, Taizhou People's Hospital, Taizhou, China
| | - Ying Liu
- Department of Neurology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China,Department of Neurology, Taizhou People's Hospital, Taizhou, China,Ying Liu ✉
| | - Jianxin Jiang
- Department of Neurosurgery, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China,Department of Neurosurgery, Taizhou People's Hospital, Taizhou, China,*Correspondence: Jianxin Jiang ✉
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Ghosh B, Rahman MM, Saha T, Hossain MJ, Alam S, Al-Aman DAA, Kayser MS, Islam MS, Islam MK, Singh A, Ahmed T. Drinking Water Sources along the Banks of Buriganga River of Bangladesh are Polluted and Possess Serious Health Risks: A Comprehensive In Vivo Analysis. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2023; 2023:3369163. [PMID: 36684485 PMCID: PMC9848808 DOI: 10.1155/2023/3369163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/26/2022] [Accepted: 10/05/2022] [Indexed: 01/13/2023]
Abstract
Background The river Buriganga, one of the major dumping zones of industrial wastes in Bangladesh, is responsible for contaminating the drinking water sources along its length. This study aimed to assess the water quality from these sources by monitoring the changes in hematological, biochemical, and histological parameters caused in healthy rats due to their consumption. Methods Using ethylenediaminetetraacetic acid (EDTA) as an anticoagulant agent, hematological and biochemical analyses of Sprague-Dawley rat models were executed in this study. Following blood sampling, the rats were sacrificed, and the heart, lungs, kidneys, liver, and spleen were separated to carry out the histological analysis. Later, to perform the statistical analysis, SPSS, V.25.0 was utilized. Results A significant rise (p < 0.02) in body weight was recorded due to increased protein synthesis, inflammations; increased lymphocyte, white blood cell (WBC), and neutrophil count but hemoglobin (20.0 ± 1.39 g/dL vs. 15.25 ± 0.36 g/dL; p) and red blood cell (RBC) count ((6.24 ± 0.45) × 106/µL vs. (5.47 ± 0.34) × 106/µL)) decreased due to infections and hematopoietic stem cell poisoning by pathogens in water samples. Elevated (p < 0.01) serum urea, creatinine, alanine, and aspartate aminotransferase levels indicated kidney malfunction and hepatic tissue necrosis. Histological analysis revealed gross lesions, internal hemorrhages in the brain; inflammations, granulomas, migrating macrophages in the spleen; fibrosis (resulting in hypo-perfusion), and collagen formation in cardiac muscles. Conclusions The findings in this study provide comprehensive evidence, based on in vivo analysis, that the water bodies around the Buriganga river are likely to be contaminated with toxic chemicals and microbial entities making them unfit for human consumption.
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Affiliation(s)
- Banna Ghosh
- Department of Pharmacy, State University of Bangladesh, 77 Satmasjid Road, Dhanmondi, Dhaka 1205, Bangladesh
| | - Muhammed Mahfuzur Rahman
- Department of Pharmacy, State University of Bangladesh, 77 Satmasjid Road, Dhanmondi, Dhaka 1205, Bangladesh
| | - Tanoy Saha
- Department of Pharmacy, State University of Bangladesh, 77 Satmasjid Road, Dhanmondi, Dhaka 1205, Bangladesh
| | - Md. Jamal Hossain
- Department of Pharmacy, State University of Bangladesh, 77 Satmasjid Road, Dhanmondi, Dhaka 1205, Bangladesh
| | - Safaet Alam
- Drugs and Toxins Research Division, BCSIR Laboratories Rajshahi, Bangladesh Council of Scientific and Industrial Research, Rajshahi 6206, Bangladesh
| | - D. A. Anwar Al-Aman
- Department of Pharmacy, State University of Bangladesh, 77 Satmasjid Road, Dhanmondi, Dhaka 1205, Bangladesh
| | - Md. Shahidulla Kayser
- Department of Pharmacy, State University of Bangladesh, 77 Satmasjid Road, Dhanmondi, Dhaka 1205, Bangladesh
| | - Md. Shariful Islam
- Department of Pharmacy, State University of Bangladesh, 77 Satmasjid Road, Dhanmondi, Dhaka 1205, Bangladesh
| | - Md. Kamrul Islam
- Department of Pharmacy, State University of Bangladesh, 77 Satmasjid Road, Dhanmondi, Dhaka 1205, Bangladesh
| | - Amit Singh
- Department of Pharmacy, State University of Bangladesh, 77 Satmasjid Road, Dhanmondi, Dhaka 1205, Bangladesh
| | - Tufael Ahmed
- Department of Pharmacy, State University of Bangladesh, 77 Satmasjid Road, Dhanmondi, Dhaka 1205, Bangladesh
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Ren S, Chen Y, Wang L, Wu G. Neuronal ferroptosis after intracerebral hemorrhage. Front Mol Biosci 2022; 9:966478. [PMID: 35992267 PMCID: PMC9388724 DOI: 10.3389/fmolb.2022.966478] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a devastating form of stroke with high rates of morbidity, mortality, and disability. It induces cell death that is responsible for the secondary brain injury (SBI). The underlying mechanism of SBI after ICH is still unclear, and whether it is related to iron overload is worthy to be discussed. Ferroptosis is an iron-dependent non-apoptotic modes of cell death and plays a particularly important role in the occurrence and progression of ICH. Many ICH-induced regulators and signalling pathways of ferroptosis have been reported as promising targets for treating ICH. In this article, we review the definition, characteristics, and inhibition methods of neuronal ferroptosis caused by iron deposition after ICH, and review the biomarkers for ferroptosis.
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Affiliation(s)
- Siying Ren
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Yue Chen
- Graduate School of Guizhou Medical University, Guiyang, China
| | - Likun Wang
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Guofeng Wu
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang, China
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12
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Bader ER, Pana TA, Barlas RS, Metcalf AK, Potter JF, Myint PK. Elevated inflammatory biomarkers and poor outcomes in intracerebral hemorrhage. J Neurol 2022; 269:6330-6341. [PMID: 35869372 PMCID: PMC9618534 DOI: 10.1007/s00415-022-11284-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/22/2022] [Accepted: 07/09/2022] [Indexed: 11/08/2022]
Abstract
Background Accumulating evidence suggests that spontaneous intracerebral hemorrhage (ICH) is associated with a reactive neuroinflammatory response. However, it remains unclear if circulating inflammatory biomarkers are associated with adverse outcomes in ICH. To address this knowledge gap, we conducted a cohort study using a prospectively maintained stroke register in the United Kingdom to assess the prognostic value of admission inflammatory biomarkers in ICH. Methods The Norfolk and Norwich Stroke and TIA Register recorded consecutive ICH cases. The primary exposures of interest were elevation of white cell count (WCC; > 10 × 109/L), elevation of c-reactive protein (CRP; > 10 mg/L), and co-elevation of both biomarkers, at the time of admission. Modified Poisson and Cox regressions were conducted to investigate the relationship between co-elevation of WCC and CRP at admission and outcomes following ICH. Functional outcome, multiple mortality timepoints, and length of stay were assessed. Results In total, 1714 ICH cases were identified from the register. After adjusting for covariates, including stroke-associated pneumonia, co-elevation of WCC and CRP at admission was independently associated with significantly increased risk of poor functional outcome (RR 1.08 [95% CI 1.01–1.15]) and inpatient mortality (RR 1.21 [95% CI 1.06–1.39]); and increased 90-day (HR 1.22 [95% CI 1.03–1.45]), and 1-year mortality (HR 1.20 [95% CI 1.02–1.41]). Individual elevation of WCC or CRP was also associated with poor outcomes. Conclusions Elevated inflammatory biomarkers were associated with poor outcomes in ICH. This study indicates that these readily available biomarkers may be valuable for prognostication and underscore the importance of inflammation in ICH. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-11284-8.
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13
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Aronowski J, Sansing LH, Xi G, Zhang JH. Mechanisms of Damage After Cerebral Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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14
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Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Tobieson L, Gard A, Ruscher K, Marklund N. Intracerebral Proinflammatory Cytokine Increase in Surgically Evacuated Intracerebral Hemorrhage: A Microdialysis Study. Neurocrit Care 2021; 36:876-887. [PMID: 34850333 PMCID: PMC9110446 DOI: 10.1007/s12028-021-01389-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/25/2021] [Indexed: 11/28/2022]
Abstract
Background Treatment options for spontaneous intracerebral hemorrhage (ICH) are limited. A possible inflammatory response in the brain tissue surrounding an ICH may exacerbate the initial injury and could be a target for treatment of subsequent secondary brain injury. The study objective was to compare levels of inflammatory mediators in the interstitial fluid of the perihemorrhagic zone (PHZ) and in seemingly normal cortex (SNX) in the acute phase after surgical evacuation of ICH, with the hypothesis being that a difference could be demonstrated between the PHZ and the SNX. Methods In this observational study, ten patients needing surgical evacuation of supratentorial ICH received two cerebral microdialysis catheters: one in the PHZ and one in the SNX that is remote from the ICH. The microdialysate was analyzed for energy metabolites (including lactate pyruvate ratio and glucose) and for inflammatory mediators by using a multiplex immunoassay of 27 cytokines and chemokines at 6–10 h, 20–26 h, and 44–50 h after surgery.
Results A metabolic crisis, indicated by altered energy metabolic markers, that persisted throughout the observation period was observed in the PHZ when compared with the SNX. Proinflammatory cytokines interleukin (IL) 8, tumor necrosis factor α, IL-2, IL-1β, IL-6 and interferon γ, anti-inflammatory cytokine IL-13, IL-4, and vascular endothelial growth factor A were significantly higher in PHZ compared with SNX and were most prominent at 20–26 h following ICH evacuation.
Conclusions Higher levels of both proinflammatory and anti-inflammatory cytokines in the perihemorrhagic brain tissue implies a complex role for inflammatory mediators in the secondary injury cascades following ICH surgery, suggesting a need for targeted pharmacological interventions. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01389-9.
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Affiliation(s)
- Lovisa Tobieson
- Departments of Neurosurgery in Linköping and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Anna Gard
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
| | - Karsten Ruscher
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Lund, Sweden.,Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skåne University Hopsital, Lund, Sweden
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16
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Troiani Z, Ascanio L, Rossitto CP, Ali M, Mohammadi N, Majidi S, Mocco J, Kellner CP. Prognostic Utility of Serum Biomarkers in Intracerebral Hemorrhage: A Systematic Review. Neurorehabil Neural Repair 2021; 35:946-959. [PMID: 34541960 DOI: 10.1177/15459683211041314] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background. Intracerebral hemorrhage (ICH) accounts for 10-20% of all strokes and is associated with high morbidity and mortality. Recent studies have identified serum biomarkers as a means to improve outcome prognostication in poor grade ICH patients. Poor prognosis of ICH patients and complex pathophysiology of the disease necessitate prognostic serum biomarkers to help guide treatment recommendations. Objective. The objective is to systematically review all biomarkers used to predict long-term functional outcome in patients with spontaneous intracerebral hemorrhage. Results. We identified 36 studies investigating the predictive utility of 50 discrete biomarkers. Data from 4865 ICH patients were reviewed. Inflammatory biomarkers (11/50) were most often studied, followed by oxidative (8/50), then neuron and astrocyte-specific (7/50). S100 calcium binding protein B, white blood cell count, and copeptin were the most often studied individual biomarkers. The prognostic utility of 23 biomarkers was analyzed using receiver operating characteristic curves. Area under the curve (AUC) values for all available biomarkers except neutrophil/lymphocyte ratio were acceptable. Twenty of the 23 biomarkers were characterized by at least one excellent AUC value. Vascular endothelial growth factor, glial fibrillary astrocyte protein, and S100 calcium binding protein B were characterized by outstanding AUC. Conclusions. We identified the inflammatory and neuron and astrocyte-specific biomarker categories as having the greatest number of significant individual biomarker predictors of long-term outcome. Further investigation utilizing cross-validation of prediction models in a second independent group and blinded assessment of outcomes for the predictive utility of biomarkers in patients with ICH is warranted.
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Affiliation(s)
- Zachary Troiani
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Luis Ascanio
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Christina P Rossitto
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Muhammad Ali
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Nicki Mohammadi
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Shahram Majidi
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Christopher P Kellner
- Department of Neurosurgery, 5925Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
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Early Inflammatory Cytokine Expression in Cerebrospinal Fluid of Patients with Spontaneous Intraventricular Hemorrhage. Biomolecules 2021; 11:biom11081123. [PMID: 34439789 PMCID: PMC8394793 DOI: 10.3390/biom11081123] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/10/2021] [Accepted: 07/13/2021] [Indexed: 12/28/2022] Open
Abstract
We investigated cerebrospinal fluid (CSF) expression of inflammatory cytokines and their relationship with spontaneous intracerebral and intraventricular hemorrhage (ICH, IVH) and perihematomal edema (PHE) volumes in patients with acute IVH. Twenty-eight adults with IVH requiring external ventricular drainage for obstructive hydrocephalus had cerebrospinal fluid (CSF) collected for up to 10 days and had levels of interleukin-1α (IL-1α), IL-1β, IL-6, IL-8, IL-10, tumor necrosis factor-α (TNFα), and C-C motif chemokine ligand CCL2 measured using enzyme-linked immunosorbent assay. Median [IQR] ICH and IVH volumes at baseline (T0) were 19.8 [5.8–48.8] and 14.3 [5.3–38] mL respectively. Mean levels of IL-1β, IL-6, IL-10, TNF-α, and CCL2 peaked early compared to day 9–10 (p < 0.05) and decreased across subsequent time periods. Levels of IL-1β, IL-6, IL-8, IL-10, and CCL2 had positive correlations with IVH volume at days 3–8 whereas positive correlations with ICH volume occurred earlier at day 1–2. Significant correlations were found with PHE volume for IL-6, IL-10 and CCL2 at day 1–2 and with relative PHE at days 7–8 or 9–10 for IL-1β, IL-6, IL-8, and IL-10. Time trends of CSF cytokines support experimental data suggesting association of cerebral inflammatory responses with ICH/IVH severity. Pro-inflammatory markers are potential targets for injury reduction.
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Leasure AC, Kuohn LR, Vanent KN, Bevers MB, Kimberly WT, Steiner T, Mayer SA, Matouk CC, Sansing LH, Falcone GJ, Sheth KN. Association of Serum IL-6 (Interleukin 6) With Functional Outcome After Intracerebral Hemorrhage. Stroke 2021; 52:1733-1740. [PMID: 33682454 PMCID: PMC8085132 DOI: 10.1161/strokeaha.120.032888] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/31/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVES IL-6 (interleukin 6) is a proinflammatory cytokine and an established biomarker in acute brain injury. We sought to determine whether admission IL-6 levels are associated with severity and functional outcome after spontaneous intracerebral hemorrhage (ICH). METHODS We performed an exploratory analysis of the recombinant activated FAST trial (Factor VII for Acute ICH). Patients with admission serum IL-6 levels were included. Regression analyses were used to assess the associations between IL-6 and 90-day modified Rankin Scale. In secondary analyses, we used linear regression to evaluate the association between IL-6 and baseline ICH and perihematomal edema volumes. RESULTS Of 841 enrolled patients, we included 552 (66%) with available admission IL-6 levels (mean age 64 [SD 13], female sex 203 [37%]). IL-6 was associated with poor outcome (modified Rankin Scale, 4-6; per additional 1 ng/L, odds ratio, 1.30 [95% CI, 1.04-1.63]; P=0.02) after adjustment for known predictors of outcome after ICH and treatment group. IL-6 was associated with ICH volume after adjustment for age, sex, and ICH location, and this association was modified by location (multivariable interaction, P=0.002), with a stronger association seen in lobar (β, 12.51 [95% CI, 6.47-18.55], P<0.001) versus nonlobar (β 5.32 [95% CI, 3.36-7.28], P<0.001) location. IL-6 was associated with perihematomal edema volume after adjustment for age, sex, ICH volume, and ICH location (β 1.22 [95% CI, 0.15-2.29], P=0.03). Treatment group was not associated with IL-6 levels or outcome. CONCLUSIONS In the FAST trial population, higher admission IL-6 levels were associated with worse 90-day functional outcome and larger ICH and perihematomal edema volumes.
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Affiliation(s)
- Audrey C. Leasure
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Lindsey R. Kuohn
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin N. Vanent
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew B. Bevers
- Divisions of Stroke, Cerebrovascular and Critical Care Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - W. Taylor Kimberly
- Department of Neurology, Division of Neurocritical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stephan A. Mayer
- Departments of Neurology and Neurosurgery, New York Medical College, Westchester Medical Center Health Network, Valhalla, NY, USA
| | - Charles C. Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven CT, USA
| | - Lauren H. Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Guido J. Falcone
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin N. Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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Mohamed WS, Kamel AE, Abdelwahab AH, Mahdy ME. High neutrophil-to-lymphocyte ratio predicts early neurological deterioration in spontaneous intracerebral hemorrhage patients. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-020-00267-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Intracerebral hemorrhage (ICH) is caused by bleeding, primarily into parenchymal brain tissue, and accounts for 9 to 27% of all strokes worldwide. Higher neutrophils, lower lymphocytes, and higher neutrophil-to-lymphocytes ratio (NLR) values predict worse outcomes after spontaneous intracranial hemorrhage (sICH) and could aid in the risk stratification of patients.
Methods
Eighty patients with sICH within the first 24 h of stroke onset and admitted into the neurology intensive care unit of an Egyptian university hospital and were assessed by GCS for consciousness level and NIHSS for stroke severity assessment, complete blood count, and special attention to NLR. Patients were reevaluated by GCS and NIHSS on the 7th day of the stroke. Early neurological deterioration (END) was defined as four points or a greater increase in the NIHSS score or two points or a greater decrease in GCS or death.
Results
END was recorded in 21.25% of patients while non-END was recorded in 78.75%. END was highly significantly associated with a low grade of GCS, high grade of NIHSS, elevated absolute lymphocyte count (ALC), and elevated NLR. Lower GCS score, higher NIHSS score, larger hematoma volume, and higher NLR values were independent predictors for END. The best cutoff of NLR in END prediction was > 9.1.
Conclusion
NLR is a trustworthy early predictor of sICH outcome.
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Cherevatenko RF, Antsiferov OV, Skachilova SY, Pokrovsky MV, Gureev VV, Banchuk II, Banchuk AY, Golubinskaya MI, Syromyatnikova AA, Rozhkov IS, Mostovykh AA. THE SEARCH FOR NEUROPROTECTIVE COMPOUNDS AMONG NEW ETHYLTHIADIAZOLE DERIVATIVES. PHARMACY & PHARMACOLOGY 2021. [DOI: 10.19163/2307-9266-2019-8-4-263-272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The aim of the study is to search compounds with neuroprotective properties among new ethylthiadiazole derivatives in simulated traumatic brain injury.Materials and methods. The experiment was carried out on 78 white male rats 270±20 g line “Wistar” 5–6 months of age and 120 outbred sexually mature mice weighing 20±2 grams. The article describes the search for compounds with neuroprotective properties among new ethylthiadiazole derivatives under the codes LKHT 4–15, LKHT 10–18, LKHT 11–18, and LKHT 12–18 in experimental traumatic brain injury in rats. Acute toxicity of the compounds was studied. Pharmacological screening was performed using behavioral and neurological research methods. The McGraw stroke score scale modified by I.V. Gannushkina and the mNSS psychometric scale were used in the study. The open field and Rota-rod tests were used to assess the behavioral status of the animals.Results. The compound-LKHT 12–18 at a dose of 50 mg/kg was detected as a leader. In pharmacological correction of pathology, this compound had the lowest percentage of fatality among the studied compounds (8%), the severity of neurological deficit was significantly reduced, the lowest scores and a higher level of motor activity of the limbs were registered. The number of rearing in the group of animals receiving the compound LKHT 12–18 at the dose of 50 mg/kg increased by 1.5 times, statistically significant (p<0.05) in comparison with the control group. Based on the results of the “Rota-rod” test, the total time of holding animals on the rod for 3 attempts was statistically significantly different in the groups administered with LKHT 12–18 derivatives (1.5 times longer) at the dose of 50 mg/kg compared with the control (p<0.05).Conclusion. Based on the results obtained in this study, it is planned to study in more detail the compound LKHT 12–18 at the dose of 50 mg/kg.
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Affiliation(s)
| | | | - S. Y. Skachilova
- Russian Scientific Center for the Safety of Biologically Active Substances
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21
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Bernstein JE, Browne JD, Savla P, Wiginton J, Patchana T, Miulli DE, Wacker MR, Duong J. Inflammatory Markers in Severity of Intracerebral Hemorrhage II: A Follow Up Study. Cureus 2021; 13:e12605. [PMID: 33585095 PMCID: PMC7872478 DOI: 10.7759/cureus.12605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction Spontaneous intracerebral hemorrhage (ICH) results in significant morbidity and mortality. The pathogenesis of brain injury after ICH is thought to be due to mechanical damage followed by ischemic, cytotoxic, and inflammatory changes in the underlying and surrounding tissue. Various inflammatory and non-inflammatory biomarkers have been studied as predictors and potential therapeutic targets for intracerebral hemorrhage. Our prior study showed an association with low vascular endothelial growth factor (VEGF) levels and increased mortality. This current study looks to expand on our prior results and will look at the relationship between tumor necrosis factor alpha (TNFα), C-reactive protein (CRP), VEGF, Homocysteine (Hcy), and CRP to albumin ratio (CAR) in predicting outcomes and severity in spontaneous intracerebral hemorrhage. Methods We conducted a retrospective chart review of patients with spontaneous intracerebral hemorrhage with TNFα, CRP, VEGF, Hcy levels drawn on admission. Albumin and CRP levels on admission were used to calculate CAR. Ninety-nine patients were included in the study. Primary outcomes included death, early neurologic decline (END), and hemorrhage size. Secondary outcomes included late neurologic decline (LND), Glasgow Coma Scale (GCS) on admission, GCS on discharge, ICH score, change in hemorrhage size, need for surgical intervention, and length of ICU stay. Results A total of 99 patients were included in this study, with 42% requiring surgical intervention and an overall mortality of 16%. Basal ganglia hemorrhage was seen in 41% of patients. Hcy and CAR were significantly correlated with ICH size in basal ganglia patients (r-=0.36, p=0.03; r=0.43, p=0.03, respectively). CAR was significantly correlated with ICH score (r=0.33, p=0.007874). Admission VEGF levels less than 45 pg/ml had 8.4-fold increase in mortality (odds ratio [OR] 8.4545, p=0.0488). Patients with TNFα levels greater than 1.40 pg/ml had a 4.1-fold increase in mortality (OR 4.1, p=0.04) Conclusion Our study demonstrated that low levels (<45 pg/ml) of VEGF were associated with an 8.4-fold increase in mortality, supporting the neuroprotective effect of this protein. Elevated Hcy and CAR levels were associated with an increase in hemorrhage size in patients with basal ganglia hemorrhages. TNFα levels greater than 1.40 pg/ml were associated with a 4.1-fold increase in mortality, and this together with CAR being correlated with increased hemorrhage size and ICH score further demonstrate the inflammatory consequences after intracerebral hemorrhage. Future studies directed at lowering CRP, TNFα, and Hcy and/or increasing VEGF in intracerebral hemorrhage patients are needed and may be beneficial.
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Affiliation(s)
- Jacob E Bernstein
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Jonathan D Browne
- School of Medicine, California University of Science and Medicine, Colton, USA
| | - Paras Savla
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James Wiginton
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Tye Patchana
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
| | | | - Jason Duong
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
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22
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Gómez-Lado N, López-Arias E, Iglesias-Rey R, Díaz-Platas L, Medín-Aguerre S, Fernández-Ferreiro A, Posado-Fernández A, García-Varela L, Rodríguez-Pérez M, Campos F, Del Pino P, Ruibal Á, Pardo-Montero J, Castillo J, Aguiar P, Sobrino T. [ 18F]-FMISO PET/MRI Imaging Shows Ischemic Tissue around Hematoma in Intracerebral Hemorrhage. Mol Pharm 2020; 17:4667-4675. [PMID: 33186043 DOI: 10.1021/acs.molpharmaceut.0c00932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Intracerebral hemorrhage (ICH), being the most severe cerebrovascular disease, accounts for 10-15% of all strokes. Hematoma expansion is one of the most important factors associated with poor outcome in intracerebral hemorrhage (ICH). Several studies have suggested that an "ischemic penumbra" might arise when the hematoma has a large expansion, but clinical studies are inconclusive. We performed a preclinical study to demonstrate the presence of hypoxic-ischemic tissue around the hematoma by means of longitudinal [18F]-fluoromisonidazole ([18F]-FMISO) PET/MRI studies over time in an experimental ICH model. Our results showed that all [18F]-FMISO PET/MRI images exhibited hypoxic-ischemic tissue around the hematoma area. A significant increase of [18F]-FMISO uptake was found at 18-24 h post-ICH when the maximum of hematoma volume is achieved and this increase disappeared before 42 h. These results demonstrate the presence of hypoxic tissue around the hematoma and open the possibility of new therapies aimed to reduce ischemic damage associated with ICH.
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Affiliation(s)
- Noemí Gómez-Lado
- Molecular Imaging Research Group, Nuclear Medicine Department, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain.,Molecular Imaging and Medical Physics Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, University of Santiago de Compostela (USC), University Clinical Hospital, Santiago de Compostela 15706, Spain
| | - Esteban López-Arias
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain
| | - Ramón Iglesias-Rey
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain
| | - Lucía Díaz-Platas
- Galician PET Radiopharmacy Unit, GALARIA, University Clinical Hospital, Santiago de Compostela 15706, Spain
| | - Santiago Medín-Aguerre
- Galician PET Radiopharmacy Unit, GALARIA, University Clinical Hospital, Santiago de Compostela 15706, Spain
| | - Anxo Fernández-Ferreiro
- Pharmacology Group, Pharmacy Department, University Clinical Hospital, University of Santiago de Compostela, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain
| | - Adrián Posado-Fernández
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain
| | - Lara García-Varela
- Molecular Imaging Research Group, Nuclear Medicine Department, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain
| | - Manuel Rodríguez-Pérez
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain
| | - Francisco Campos
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain
| | - Pablo Del Pino
- Center for Research in Biological Chemistry and Molecular Materials (CIQUS), Particle Physics Departament, University of Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - Álvaro Ruibal
- Molecular Imaging Research Group, Nuclear Medicine Department, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain.,Molecular Imaging and Medical Physics Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, University of Santiago de Compostela (USC), University Clinical Hospital, Santiago de Compostela 15706, Spain
| | - Juan Pardo-Montero
- Group of Medical Physics and Biomathematics, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain
| | - José Castillo
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain
| | - Pablo Aguiar
- Molecular Imaging Research Group, Nuclear Medicine Department, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain.,Molecular Imaging and Medical Physics Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, University of Santiago de Compostela (USC), University Clinical Hospital, Santiago de Compostela 15706, Spain
| | - Tomás Sobrino
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela 15706, Spain
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Dasari R, Bonsack F, Sukumari-Ramesh S. Brain injury and repair after intracerebral hemorrhage: The role of microglia and brain-infiltrating macrophages. Neurochem Int 2020; 142:104923. [PMID: 33248206 DOI: 10.1016/j.neuint.2020.104923] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/13/2020] [Accepted: 11/22/2020] [Indexed: 12/12/2022]
Abstract
Intracerebral hemorrhage (ICH) is a major public health problem characterized by cerebral bleeding. Despite recent advances in preclinical studies, there is no effective treatment for ICH making it the deadliest subtype of stroke. The lack of effective treatment options partly attributes to the complexity as well as poorly defined pathophysiology of ICH. The emerging evidence indicates the potential of targeting secondary brain damage and hematoma resolution for improving neurological outcomes after ICH. Herein, we provide an overview of our understanding of the functional roles of activated microglia and brain-infiltrating monocyte-derived macrophages in brain injury and repair after ICH. The clinical and preclinical aspects that we discuss in this manuscript are related to ICH that occurs in adults, but not in infants. Also, we attempt to identify the knowledge gap in the field for future functional studies given the potential of targeting microglia and brain-infiltrating macrophages for therapeutic intervention after ICH.
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Affiliation(s)
- Rajaneekar Dasari
- Department of Pharmacology and Toxicology, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Frederick Bonsack
- Department of Pharmacology and Toxicology, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Sangeetha Sukumari-Ramesh
- Department of Pharmacology and Toxicology, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA.
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Mosarrezaii A, Amiri-Nikpour MR, Mehryar HR, Choobi Anzali B, Nourooz-Zadeh S, Babaei S, Farrokhi H. Investigating the relationship between interleukin-6 serum levels and outcome in acute ischemic CVA. Brain Behav 2020; 10:e01668. [PMID: 32583980 PMCID: PMC7428482 DOI: 10.1002/brb3.1668] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 01/27/2020] [Accepted: 02/05/2020] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Interleukin-6 (IL-6) is among the inflammatory mediators exhibiting elevated levels in ischemic stroke (IS) patients. The present study set out to evaluate the relationship between serum levels of interleukin-6 with long-term and at-hospital outcomes of acute ischemic stroke in patients hospitalized at Imam Khomeini Hospital, Urmia, Iran, from 2017 to 2018. METHOD AND MATERIALS This cross-sectional descriptive study enrolled 29 and 31 acute stroke patients for long-term and at-hospital observation, respectively. Evaluation of stroke severity was performed using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) on days 1, 5, and 90. Serum IL-6 level was measured via enzyme-linked immunosorbent assay (ELISA) on days one and five. RESULTS In the present cohort study, the following population were enrolled: for long-term evaluation, 11 (38%) men and 18 (63%) women with a mean age of 64.5 ± 14.9 years, and for at-hospital evaluation: 11 (37.5%) men and 20 (64.5%) with a mean age of 65.25 ± 14.37 years. A significant positive correlation was observed between IL-6 levels with NIHSS and mRS scores of the patients from time of admission until the end of the follow-up period (long-term: p < .001; at-hospital: 0.022). CONCLUSION The evidence from the present study suggests that IL-6 contributes to the determination of the severity of ischemic strokes and may be useful in predicting prognosis. However, larger scale studies are required to further establish these finds.
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Affiliation(s)
- Arash Mosarrezaii
- Department of Neurology, Urmia University of Medical Sciences, Urmia, Iran
| | | | - Hamid Reza Mehryar
- Clinical Research Development Unit of Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran
| | - Babak Choobi Anzali
- Department of Emergency Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | | | - Shadi Babaei
- Urmia University of Medical Sciences, Urmia, Iran
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Hervella P, Rodríguez-Yáñez M, Pumar JM, Ávila-Gómez P, da Silva-Candal A, López-Loureiro I, Rodríguez-Maqueda E, Correa-Paz C, Castillo J, Sobrino T, Campos F, Iglesias-Rey R. Antihyperthermic treatment decreases perihematomal hypodensity. Neurology 2020; 94:e1738-e1748. [PMID: 32221027 PMCID: PMC7282877 DOI: 10.1212/wnl.0000000000009288] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 11/21/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the effect on perihematomal hypodensity and outcome of a decrease in body temperature in the first 24 hours in patients with intracerebral hemorrhage (ICH). METHODS In this retrospective study on a prospectively registered database, among the 1,100 patients, 795 met all the inclusion criteria. Temperature variations in the first 24 hours and perihematomal hypodensity (PHHD) were recorded. Patients ≥37.5°C were treated with antihyperthermic drugs for at least 48 hours. The main objective was to determine the association among temperature variation, PHHD, and outcome at 3 months. RESULTS The decrease in temperature in the first 24 hours increased the possibility of good outcome 11-fold. Temperature decrease, lower PHHD volume, and a good outcome were observed in 31.8% of the patients who received antihyperthermic treatment. CONCLUSION The administration of early antihyperthermic treatment in patients with spontaneous ICH with a basal axillary temperature ≥37.5°C resulted in good outcome in a third of the treated patients.
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Affiliation(s)
- Pablo Hervella
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain.
| | - Manuel Rodríguez-Yáñez
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - José Manuel Pumar
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Paulo Ávila-Gómez
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Andrés da Silva-Candal
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Ignacio López-Loureiro
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Elena Rodríguez-Maqueda
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Clara Correa-Paz
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - José Castillo
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Tomás Sobrino
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Francisco Campos
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Ramón Iglesias-Rey
- From the Clinical Neurosciences Research Laboratory (LINC) (P.H., P.Á.-G., A.d.S.-C., I.L.-L., E.R.-M., C.-C.P., J.C., T.S., F.C., R.I.-R.), Health Research Institute of Santiago de Compostela (IDIS); and Stroke Unit, Department of Neurology (M.R.-Y.), and Department of Neuroradiology (J.M.P.), Hospital Clínico Universitario, Santiago de Compostela, Spain.
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Pinchi E, Luigi C, Paola S, Gianpietro V, Raoul T, Mauro A, Paola F. MicroRNAs: The New Challenge for Traumatic Brain Injury Diagnosis. Curr Neuropharmacol 2020; 18:319-331. [PMID: 31729300 PMCID: PMC7327940 DOI: 10.2174/1570159x17666191113100808] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/30/2019] [Accepted: 11/10/2019] [Indexed: 12/13/2022] Open
Abstract
The acronym TBI refers to traumatic brain injury, an alteration of brain function, or an evidence of brain pathology, that is caused by an external force. TBI is estimated to become the third leading cause of permanent disability and mortality worldwide. TBI-related injuries can be classified in many ways, according to the degree of severity or the pathophysiology of brain injury (primary and secondary damage). Numerous cellular pathways act in secondary brain damage: excitotoxicity (mediated by excitatory neurotransmitters), free radical generation (due to mitochondrial impairment), neuroinflammatory response (due to central nervous system and immunoactivation) and apoptosis. In this scenario, microRNAs are implicated in the regulation of almost all genes at the post-transcriptional level. Several microRNAs have been demonstrated to be specifically expressed in particular cerebral areas; moreover, physiological changes in microRNA expression during normal cerebral development upon the establishment of neural networks have been characterized. More importantly, microRNAs show profound alteration in expression in response to brain pathological states, both traumatic or not. This review summarizes the most important molecular networks involved in TBI and examines the most recent and important findings on TBI-related microRNAs, both in animal and clinical studies. The importance of microRNA research holds promise to find biomarkers able to unearth primary and secondary molecular patterns altered upon TBI, to ultimately identify key points of regulation, as a valuable support in forensic pathology and potential therapeutic targets for clinical treatment.
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Affiliation(s)
- Enrica Pinchi
- Address correspondence to this author at the Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy; E-mail:
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Gruenbaum BF, Kutz R, Zlotnik A, Boyko M. Blood glutamate scavenging as a novel glutamate-based therapeutic approach for post-stroke depression. Ther Adv Psychopharmacol 2020; 10:2045125320903951. [PMID: 32110376 PMCID: PMC7026819 DOI: 10.1177/2045125320903951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/31/2019] [Indexed: 12/16/2022] Open
Abstract
Post-stroke depression (PSD) is a major complication of stroke that significantly impacts functional recovery and quality of life. While the exact mechanism of PSD is unknown, recent attention has focused on the association of the glutamatergic system in its etiology and treatment. Minimizing secondary brain damage and neuropsychiatric consequences associated with excess glutamate concentrations is a vital part of stroke management. The blood glutamate scavengers, oxaloacetate and pyruvate, degrade glutamate in the blood to its inactive metabolite, 2-ketoglutarate, by the coenzymes glutamate-oxaloacetate transaminase (GOT) and glutamate-pyruvate transaminase (GPT), respectively. This reduction in blood glutamate concentrations leads to a subsequent shift of glutamate down its concentration gradient from the blood to the brain, thereby decreasing brain glutamate levels. Although there are not yet any human trials that support blood glutamate scavengers for clinical use, there is increasing evidence from animal research of their efficacy as a promising new therapeutic approach for PSD. In this review, we present recent evidence in the literature of the potential therapeutic benefits of blood glutamate scavengers for reducing PSD and other related neuropsychiatric conditions. The evidence reviewed here should be useful in guiding future clinical trials.
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Affiliation(s)
- Benjamin F Gruenbaum
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Ruslan Kutz
- Division of Anesthesiology and Critical Care, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alexander Zlotnik
- Division of Anesthesiology and Critical Care, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Matthew Boyko
- Division of Anesthesiology and Critical Care, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84101, Israel
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Wilkinson CM, Kalisvaart ACJ, Kung TFC, Maisey DR, Klahr AC, Dickson CT, Colbourne F. The collagenase model of intracerebral hemorrhage in awake, freely moving animals: The effects of isoflurane. Brain Res 2019; 1728:146593. [PMID: 31816320 DOI: 10.1016/j.brainres.2019.146593] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/13/2019] [Accepted: 12/04/2019] [Indexed: 01/17/2023]
Abstract
Intracerebral hemorrhage (ICH) is a devastating stroke often modelled in rats. Isoflurane anesthetic, commonly used in preclinical research, affects general physiology (e.g., blood pressure) and electrophysiology (e.g., burst suppression) in many ways. These physiological changes may detract from the clinical relevance of the model. Here, we revised the standard collagenase model to produce an ICH in rats without anesthetic. Guide cannulas were implanted stereotaxically under anesthetic. After 3 days of recovery, collagenase was infused through an internal cannula into the striatum of animals randomly assigned to the non-anesthetized or isoflurane group. We assessed whether isoflurane affected hematoma volume, core temperature, movement activity, pain, blood pressure, and seizure activity. With a small ICH, there was a hematoma volume increased from 8.6 (±3.3, 95% confidence interval) µL in anesthetized rats to 13.2 (±3.1) µL in non-anesthetized rats (P = 0.008), but with a larger ICH, hematoma volumes were similar. Isoflurane decreased temperature by 1.3 °C (±0.16 °C, P < 0.001) for 2 h and caused a 35.1 (±1.7) mmHg group difference in blood pressure (P < 0.007) for 12 m. Blood glucose increased twofold after isoflurane procedures (P < 0.001). Pain, as assessed with the rat grimace scale, did not differ between groups. Seizure incidence rate (62.5%) in non-anesthetized ICH rats was similar to historic amounts (61.3%). In conclusion, isoflurane appears to have some significant and injury size-dependent effects on the collagenase model. Thus, when anesthetic effects are a known concern, the use of the standardized cannula infusion approach is scientifically and ethically acceptable.
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Affiliation(s)
| | | | - Tiffany F C Kung
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - D Ryan Maisey
- Social Sciences - Augustana Faculty, University of Alberta, Camrose, Canada
| | - Ana C Klahr
- Social Sciences - Augustana Faculty, University of Alberta, Camrose, Canada
| | - Clayton T Dickson
- Department of Psychology, University of Alberta, Edmonton, Canada; Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada; Department of Physiology, University of Alberta, Edmonton, Canada
| | - Frederick Colbourne
- Department of Psychology, University of Alberta, Edmonton, Canada; Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada.
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Robicsek SA, Bhattacharya A, Rabai F, Shukla K, Doré S. Blood-Related Toxicity after Traumatic Brain Injury: Potential Targets for Neuroprotection. Mol Neurobiol 2019; 57:159-178. [PMID: 31617072 DOI: 10.1007/s12035-019-01766-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 02/07/2023]
Abstract
Emergency visits, hospitalizations, and deaths due to traumatic brain injury (TBI) have increased significantly over the past few decades. While the primary early brain trauma is highly deleterious to the brain, the secondary injury post-TBI is postulated to significantly impact mortality. The presence of blood, particularly hemoglobin, and its breakdown products and key binding proteins and receptors modulating their clearance may contribute significantly to toxicity. Heme, hemin, and iron, for example, cause membrane lipid peroxidation, generate reactive oxygen species, and sensitize cells to noxious stimuli resulting in edema, cell death, and increased morbidity and mortality. A wide range of other mechanisms such as the immune system play pivotal roles in mediating secondary injury. Effective scavenging of all of these pro-oxidant and pro-inflammatory metabolites as well as controlling maladaptive immune responses is essential for limiting toxicity and secondary injury. Hemoglobin metabolism is mediated by key molecules such as haptoglobin, heme oxygenase, hemopexin, and ferritin. Genetic variability and dysfunction affecting these pathways (e.g., haptoglobin and heme oxygenase expression) have been implicated in the difference in susceptibility of individual patients to toxicity and may be target pathways for potential therapeutic interventions in TBI. Ongoing collaborative efforts are required to decipher the complexities of blood-related toxicity in TBI with an overarching goal of providing effective treatment options to all patients with TBI.
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Affiliation(s)
- Steven A Robicsek
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease and McKnight Brain Institute, College of Medicine, University of Florida, 1275 Center Drive, Biomed Sci J493, Gainesville, FL, 32610, USA. .,Departments of Neurosurgery, Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA.
| | - Ayon Bhattacharya
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease and McKnight Brain Institute, College of Medicine, University of Florida, 1275 Center Drive, Biomed Sci J493, Gainesville, FL, 32610, USA.,Department of Pharmacology, KPC Medical College, West Bengal University of Health Sciences, Kolkata, West Bengal, India
| | - Ferenc Rabai
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease and McKnight Brain Institute, College of Medicine, University of Florida, 1275 Center Drive, Biomed Sci J493, Gainesville, FL, 32610, USA
| | - Krunal Shukla
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease and McKnight Brain Institute, College of Medicine, University of Florida, 1275 Center Drive, Biomed Sci J493, Gainesville, FL, 32610, USA
| | - Sylvain Doré
- Department of Anesthesiology, Center for Translational Research in Neurodegenerative Disease and McKnight Brain Institute, College of Medicine, University of Florida, 1275 Center Drive, Biomed Sci J493, Gainesville, FL, 32610, USA. .,Departments of Neurology, Psychiatry, Pharmaceutics and Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA.
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Bruch GE, Fernandes LF, Bassi BL, Alves MTR, Pereira IO, Frézard F, Massensini AR. Liposomes for drug delivery in stroke. Brain Res Bull 2019; 152:246-256. [DOI: 10.1016/j.brainresbull.2019.07.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 06/26/2019] [Accepted: 07/12/2019] [Indexed: 12/26/2022]
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Abstract
Mast cells are first responders to intracerebral hemorrhage. They release potent mediators that can disrupt the blood-brain barrier promoting injury, vasogenic edema formation, and hematoma exacerbation. Also, mast cells recruit other inflammatory cells that maintain and amplify brain damage. Given their early role in the cascade of events in intracerebral hemorrhage, mast cells may offer an alternative target for antichemotactic interventions.
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Affiliation(s)
- Mustafa Yehya
- Cerebrovascular and Neurocritical Care Division, Department of Neurology, Wexner Medical Center, The Ohio State University, 333 W. 10th Ave, Graves Hall, Rm. 3172, Columbus, OH, 43210, USA
| | - Michel T Torbey
- Cerebrovascular and Neurocritical Care Division, Department of Neurology, Wexner Medical Center, The Ohio State University, 333 W. 10th Ave, Graves Hall, Rm. 3172, Columbus, OH, 43210, USA. .,Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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32
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Chen B, Chen Z, Liu M, Gao X, Cheng Y, Wei Y, Wu Z, Cui D, Shang H. Inhibition of neuronal ferroptosis in the acute phase of intracerebral hemorrhage shows long-term cerebroprotective effects. Brain Res Bull 2019; 153:122-132. [PMID: 31442590 DOI: 10.1016/j.brainresbull.2019.08.013] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 08/10/2019] [Accepted: 08/18/2019] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) is a devastating subtype of stroke because it has few viable therapeutic options to intervene against primary or second brain injury. Recently, evidence has suggested that ferroptosis, a nonapoptotic form of cell death, is involved in ICH. In this study, we examined whether ICH-induced neuron death is partly ferroptotic in humans and assessed its temporal and spatial characteristics in mice. Furthermore, the ferroptosis inhibitor ferrostatin-1 (Fer-1) was used to examine the role of ferroptosis after ICH. Fold changes in ferroptosis-related gene expression, intracellular iron levels, malondialdehyde (MDA) levels, and both protein levels and cellular localization of cyclooxygenase-2 (COX-2) were measured to monitor ferroptosis. Transmission electron microscopy (TEM) was also performed to examine the ultrastructure of cells after ICH. We found that the expression level of prostaglandin-endoperoxide synthase (PTGS2) was increased in both in vitro and in vivo ICH models; by comparison, expression level of RPL8 was increased in human brain tissue. In mice, iron and MDA levels were significantly increased 3 h after ICH; COX-2 levels were increased at 12 h after ICH and peaked at 3 days after ICH; COX-2 colocalized with NeuN (a neuronal biomarker); and TEM showed that shrunken mitochondria were found at 3 h, 3 days, and 7 days after ICH. Moreover, ICH-induced neurological deficits, memory impairment and brain atrophy were reduced by Fer-1 treatment. Our results demonstrated that neuronal ferroptosis occurs during the acute phase of ICH in brain areas distant from the hematoma and that inhibition of ferroptosis by Fer-1 exerted a long-term cerebroprotective effect.
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Affiliation(s)
- Bin Chen
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Zhenghong Chen
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Mingjian Liu
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaorong Gao
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yijun Cheng
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yongxu Wei
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Zhebao Wu
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Derong Cui
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China.
| | - Hanbing Shang
- Department of Neurosurgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.
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Frank D, Kuts R, Tsenter P, Gruenbaum BF, Grinshpun Y, Zvenigorodsky V, Shelef I, Natanel D, Brotfain E, Zlotnik A, Boyko M. The effect of pyruvate on the development and progression of post-stroke depression: A new therapeutic approach. Neuropharmacology 2019; 155:173-184. [PMID: 31153808 DOI: 10.1016/j.neuropharm.2019.05.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/26/2019] [Accepted: 05/30/2019] [Indexed: 12/27/2022]
Abstract
Post-stroke depression (PSD) is a common and serious complication following stroke. Both stroke and depression have independently been associated with pathologically elevated glutamate levels in the brain's extra-cerebral fluid (ECF). Here we evaluate an alternative therapeutic approach to PSD with pyruvate. Rats were randomly assigned into one of 3 groups: Middle Cerebral Artery Occlusion (MCAO) plus pyruvate treatment, MCAO plus placebo treatment, and sham operated rats. Post-MCAO depressive and anxiety-like behavior was assessed, along with neurological status, brain infarct zone, brain edema, blood brain barrier (BBB) breakdown, cerebrospinal fluid and blood glutamate levels. Anxiety-like behavior and levels of blood alanine and α-ketoglutarate were measured in naïve rats treated with pyruvate, as a control. Post-stroke neurological deficit with concurrent elevation in glutamate levels were demonstrated, with peak glutamate levels 24 h after MCAO. Treatment with pyruvate led to reduced glutamate levels 24 h after MCAO and improved neurologic recovery. Pyruvate treatment reduced lesion volume, brain edema and the extent of BBB permeability 24 h post-MCAO. Naïve rats treated with pyruvate showed increased levels of α-ketoglutarate. Rats demonstrated post-stroke depressive behavior that was improved by the administration of pyruvate. There was less anxiety-like behavior in post-stroke rats treated with placebo in comparison to the post-stroke rats treated with pyruvate or sham operated rats. Glutamate scavenging with pyruvate appears to be an effective as a method in providing neuroprotection following stroke and as a therapeutic option for the treatment of PSD by reducing the consequent elevations in CNS glutamate levels.
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Affiliation(s)
- Dmitry Frank
- Department of Anesthesiology and Critical Care, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ruslan Kuts
- Department of Anesthesiology and Critical Care, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Philip Tsenter
- Division of Internal Medicine, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Benjamin F Gruenbaum
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Yulia Grinshpun
- Department of Anesthesiology and Critical Care, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Vladislav Zvenigorodsky
- Department of Radiology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ilan Shelef
- Department of Radiology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dmitry Natanel
- Department of Anesthesiology and Critical Care, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Evgeny Brotfain
- Department of Anesthesiology and Critical Care, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alexander Zlotnik
- Department of Anesthesiology and Critical Care, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Matthew Boyko
- Department of Anesthesiology and Critical Care, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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Bennett C, Mohammed F, Álvarez-Ciara A, Nguyen MA, Dietrich WD, Rajguru SM, Streit WJ, Prasad A. Neuroinflammation, oxidative stress, and blood-brain barrier (BBB) disruption in acute Utah electrode array implants and the effect of deferoxamine as an iron chelator on acute foreign body response. Biomaterials 2019; 188:144-159. [PMID: 30343257 PMCID: PMC6300159 DOI: 10.1016/j.biomaterials.2018.09.040] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/20/2018] [Accepted: 09/24/2018] [Indexed: 02/06/2023]
Abstract
The use of intracortical microelectrode arrays has gained significant attention in being able to help restore function in paralysis patients and study the brain in various neurological disorders. Electrode implantation in the cortex causes vasculature or blood-brain barrier (BBB) disruption and thus elicits a foreign body response (FBR) that results in chronic inflammation and may lead to poor electrode performance. In this study, a comprehensive insight into the acute molecular mechanisms occurring at the Utah electrode array-tissue interface is provided to understand the oxidative stress, neuroinflammation, and neurovascular unit (astrocytes, pericytes, and endothelial cells) disruption that occurs following microelectrode implantation. Quantitative real time polymerase chain reaction (qRT-PCR) was used to quantify the gene expression at acute time-points of 48-hr, 72-hr, and 7-days for factors mediating oxidative stress, inflammation, and BBB disruption in rats implanted with a non-functional 4 × 4 Utah array in the somatosensory cortex. During vascular disruption, free iron released into the brain parenchyma can exacerbate the FBR, leading to oxidative stress and thus further contributing to BBB degradation. To reduce the free iron released into the brain tissue, the effects of an iron chelator, deferoxamine mesylate (DFX), was also evaluated.
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Affiliation(s)
- Cassie Bennett
- Department of Biomedical Engineering, University of Miami, FL, USA
| | - Farrah Mohammed
- Department of Biomedical Engineering, University of Miami, FL, USA
| | | | | | | | - Suhrud M Rajguru
- Department of Biomedical Engineering, University of Miami, FL, USA
| | | | - Abhishek Prasad
- Department of Biomedical Engineering, University of Miami, FL, USA.
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35
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Bobinger T, Burkardt P, B Huttner H, Manaenko A. Programmed Cell Death after Intracerebral Hemorrhage. Curr Neuropharmacol 2018; 16:1267-1281. [PMID: 28571544 PMCID: PMC6251052 DOI: 10.2174/1570159x15666170602112851] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/26/2017] [Accepted: 06/01/2017] [Indexed: 01/01/2023] Open
Abstract
Background: Intracerebral hemorrhage (ICH) accounts for up to 15% of all strokes and is characterized by high rates of mortality and morbidity. The post-ICH brain injury can be distinguished in 1) primary, which are caused by disrup-tion and mechanical deformation of brain tissue due to hematoma growth and 2) secondary, which are induced by microglia activation, mitochondrial dysfunction, neurotransmitter and inflammatory mediator release. Although these events typically lead to necrosis, the occurrence of programmed cell death has also been reported after ICH. Methods: We reviewed recent publications describing advance in pre- and clinic ICH research. Results: At present, treatment of ICH patients is based on oral anticoagulant reversal, management of blood pressure and other medical complications. Several pre-clinical studies showed promising results and demonstrated that anti-oxidative and anti-inflammatory treatments reduced neuronal cell death, however, to date, all of these attempts have failed in randomized controlled clinical trials. Yet, the time frame of administration may be crucial in translation from animal to clinical studies. Furthermore, the latest pre-clinical research points toward the existence of other, apoptosis-unrelated forms kinds of pro-grammed cell death. Conclusion: Our review summarizes current knowledge of pathways leading to programmed cell death after ICH in addition to data from clinical trials. Some of the pre-clinical results have not yet demonstrated clinical confirmation, however they sig-nificantly contribute to our understanding of post-ICH pathology and can contribute to development of new therapeutic ap-proaches, decreasing mortality and improving ICH patients’ quality of life.
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Affiliation(s)
- Tobias Bobinger
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Petra Burkardt
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Anatol Manaenko
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
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Bernstein JE, Savla P, Dong F, Zampella B, Wiginton JG, Miulli DE, Wacker MR, Menoni R. Inflammatory Markers and Severity of Intracerebral Hemorrhage. Cureus 2018; 10:e3529. [PMID: 30613458 PMCID: PMC6314395 DOI: 10.7759/cureus.3529] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and purpose The pathogenesis of brain injury after intracerebral hemorrhage is thought to be due to mechanical damage followed by ischemic, cytotoxic, and inflammatory changes in the underlying and surrounding tissue.In recent years, there has been a greater research interest into the various inflammatory biomarkers and growth factors that are secreted during intracerebral hemorrhage. The biomarkers investigated in this study are tumor necrosis factor alpha (TNF alpha), C-reactive protein (CRP), homocysteine (Hcy), and vascular endothelial growth factor (VEGF). The aim of this study was to further investigate the effects of these biomarkers in predicting the acute severity outcome of intracerebral hemorrhage (ICH). Methods We conducted a retrospective chart review of patients with spontaneous ICH with TNF alpha, CRP, VEGF, and Hcy levels drawn on admission. Forty-two patients with spontaneous ICH with at least one of the above labs were included in the study. Primary outcomes included death, Glasgow Coma Scale (GCS) on admission, early neurologic decline (END), and hemorrhage size. Secondary outcomes included GCS on discharge, ICH score, functional outcome risk stratification scale of intracerebral hemorrhage (FUNC score), change in hemorrhage size, need for surgical intervention, and length of intensive care unit (ICU) stay. Results Forty-two patients with spontaneous intracerebral hemorrhage (ICH) were analyzed, 12 patients (28.5%) required surgical intervention, and four patients (9.5%) died. Only low VEGF serum values were found to predict mortality. TNF alpha, CRP, Hcy, and VEGF levels in our patients with ICH were not found to predict early neurologic decline and were not correlated with GCS on admission, initial hemorrhage size, change in hemorrhage size, need for surgical intervention, ICH score, FUNC score, midline shift, and length of ICU stay. CRP and Hcy were elevated in 58% and 31% of patients tested, respectively. GCS on admission and ICH score were significantly associated with mortality. Conclusion After careful statistical review of the data obtained from this patient population, only low VEGF values were found to be a significant predictor of mortality. However, elevated CRP and Hcy levels were associated with a non-significant trend in hemorrhage size and mortality suggesting that CRP and Hcy-lowering therapies may decrease hemorrhagic stroke risk and severity.
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Affiliation(s)
- Jacob E Bernstein
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Paras Savla
- Osteopathy, College of Osteopathic Medicine - Touro University, Vallejo, USA
| | - Fanglong Dong
- Clinical Research, Western University of Health Sciences, Pomona, USA
| | - Bailey Zampella
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James G Wiginton
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Margaret R Wacker
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Rosalinda Menoni
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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The neuroprotective effects and probable mechanisms of Ligustilide and its degradative products on intracerebral hemorrhage in mice. Int Immunopharmacol 2018; 63:43-57. [DOI: 10.1016/j.intimp.2018.06.045] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 06/14/2018] [Accepted: 06/29/2018] [Indexed: 12/24/2022]
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Di Napoli M, Slevin M, Popa-Wagner A, Singh P, Lattanzi S, Divani AA. Monomeric C-Reactive Protein and Cerebral Hemorrhage: From Bench to Bedside. Front Immunol 2018; 9:1921. [PMID: 30254628 PMCID: PMC6141664 DOI: 10.3389/fimmu.2018.01921] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/03/2018] [Indexed: 12/14/2022] Open
Abstract
C-reactive protein (CRP) is an important mediator and a hallmark of the acute-phase response to inflammation. High-sensitivity assays that accurately measure levels of CRP have been recommended for use in risk assessment in ischemic stroke patients. Elevation of CRP during the acute-phase response in intracerebral hemorrhage (ICH) is also associated with the outcomes such as death and vascular complications. However, no association has been found with the increased risk of ICH. The aim of this review is to synthesize the published literature on the associations of CRP with acute ICH both as a risk biomarker and predictor of short- and long-term outcomes as well as its role as a pathogenic determinant. We believe before any clinical utility, a critical appraisal of the strengths and deficiencies of the accumulated evidence is required both to evaluate the current state of knowledge and to improve the design of future clinical studies.
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Affiliation(s)
- Mario Di Napoli
- Department of Neurology and Stroke Unit, San Camillo de' Lellis General Hospital, Rieti, Italy
| | - Mark Slevin
- Healthcare Science, Manchester Metropolitan University, Manchester, United Kingdom
| | - Aurel Popa-Wagner
- Department of Neurology, University of Medicine Essen, Essen, Germany.,Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy, Craiova, Romania
| | - Puneetpal Singh
- Department of Human Genetics, Punjabi University, Patiala, India
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Afshin A Divani
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States.,Department of Neurosurgery, University of Minnesota, Minneapolis, MN, United States
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Modeling prognostic factors for poor neurological outcome in conservatively treated patients with intracerebral hemorrhage: A focus on TNF-α. Clin Neurol Neurosurg 2018; 172:51-58. [DOI: 10.1016/j.clineuro.2018.06.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/15/2018] [Accepted: 06/26/2018] [Indexed: 12/21/2022]
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40
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Landreneau MJ, Mullen MT, Messé SR, Cucchiara B, Sheth KN, McCullough LD, Kasner SE, Sansing LH. CCL2 and CXCL10 are associated with poor outcome after intracerebral hemorrhage. Ann Clin Transl Neurol 2018; 5:962-970. [PMID: 30128320 PMCID: PMC6093844 DOI: 10.1002/acn3.595] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/02/2018] [Accepted: 05/22/2018] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Intracerebral hemorrhage carries a high mortality and survivors are frequently left with significant disability. Immunological mechanisms may play an important role in hemorrhage-induced brain injury, however, research linking these mechanisms with clinical outcome remains limited. We aim to identify serum inflammatory mediators that are associated with outcome after intracerebral hemorrhage in order to translate data from experimental models to a patient cohort and identify potential targets worthy of reverse translation. METHODS A prospective cohort study at two comprehensive stroke centers enrolled patients with spontaneous intracerebral hemorrhage. Peripheral blood was collected at 6, 24, and 72 h from onset. Functional outcome was assessed at 90 days using the modified Rankin Scale (mRS). Serum inflammatory mediators were measured using multiplex ELISA. Multivariable modeling identified serum biomarkers independently associated with functional outcome at 90 days. RESULTS 115 patients completed the study. At 6 h after onset, patients with elevated CCL2 had worse mRS score at day 90 (OR 4.07, 95% CI 1.27-13.10, P = 0.02) after adjusting for age, gender, ICH volume, IVH, infratentorial location and NIHSS score. At 24 and 72 h after onset, elevation in CXCL10 was independently associated with worse 90 days mRS score (24 h: OR 8.08, 95% CI 2.69-24.30, P < 0.001; 72 h: OR 3.89, 95% CI 1.12-13.49, P = 0.03). INTERPRETATION Acute and subacute elevations in specific immune factors are associated with poor outcome, highlighting potential pathways that may contribute to ongoing brain injury in patients with intracerebral hemorrhage.
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Affiliation(s)
| | - Michael T. Mullen
- Department of NeurologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | - Steven R. Messé
- Department of NeurologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | - Brett Cucchiara
- Department of NeurologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | - Kevin N. Sheth
- Department of NeurologyYale University School of MedicineNew HavenConnecticut
- Center for Neuroepidemiology and Clinical Neurological ResearchYale School of MedicineNew HavenConnecticut
| | - Louise D. McCullough
- Department of NeurologyUniversity of Texas Health Sciences Center at HoustonHoustonTexas
| | - Scott E. Kasner
- Department of NeurologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | - Lauren H. Sansing
- Department of NeurologyYale University School of MedicineNew HavenConnecticut
- Center for Neuroepidemiology and Clinical Neurological ResearchYale School of MedicineNew HavenConnecticut
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Peripheral glutamate and TNF-α levels in patients with intracerebral hemorrhage: Their prognostic values and interactions toward the formation of the edemal volume. Neurol Neurochir Pol 2018; 52:207-214. [DOI: 10.1016/j.pjnns.2017.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/06/2017] [Accepted: 10/08/2017] [Indexed: 11/23/2022]
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Critical role for Annexin A7 in secondary brain injury mediated by its phosphorylation after experimental intracerebral hemorrhage in rats. Neurobiol Dis 2018; 110:82-92. [DOI: 10.1016/j.nbd.2017.11.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/14/2017] [Accepted: 11/27/2017] [Indexed: 01/27/2023] Open
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Rendevski V, Aleksovski B, Stojanov D, Mihajlovska-Rendevska A, Aleksovski V, Baneva-Dolnenec N, Nikodijevic D, Gudeva-Nikovska D. Validation of the ELISA Method for Quantitative Detection of TNF-α in Patients with Intracerebral Hemorrhage. Open Access Maced J Med Sci 2017; 5:703-707. [PMID: 29104676 PMCID: PMC5661705 DOI: 10.3889/oamjms.2017.170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/01/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023] Open
Abstract
AIM: We aimed to investigate the sensitivity, reproducibility and validity of the commercial ELISA kits for quantitative detection of TNF-α and their potential application for screening purposes in patients with ICH. METHODS: Analysis of six independent standard series, evaluation of the deviation of the TNF-α concentration in patients with ICH, standard addition and visual analysis of whole UV-Vis spectra were carefully performed. RESULTS: Low standard deviations of the absorbance were detected for every standard, as well as in the samples of healthy controls and patients with ICH. The standard addition series have also confirmed high sensitivity and reproducibility of the assay, with a congruent shift of the standard curves with the concentration of TNF-α for the added plasma. The visual analyses of the gained spectra have revealed the absence of any matrix effects from the addition of the human plasma in the reconstituted standards. CONCLUSION: The commercial ELISA kits can be used in the clinical practice for screening purposes of the plasma TNF-α levels in patients with ICH.
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Affiliation(s)
- Vladimir Rendevski
- University Clinic for Neurosurgery, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Boris Aleksovski
- Faculty of Natural Sciences and Mathematics, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Dragan Stojanov
- Center of Radiology, Clinical Center Niš, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Ana Mihajlovska-Rendevska
- University Clinic for Radiology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Vasko Aleksovski
- University Clinic for Neurology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Natalija Baneva-Dolnenec
- University Clinic for Neurology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Dijana Nikodijevic
- University Clinic for Neurology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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Schneider T, Frieling D, Schroeder J, Regelsberger J, Schoen G, Fiehler J, Gellißen S. Perihematomal diffusion restriction as a common finding in large intracerebral hemorrhages in the hyperacute phase. PLoS One 2017; 12:e0184518. [PMID: 28922367 PMCID: PMC5602530 DOI: 10.1371/journal.pone.0184518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/27/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose There is growing evidence that a perihematomal area of restricted diffusion (PDR) exists in intraparenchymal hemorrhages (IPH) within 1 week of symptom onset (SO). Here, we study characteristics and the clinical impact of the PDR in patients with hyperacute (≤ 6 hours from SO) IPH by means of apparent diffusion coefficient (ADC). Methods This monocentric, retrospective study includes 83 patients with first-ever primary IPH from 09/2002-10/2015. 3D volumetric segmentation was performed for the IPH, PDR, and perihematomal edema (PHE) on fluid-attenuated inversion recovery, T2*/susceptibility weighted images, and ADC images. Results A PDR was seen in 56/83 patients (67.5%) presenting with hyperacute IPH. Multivariate logistic regression analysis revealed every 10-year increase of age (HR 1.929, 95% CI 1.047–3.552, P = .035) and male gender (HR 5.672, 95% CI 1.038–30.992, P = .045) as significant predictors of the presence of a PDR, but not IPH size, IPH location, nor National Institutes of Health Stroke Scale Score (NIHSS) at admission. We found no difference in NIHSS at discharge, hematoma removal, or mortality rate in PDR-positive patients. ADC values of the PDR show a step-wise normalization with increasing time from SO. Conclusions Occurrence of a PDR is a common finding in supratentorial hyperacute IPH, but shows no adverse short-term clinical impact. It may represent transient oligemic and metabolic changes.
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Affiliation(s)
- Tanja Schneider
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Diagnostic and Interventional Radiology, Schön Klinik Hamburg Eilbek, Hamburg, Germany
- * E-mail:
| | - David Frieling
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Schroeder
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schoen
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Svensson EH, Söderholm M, Abul-Kasim K, Engström G. Tumor Necrosis Factor Receptor 1 and 2 Are Associated With Risk of Intracerebral Hemorrhage. Stroke 2017; 48:2710-2715. [PMID: 28830973 DOI: 10.1161/strokeaha.117.017849] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/21/2017] [Accepted: 07/26/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Raised plasma concentrations of tumor necrosis factor receptors (TNFR) have been linked to arterial stiffness, cerebral microbleeds, and vascular events. The aim of this study was to investigate the association of circulating levels of TNFR1 and TNFR2 with risk for future intracerebral hemorrhage (ICH). METHODS The population-based MDCS cohort (Malmö Diet and Cancer Study; n=28 449) was conducted in 1991 to 1996. A nested case-control study was performed in the MDCS, including 220 cases who experienced ICH during the follow-up period (mean age at inclusion 62 years, 48% men) and 244 matched controls. Of the 220 ICH cases, 68 died within 28 days. Conditional logistic regression was used to study the association between plasma levels of TNFR1 and TNFR2 and incident ICH, adjusting for known ICH risk factors. RESULTS Concentrations of both TNFR1 and TNFR2 were significantly higher in subjects who developed ICH during the follow-up. The associations remained after adjustment for ICH risk factors (TNFR1: odds ratio [OR], 2.28; 95% confidence interval [CI], 1.26-4.11; P=0.006; TNFR2: OR, 1.77; CI, 1.16-2.70; P=0.008). ORs were somewhat higher for nonlobar ICH (3.04; CI, 1.29-7.14 and 2.39; CI, 1.32-4.32, respectively) than for lobar ICH (2.03; CI, 0.93-4.41 and 1.35; CI, 0.78-2.37, respectively). TNFR1 and TNFR2 were also associated with increased risk of fatal ICH (TNFR1: OR, 4.42; CI, 1.67-11.6; TNFR2: OR, 2.90; CI, 1.50-5.58) and with poor functional outcome according to the modified Rankin Scale. CONCLUSIONS High plasma levels of TNFR1 and TNFR2 were associated with incident ICH, most clearly with ICH of nonlobar location. The results suggest that tumor necrosis factor-mediated inflammation could be associated with vascular changes preceding ICH.
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Affiliation(s)
- Edith H Svensson
- From the Department of Clinical Science in Malmö, Lund University, Sweden (E.H.S., M.S., G.E.); and Department of Neurology and Rehabilitation Medicine (M.S.) and Division of Neuroradiology (K.A.-K.), Skåne University Hospital in Lund and Malmö, Sweden
| | - Martin Söderholm
- From the Department of Clinical Science in Malmö, Lund University, Sweden (E.H.S., M.S., G.E.); and Department of Neurology and Rehabilitation Medicine (M.S.) and Division of Neuroradiology (K.A.-K.), Skåne University Hospital in Lund and Malmö, Sweden
| | - Kasim Abul-Kasim
- From the Department of Clinical Science in Malmö, Lund University, Sweden (E.H.S., M.S., G.E.); and Department of Neurology and Rehabilitation Medicine (M.S.) and Division of Neuroradiology (K.A.-K.), Skåne University Hospital in Lund and Malmö, Sweden
| | - Gunnar Engström
- From the Department of Clinical Science in Malmö, Lund University, Sweden (E.H.S., M.S., G.E.); and Department of Neurology and Rehabilitation Medicine (M.S.) and Division of Neuroradiology (K.A.-K.), Skåne University Hospital in Lund and Malmö, Sweden.
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Singh N, Bansal Y, Bhandari R, Marwaha L, Singh R, Chopra K, Kuhad A. Naringin Reverses Neurobehavioral and Biochemical Alterations in Intracerebroventricular Collagenase-Induced Intracerebral Hemorrhage in Rats. Pharmacology 2017; 100:172-187. [PMID: 28668949 DOI: 10.1159/000453580] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 11/18/2016] [Indexed: 12/13/2022]
Abstract
Intracerebral hemorrhage (ICH) contributes to 10-15% of all strokes and is a high risk factor for morbidity and mortality as compared to other subtypes of stroke, that is, cerebral ischemia and subarachnoid hemorrhage. Oxidative stress (OS)-induced neuroinflammation and neuronal cell death contribute towards the hallmarks of ICH. Spared antioxidant levels, increased inflammatory cytokines and free radicals in ICH lead to neuronal death and exaggerate the hallmarks of ICH. Intracerebroventricular (ICV) collagenase (COL-induced neuronal cell damage and cognitive deficits form a widely recognized experimental model for ICH. Naringin (NGN), a natural antioxidant bioflavonoid, has shown potent neuroprotective effects in different neurodegenerative diseases. However, its potential is least explored in pathological conditions, such as hemorrhagic stroke. This study is aimed at exploring the protective effects of NGN against ICV-COL induced behavioral, neurological and memory deficits in rats. ICV-ICH was induced by single, unilateral intrastriatal injection of COL (1 IU in 2 µL, ICV) over 10 min. From 2nd day onwards, NGN was administered in three different doses (10, 20, and 40 mg/kg; p.o.). Animals were subjected to a battery of behavioral tests to assess behavioral changes, including neurological scoring tests (cylinder test, spontaneous motility, righting reflex, horizontal bar test, forelimb flexion), actophotometer, rotarod, Randall Selitto and von Frey. Poststroke depression and memory deficits were estimated using forced swim test and Morris water maze test, respectively. Poststroke depression, neurological and cognitive deficits were mitigated dose dependently by NGN administration. NGN administration also attenuated the nitro-OS and restored tumor necrosis factor-α and endogenous antioxidant levels. Our research demonstrates that NGN has a protective effect against ICH-induced neurocognitive deficits, along with mitigation of oxido-nitrosative and inflammatory stress.
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Affiliation(s)
- Navdeep Singh
- Pharmacology Research Laboratory, University Institute of Pharmaceutical Sciences, UGC-Centre of Advanced Study, Panjab University, Chandigarh, India
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Mao LL, Yuan H, Wang WW, Wang YJ, Yang MF, Sun BL, Zhang ZY, Yang XY. Adoptive Regulatory T-cell Therapy Attenuates Perihematomal Inflammation in a Mouse Model of Experimental Intracerebral Hemorrhage. Cell Mol Neurobiol 2017; 37:919-929. [PMID: 27678140 DOI: 10.1007/s10571-016-0429-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/22/2016] [Indexed: 01/01/2023]
Abstract
The CD4+CD25+ regulatory T cells (Tregs), an innate immunomodulator, suppress cerebral inflammation and maintain immune homeostasis in multiple central nervous system injury, but its role in intracerebral hemorrhage (ICH) has not been fully characterized. This study investigated the effect of Tregs on brain injury using the mouse ICH model, which is established by autologous blood infusion. The results showed that tail intravenous injection of Tregs significantly reduced brain water content and Evans blue dye extravasation of perihematoma at day (1, 3 and 7), and improved short- and long-term neurological deficits following ICH in mouse model. Tregs treatment reduced the content of pro-inflammatory cytokines interleukin (IL)-1β, IL-6, tumor necrosis factor-α, and malondialdehyde, while increasing the superoxide dismutase (SOD) enzymatic activity at day (1, 3 and 7) following ICH. Furthermore, Tregs treatment obviously reduced the number of NF-κB+, IL-6+, TUNEL+ and active caspase-3+ cells at day 3 after ICH. These results indicate that adoptive transfer of Tregs may provide neuroprotection following ICH in mouse models.
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Affiliation(s)
- Lei-Lei Mao
- Key Lab of Cerebral Microcirculation at the Universities of Shandong, Life Science Research Centre of Taishan Medical University, Taian, 271016, Shandong, China
| | - Hui Yuan
- Key Lab of Cerebral Microcirculation at the Universities of Shandong, Life Science Research Centre of Taishan Medical University, Taian, 271016, Shandong, China
- Department of Neurology, Affiliated Hospital of Taishan Medical University, Taian, 271016, Shandong, China
| | - Wen-Wen Wang
- Key Lab of Cerebral Microcirculation at the Universities of Shandong, Life Science Research Centre of Taishan Medical University, Taian, 271016, Shandong, China
| | - Yu-Jing Wang
- Key Lab of Cerebral Microcirculation at the Universities of Shandong, Life Science Research Centre of Taishan Medical University, Taian, 271016, Shandong, China
| | - Ming-Feng Yang
- Key Lab of Cerebral Microcirculation at the Universities of Shandong, Life Science Research Centre of Taishan Medical University, Taian, 271016, Shandong, China
| | - Bao-Liang Sun
- Key Lab of Cerebral Microcirculation at the Universities of Shandong, Life Science Research Centre of Taishan Medical University, Taian, 271016, Shandong, China
- Department of Neurology, Affiliated Hospital of Taishan Medical University, Taian, 271016, Shandong, China
| | - Zong-Yong Zhang
- Key Lab of Cerebral Microcirculation at the Universities of Shandong, Life Science Research Centre of Taishan Medical University, Taian, 271016, Shandong, China.
| | - Xiao-Yi Yang
- Key Lab of Cerebral Microcirculation at the Universities of Shandong, Life Science Research Centre of Taishan Medical University, Taian, 271016, Shandong, China.
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Rajapathy SK, Idris Z, Kandasamy R, Hieng AWS, Abdullah JM. Inflammatory Biomarkers and Their Value in Predicting Survival and Outcome among Patients with Spontaneous Intracerebral Haemorrhage. Malays J Med Sci 2017; 24:51-65. [PMID: 28814933 DOI: 10.21315/mjms2017.24.3.7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/23/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Spontaneous intracerebral haemorrhage (SICH) has emerged as one of the most devastating forms of stroke in recent decades. This disease is noted to carry a 30-day mortality rate of approximately 45%. An increasing number of studies have implicated a complex immune-mediated and inflammation-mediated cascade of responses in the pathophysiology of SICH and the resultant neurologic outcome. Several clinical studies have demonstrated an association between inflammatory markers and outcome in patients with SICH. However, the exact relationship between serum biomarkers and functional outcomes amongst survivors has not been clearly elucidated. This study aimed to evaluate the changes in peripheral leukocyte count (WBC count) and C-reactive protein (CRP) levels in patients with SICH and to correlate these findings with survival and functional outcome. METHODOLOGY A prospective, descriptive and correlational study was conducted at Sarawak General Hospital (SGH) over the span of two years (April 2013-April 2015). Patients aged between 30 years and 75 years with supratentorial intracerebral bleed secondary to uncontrolled hypertension were recruited in this study. Data pertaining to the demography, clinical and radiological parameters, peripheral WBC count and CRP levels were obtained. Mortality and functional outcomes were determined at 6 months post ictus. Patients were recruited following the fulfilment of exclusion and inclusion criteria, and all obtained data were analysed with the Statistical Package for Social Sciences (SPSS) for Windows version 21.0. RESULTS A total of 60 patients with a mean age of 56 years were recruited in this study. We found that approximately 16 patients were less than or equal to 50 years old (26.7%) and that 44 patients belonged to the older age group of above 50 years (73.3%). The Glasgow Coma Scale (GCS) score on admission ranged from 9 to 14/15 with a median value of 11/15. The mean clot volume was 20.1 cm3. The GCS score on admission and clot volume were significantly associated with the Glasgow Outcome Scale (GOS) at 6 months and overall survival (P < 0.05). The elevated WBC count and CRP level on admission and at 72 hours post admission were significantly associated with GOS at 6 months and overall survival (P < 0.05). Thus, the GCS score, clot volume, WBC count and CRP levels on admission and at 72 hours post admission can be used to predict functional outcome at 6 months and overall survival in patients with SICH. CONCLUSION We could conclude via this study that for patients with SICH, the main determinants or predictors of functional outcome at 6 months and overall survival were noted to be the GCS score on admission, clot size, WBC count and CRP levels on admission and at 72 hours post admission.
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Affiliation(s)
- Senthil Kumar Rajapathy
- Department of Neurosciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia.,Department of Neurosurgery, Sarawak General Hospital, Jalan Hospital, 93586 Kuching, Sarawak, Malaysia
| | - Zamzuri Idris
- Department of Neurosciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Regunath Kandasamy
- Department of Neurosciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Albert Wong Sii Hieng
- Department of Neurosurgery, Sarawak General Hospital, Jalan Hospital, 93586 Kuching, Sarawak, Malaysia
| | - Jafri Malin Abdullah
- Department of Neurosciences, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia.,Center for Neuroscience Services and Research, Universiti Sains Malaysia, Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan, Malaysia
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Singh N, Bansal Y, Bhandari R, Marwaha L, Singh R, Chopra K, Kuhad A. Resveratrol protects against ICV collagenase-induced neurobehavioral and biochemical deficits. JOURNAL OF INFLAMMATION-LONDON 2017; 14:14. [PMID: 28615993 PMCID: PMC5466723 DOI: 10.1186/s12950-017-0158-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 05/23/2017] [Indexed: 01/09/2023]
Abstract
Background Indeed, intracerebral hemorrhage (ICH) account for only 15% of all strokes but it is one of the most devastating subtype of stroke associated with behavioral, cognitive and neurological deficits. The primary cause of neurological deficits in ICH is the hematoma growth, generation of free radicals, inflammatory cytokines and exhausting endogenous anti-oxidant machinery. It has been found that neuroinflammation following ICH leads to exaggeration of hallmarks of ICH. With this background, the study was aimed to evaluate the protective effect of resveratrol (RSV) in intracerebroventricular (ICV) collagenase (COL) induced neurological deficits in rats. Methods The present study was designed to explore the protective effects of resveratrol (5, 10, 20 mg/kg) against ICV-COL induced ICH. Animals were subjected to a battery of behavioral tests to access behavioral changes, including neurological scoring tests (cylinder test, spontaneous motility, righting reflex, horizontal bar test, forelimb flexion), actophotometer, rotarod, Randall Sellito and von Frey. Post stroke depression was estimated using forced swim test (FST). Memory deficit was monitored using Morris water maze (MWM). Results Chronic treatment with RSV (20 mg/kg) for 21 days restored various behavioral changes, including neurological scoring tests (cylinder test, spontaneous motility, righting reflex, horizontal bar test, forelimb flexion), actophotometer, rotarod, Randall Sellito and Von Frey. RSV also restores increase in immobility time forced swim test used to evaluate post stroke depression and impaired memory deficit in Morris water maze. RSV administration also attenuated increased nitro-oxidative stress and TNF-α level. RSV being a potent antioxidant also restores changes in endogenous anti-oxidant levels. Conclusion In conclusion, our research demonstrates that RSV has a protective effect against ICH by virtue of its anti-inflammatory property and antioxidant and nitrosative stress restoring property.
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Affiliation(s)
- Navdeep Singh
- Pharmacology Research Laboratory, University Institute of Pharmaceutical Sciences, UGC-Centre of Advanced Study, Panjab University, Chandigarh, 160 014 India
| | - Yashika Bansal
- Pharmacology Research Laboratory, University Institute of Pharmaceutical Sciences, UGC-Centre of Advanced Study, Panjab University, Chandigarh, 160 014 India
| | - Ranjana Bhandari
- Pharmacology Research Laboratory, University Institute of Pharmaceutical Sciences, UGC-Centre of Advanced Study, Panjab University, Chandigarh, 160 014 India
| | - Lovish Marwaha
- Pharmacology Research Laboratory, University Institute of Pharmaceutical Sciences, UGC-Centre of Advanced Study, Panjab University, Chandigarh, 160 014 India
| | - Raghunath Singh
- Pharmacology Research Laboratory, University Institute of Pharmaceutical Sciences, UGC-Centre of Advanced Study, Panjab University, Chandigarh, 160 014 India
| | - Kanwaljit Chopra
- Pharmacology Research Laboratory, University Institute of Pharmaceutical Sciences, UGC-Centre of Advanced Study, Panjab University, Chandigarh, 160 014 India
| | - Anurag Kuhad
- Pharmacology Research Laboratory, University Institute of Pharmaceutical Sciences, UGC-Centre of Advanced Study, Panjab University, Chandigarh, 160 014 India
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Lim-Hing K, Rincon F. Secondary Hematoma Expansion and Perihemorrhagic Edema after Intracerebral Hemorrhage: From Bench Work to Practical Aspects. Front Neurol 2017; 8:74. [PMID: 28439253 PMCID: PMC5383656 DOI: 10.3389/fneur.2017.00074] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 02/20/2017] [Indexed: 01/24/2023] Open
Abstract
Intracerebral hemorrhages (ICH) represent about 10-15% of all strokes per year in the United States alone. Key variables influencing the long-term outcome after ICH are hematoma size and growth. Although death may occur at the time of the hemorrhage, delayed neurologic deterioration frequently occurs with hematoma growth and neuronal injury of the surrounding tissue. Perihematoma edema has also been implicated as a contributing factor for delayed neurologic deterioration after ICH. Cerebral edema results from both blood-brain barrier disruption and local generation of osmotically active substances. Inflammatory cellular mediators, activation of the complement, by-products of coagulation and hemolysis such as thrombin and fibrin, and hemoglobin enter the brain and induce a local and systemic inflammatory reaction. These complex cascades lead to apoptosis or neuronal injury. By identifying the major modulators of cerebral edema after ICH, a therapeutic target to counter degenerative events may be forthcoming.
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Affiliation(s)
- Krista Lim-Hing
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Fred Rincon
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
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