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Li Y, Zhou H, He X, Jin L, Zhu Y, Hu L, Feng M, Zhu J, Wang L, Zheng Y, Li S, Yan Z, Cen P, Hu J, Chen Z, Yu X, Fu X, Xu C, Cao S, Cao Y, Chen G, Wang L. Impaired microglial glycolysis promotes inflammatory responses after intracerebral haemorrhage via HK2-dependent mitochondrial dysfunction. J Adv Res 2024:S2090-1232(24)00359-X. [PMID: 39142439 DOI: 10.1016/j.jare.2024.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 06/28/2024] [Accepted: 08/10/2024] [Indexed: 08/16/2024] Open
Abstract
INTRODUCTION Intracerebral haemorrhage (ICH) is a devastating disease that leads to severe neurological deficits. Microglia are the first line of defence in the brain and play a crucial role in neurological recovery after ICH, whose activities are primarily driven by glucose metabolism. However, little is known regarding the status of glucose metabolism in microglia and its interactions with inflammatory responses after ICH. OBJECTIVES This study investigated microglial glycolysis and its mechanistic effects on microglial inflammation after ICH. METHODS We explored the status of glucose metabolism in the ipsilateral region and in fluorescence-activated-cell-sorting-isolated (FACS-isolated) microglia via 2-deoxy-[18F]fluoro-D-glucose positron emission tomography (FDG-PET) analyses and gamma emission, respectively. Energy-related targeted metabolomics, along with 13C-glucose isotope tracing, was utilised to analyse glycolytic products in microglia. Mitochondrial membrane potential and mitochondrial reactive oxygen species (MitoROS) accumulation was assessed by flow cytometry. Behavioural, western blotting, gene regulation, and enzymatic activity analyses were conducted with a focus on microglia. RESULTS Neurological dysfunction was strongly correlated with decreased FDG-PET signals in the perihaematomal region, where microglial uptake of FDG was reduced. The decreased quantity of glucose-6-phosphate (G-6-P) in microglia was attributed to the downregulation of glucose transporter 1 (GLUT1) and hexokinase 2 (HK2). Enhanced inflammatory responses were driven by HK2 suppression via decreased mitochondrial membrane potential, which could be rescued by MitoROS scavengers. HK inhibitors aggravated neurological injury by suppressing FDG uptake and enhancing microglial inflammation in ICH mice. CONCLUSION These findings indicate an unexpected metabolic status in pro-inflammatory microglia after ICH, consisting of glycolysis impairment caused by the downregulation of GLUT1 and HK2. Additionally, HK2 suppression promotes inflammatory responses by disrupting mitochondrial function, providing insight into the mechanisms by which inflammation may be facilitated after ICH and indicating that metabolic enzymes as potential targets for ICH treatment.
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Affiliation(s)
- Yin Li
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hang Zhou
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xuchao He
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lingji Jin
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yuhan Zhu
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Libin Hu
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Majing Feng
- School of Medicine, Zhejiang University, Hangzhou, China
| | - Jun Zhu
- School of Medicine, Zhejiang University, Hangzhou, China
| | - Liang Wang
- School of Medicine, Zhejiang University, Hangzhou, China
| | - Yonghe Zheng
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shiwei Li
- School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhiyuan Yan
- School of Medicine, Zhejiang University, Hangzhou, China
| | - Peili Cen
- Department of Nuclear Medicine and PET-CT Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junwen Hu
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zihang Chen
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaobo Yu
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiongjie Fu
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chaoran Xu
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shenglong Cao
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yang Cao
- Department of Neurosurgery, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, China.
| | - Gao Chen
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
| | - Lin Wang
- Department of Neurosurgery & Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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Stovell MG, Howe DJ, Thelin EP, Jalloh I, Helmy A, Guilfoyle MR, Grice P, Mason A, Giorgi-Coll S, Gallagher CN, Murphy MP, Menon DK, Carpenter TA, Hutchinson PJ, Carpenter KLH. High-physiological and supra-physiological 1,2- 13C 2 glucose focal supplementation to the traumatised human brain. J Cereb Blood Flow Metab 2023; 43:1685-1701. [PMID: 37157814 PMCID: PMC10581237 DOI: 10.1177/0271678x231173584] [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: 09/04/2022] [Revised: 03/12/2023] [Accepted: 04/02/2023] [Indexed: 05/10/2023]
Abstract
How to optimise glucose metabolism in the traumatised human brain remains unclear, including whether injured brain can metabolise additional glucose when supplied. We studied the effect of microdialysis-delivered 1,2-13C2 glucose at 4 and 8 mmol/L on brain extracellular chemistry using bedside ISCUSflex, and the fate of the 13C label in the 8 mmol/L group using high-resolution NMR of recovered microdialysates, in 20 patients. Compared with unsupplemented perfusion, 4 mmol/L glucose increased extracellular concentrations of pyruvate (17%, p = 0.04) and lactate (19%, p = 0.01), with a small increase in lactate/pyruvate ratio (5%, p = 0.007). Perfusion with 8 mmol/L glucose did not significantly influence extracellular chemistry measured with ISCUSflex, compared to unsupplemented perfusion. These extracellular chemistry changes appeared influenced by the underlying metabolic states of patients' traumatised brains, and the presence of relative neuroglycopaenia. Despite abundant 13C glucose supplementation, NMR revealed only 16.7% 13C enrichment of recovered extracellular lactate; the majority being glycolytic in origin. Furthermore, no 13C enrichment of TCA cycle-derived extracellular glutamine was detected. These findings indicate that a large proportion of extracellular lactate does not originate from local glucose metabolism, and taken together with our earlier studies, suggest that extracellular lactate is an important transitional step in the brain's production of glutamine.
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Affiliation(s)
- Matthew G Stovell
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Neurosurgery, The Walton Centre, Liverpool, UK
| | - Duncan J Howe
- Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Eric P Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Ibrahim Jalloh
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Grice
- Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Andrew Mason
- Department of Chemistry, University of Cambridge, Cambridge, UK
| | - Susan Giorgi-Coll
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Clare N Gallagher
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Michael P Murphy
- MRC Mitochondrial Biology Unit, University of Cambridge, Cambridge, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - T Adrian Carpenter
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Keri LH Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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3
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Falcone JA, Chen JW. Technical notes on the placement of cerebral microdialysis: A single center experience. Front Neurol 2023; 13:1041952. [PMID: 36698903 PMCID: PMC9868911 DOI: 10.3389/fneur.2022.1041952] [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: 09/12/2022] [Accepted: 12/21/2022] [Indexed: 01/12/2023] Open
Abstract
Background Cerebral microdialysis enables monitoring of brain metabolism and can be an important part of multimodal monitoring strategies in a variety of brain injuries. Microdialysis catheters can be placed in brain parenchyma through a burr hole, a cranial bolt, or directly at the time of an open craniotomy or craniectomy. The location of catheters in relation to brain pathology is important to the interpretation of data and guidance of interventions. Methods Here we retrospectively review the use of cerebral microdialysis at a US Regional Medical Center between March 2018 and February 2022 and provide detailed descriptions and technical nuances of the different methods to place microdialysis catheters. Results Eighty two unique microdialysis catheters were utilized in 52 patients. 35 (42.68%) were placed via a quad-lumen bolt and 47 (57.32%) were placed through craniotomies. 27 catheters (32.93%) were placed in a perilesional location, 50 (60.98%) were located in healthy tissue, and 6 (7.32%) were mispositioned. No significant difference was seen between placement by bolt or craniotomy in regard to perilesional location, mispositioning, or complications. Conclusion With careful planning and thoughtful execution, cerebral microdialysis catheters can be successfully placed though a variety of strategies to optimize and individualize brain monitoring in different clinical settings. This paper provides a detailed guide for the various methods of catheter placement to help providers begin or expand their use of cerebral microdialysis.
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Santana D, Mosteiro A, Pedrosa L, Llull L, Torné R, Amaro S. Clinical relevance of glucose metrics during the early brain injury period after aneurysmal subarachnoid hemorrhage: An opportunity for continuous glucose monitoring. Front Neurol 2022; 13:977307. [PMID: 36172028 PMCID: PMC9512056 DOI: 10.3389/fneur.2022.977307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
Hyperglycaemia, hypoglycaemia and higher glucose variability during the Early Brain Injury (EBI) period of aneurysmal subarachnoid hemorrhage (aSAH) have been associated with poor clinical outcome. However, it is unclear whether these associations are due to direct glucose-driven injury or if hyperglycaemia simply acts as a marker of initial severity. Actually, strict glucose control with intensive insulin therapy has not been demonstrated as an effective strategy for improving clinical outcomes after aSAH. Currently published studies describing an association between hyperglycaemia and prognosis in aSAH patients have been based on isolated glucose measurements and did not incorporate comprehensive dynamic evaluations, such as those derived from subcutaneous continuous glucose monitoring devices (CMG). Arguably, a more accurate knowledge on glycaemic patterns during the acute phase of aSAH could increase our understanding of the relevance of glycaemia as a prognostic factor in this disease as well as to underpin its contribution to secondary focal and diffuse brain injury. Herein, we have summarized the available evidence on the diagnostic and prognostic relevance of glucose metrics during the acute phase of cerebrovascular diseases, focusing in the EBI period after aSAH. Overall, obtaining a more precise scope of acute longitudinal glucose profiles could eventually be useful for improving glucose management protocols in the setting of acute aSAH and to advance toward a more personalized management of aSAH patients during the EBI phase.
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Affiliation(s)
- Daniel Santana
- Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Alejandra Mosteiro
- Neurosurgery Department, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Leire Pedrosa
- Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ramón Torné
- Neurosurgery Department, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
- *Correspondence: Ramón Torné
| | - Sergi Amaro
- Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
- Sergi Amaro
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5
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Svedung Wettervik T, Hånell A, Howells T, Ronne-Engström E, Enblad P, Lewén A. Association of Arterial Metabolic Content with Cerebral Blood Flow Regulation and Cerebral Energy Metabolism-A Multimodality Analysis in Aneurysmal Subarachnoid Hemorrhage. J Intensive Care Med 2022; 37:1442-1450. [PMID: 35171061 PMCID: PMC9548938 DOI: 10.1177/08850666221080054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background In this study, the association of the arterial content of oxygen, carbon
dioxide, glucose, and lactate with cerebral pressure reactivity, energy
metabolism and clinical outcome after aneurysmal subarachnoid hemorrhage
(aSAH) was investigated. Methods In this retrospective study, 60 patients with aSAH, treated at the
neurointensive care (NIC), Uppsala University Hospital, Sweden, between 2016
and 2021 with arterial blood gas (ABG), intracranial pressure, and cerebral
microdialysis (MD) monitoring were included. The first 10 days were divided
into an early phase (day 1 to 3) and a vasospasm phase (day 4 to 10). Results Higher arterial lactate was independently associated with higher/worse
pressure reactivity index (PRx) in the early phase (β = 0.32,
P = .02), whereas higher pO2 had the
opposite association in the vasospasm phase (β = −0.30,
P = .04). Arterial glucose and pCO2 were not
associated with PRx. Higher arterial lactate (β = 0.29,
P = .05) was independently associated with higher
MD-glucose in the vasospasm phase, whereas higher pO2 had the
opposite association in the vasospasm phase (β = −0.33,
P = .03). Arterial glucose and pCO2 were not
associated with MD-glucose. Higher pCO2 in the early phase, lower
arterial glucose in both phases, and lower arterial lactate in the vasospasm
phase were associated (P < .05) with better clinical
outcome. Conclusions Arterial variables associated with more vasoconstriction (higher
pO2 and lower arterial lactate) were associated with better
cerebral pressure reactivity, but worse energy metabolism. In severe aSAH,
when cerebral large-vessel vasospasm with exhausted distal vasodilation is
common, more vasoconstriction could increase distal vasodilatory reserve and
pressure reactivity, but also reduce cerebral blood flow and metabolic
supply. The MD may be useful to monitor the net effects on cerebral
metabolism in PRx-targeted NIC.
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6
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Han X, Ren H, Nandi A, Fan X, Koehler RC. Analysis of glucose metabolism by 18F-FDG-PET imaging and glucose transporter expression in a mouse model of intracerebral hemorrhage. Sci Rep 2021; 11:10885. [PMID: 34035344 PMCID: PMC8149426 DOI: 10.1038/s41598-021-90216-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 05/07/2021] [Indexed: 12/19/2022] Open
Abstract
The relationship between cerebral glucose metabolism and glucose transporter expression after intracerebral hemorrhage (ICH) is unclear. Few studies have used positron emission tomography (PET) to explore cerebral glucose metabolism after ICH in rodents. In this study, we produced ICH in mice with an intrastriatal injection of collagenase to investigate whether glucose metabolic changes in 18F-fluoro-2-deoxy-D-glucose (FDG)-PET images are associated with expression of glucose transporters (GLUTs) over time. On days 1 and 3 after ICH, the ipsilateral striatum exhibited significant hypometabolism. However, by days 7 and 14, glucose metabolism was significantly higher in the ipsilateral striatum than in the contralateral striatum. The contralateral hemisphere did not show hypermetabolism at any time after ICH. Qualitative immunofluorescence and Western blotting indicated that the expression of GLUT1 in ipsilateral striatum decreased on days 1 and 3 after ICH and gradually returned to baseline by day 21. The 18F-FDG uptake after ICH was associated with expression of GLUT1 but not GLUT3 or GLUT5. Our data suggest that ipsilateral cerebral glucose metabolism decreases in the early stage after ICH and increases progressively in the late stage. Changes in 18F-FDG uptake on PET imaging are associated with the expression of GLUT1 in the ipsilateral striatum.
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Affiliation(s)
- Xiaoning Han
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
| | - Honglei Ren
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Ayon Nandi
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Xuanjia Fan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
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Spencer P, Jiang Y, Liu N, Han J, Li Y, Vodovoz S, Dumont AS, Wang X. Update: Microdialysis for Monitoring Cerebral Metabolic Dysfunction after Subarachnoid Hemorrhage. J Clin Med 2020; 10:jcm10010100. [PMID: 33396652 PMCID: PMC7794715 DOI: 10.3390/jcm10010100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/25/2020] [Accepted: 12/25/2020] [Indexed: 01/07/2023] Open
Abstract
Cerebral metabolic dysfunction has been shown to extensively mediate the pathophysiology of brain injury after subarachnoid hemorrhage (SAH). The characterization of the alterations of metabolites in the brain can help elucidate pathophysiological changes occurring throughout SAH and the relationship between secondary brain injury and cerebral energy dysfunction after SAH. Cerebral microdialysis (CMD) is a tool that can measure concentrations of multiple bioenergetics metabolites in brain interstitial fluid. This review aims to provide an update on the implication of CMD on the measurement of metabolic dysfunction in the brain after SAH. A literature review was conducted through a general PubMed search with the terms “Subarachnoid Hemorrhage AND Microdialysis” as well as a more targeted search using MeSh with the search terms “Subarachnoid hemorrhage AND Microdialysis AND Metabolism.” Both experimental and clinical papers were reviewed. CMD is a suitable tool that has been used for monitoring cerebral metabolic changes in various types of brain injury. Clinically, CMD data have shown the dramatic changes in cerebral metabolism after SAH, including glucose depletion, enhanced glycolysis, and suppressed oxidative phosphorylation. Experimental studies using CMD have demonstrated a similar pattern of cerebral metabolic dysfunction after SAH. The combination of CMD and other monitoring tools has also shown value in further dissecting and distinguishing alterations in different metabolic pathways after brain injury. Despite the lack of a standard procedure as well as the presence of limitations regarding CMD application and data interpretation for both clinical and experimental studies, emerging investigations have suggested that CMD is an effective way to monitor the changes of cerebral metabolic dysfunction after SAH in real-time, and alternatively, the combination of CMD and other monitoring tools might be able to further understand the relationship between cerebral metabolic dysfunction and brain injury after SAH, determine the severity of brain injury and predict the pathological progression and outcomes after SAH. More translational preclinical investigations and clinical validation may help to optimize CMD as a powerful tool in critical care and personalized medicine for patients with SAH.
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Affiliation(s)
| | - Yinghua Jiang
- Correspondence: (Y.J.); (X.W.); Tel.: +504-988-9117 (Y.J.); +504-988-2646 (X.W.)
| | | | | | | | | | | | - Xiaoying Wang
- Correspondence: (Y.J.); (X.W.); Tel.: +504-988-9117 (Y.J.); +504-988-2646 (X.W.)
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Hendrix RD, Ou Y, Davis JE, Odle AK, Groves TR, Allen AR, Childs GV, Barger SW. Alzheimer amyloid-β- peptide disrupts membrane localization of glucose transporter 1 in astrocytes: implications for glucose levels in brain and blood. Neurobiol Aging 2020; 97:73-88. [PMID: 33161213 PMCID: PMC7736209 DOI: 10.1016/j.neurobiolaging.2020.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 08/25/2020] [Accepted: 10/02/2020] [Indexed: 12/12/2022]
Abstract
Alzheimer’s disease (AD) is associated with disturbances in blood glucose regulation, and type-2 diabetes elevates the risk for dementia. A role for amyloid-β peptide (Aβ) in linking these age-related conditions has been proposed, tested primarily in transgenic mouse lines that overexpress mutated amyloid precursor protein (APP). Because APP has its own impacts on glucose regulation, we examined the BRI-Aβ42 line (“Aβ42-tg”), which produces extracellular Aβ1–42 in the CNS without elevation of APP. We also looked for interactions with diet-induced obesity (DIO) resulting from a high-fat, high-sucrose (“western”) diet. Aβ42-tg mice were impaired in both spatial memory and glucose tolerance. Although DIO induced insulin resistance, Aβ1–42 accumulation did not, and the impacts of DIO and Aβ on glucose tolerance were merely additive. Aβ42-tg mice exhibited no significant differences from wild-type in insulin production, body weight, lipidemia, appetite, physical activity, respiratory quotient, an-/orexigenic factors, or inflammatory factors. These negative findings suggested that the phenotype in these mice arose from perturbation of glucose excursion in an insulin-independent tissue. To wit, cerebral cortex of Aβ42-tg mice had reduced glucose utilization, similar to human patients with AD. This was associated with insufficient trafficking of glucose transporter 1 to the plasma membrane in parenchymal brain cells, a finding also documented in human AD tissue. Together, the lower cerebral metabolic rate of glucose and diminished function of parenchymal glucose transporter 1 indicate that aberrant regulation of blood glucose in AD likely reflects a central phenomenon, resulting from the effects of Aβ on cerebral parenchyma, rather than a generalized disruption of hypothalamic or peripheral endocrinology. The involvement of a specific glucose transporter in this deficit provides a new target for the design of AD therapies.
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Affiliation(s)
- Rachel D Hendrix
- Department of Neurobiology & Developmental Sciences, Little Rock, AR, USA
| | - Yang Ou
- Department of Geriatrics, Little Rock, AR, USA
| | - Jakeira E Davis
- Graduate Program in Interdisciplinary Biomedical Sciences, Little Rock, AR, USA
| | - Angela K Odle
- Department of Neurobiology & Developmental Sciences, Little Rock, AR, USA
| | - Thomas R Groves
- Department of Neurobiology & Developmental Sciences, Little Rock, AR, USA
| | - Antiño R Allen
- Department of Neurobiology & Developmental Sciences, Little Rock, AR, USA; Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gwen V Childs
- Department of Neurobiology & Developmental Sciences, Little Rock, AR, USA
| | - Steven W Barger
- Department of Neurobiology & Developmental Sciences, Little Rock, AR, USA; Department of Geriatrics, Little Rock, AR, USA; Geriatric Research, Education & Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA.
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9
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Glucose Variability as Measured by Inter-measurement Percentage Change is Predictive of In-patient Mortality in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2020; 33:458-467. [PMID: 31933216 DOI: 10.1007/s12028-019-00906-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Critically ill aneurysmal subarachnoid hemorrhage (aSAH) patients suffer from systemic complications at a high rate. Hyperglycemia is a common intensive care unit (ICU) complication and has become a focus after aggressive glucose management was associated with improved ICU outcomes. Subsequent research has suggested that glucose variability, not a specific blood glucose range, may be a more appropriate clinical target. Glucose variability is highly correlated to poor outcomes in a wide spectrum of critically ill patients. Here, we investigate the changes between subsequent glucose values termed "inter-measurement difference," as an indicator of glucose variability and its association with outcomes in patients with aSAH. METHODS All SAH admissions to a single, tertiary referral center between 2002 and 2016 were screened. All aneurysmal cases who had more than 2 glucose measurements were included (n = 2451). We calculated several measures of variability, including simple variance, the average consecutive absolute change, average absolute change by time difference, within subject variance, median absolute deviation, and average or median consecutive absolute percentage change. Predictor variables also included admission Hunt and Hess grade, age, gender, cardiovascular risk factors, and surgical treatment. In-patient mortality was the main outcome measure. RESULTS In a multiple regression analysis, nearly all forms of glucose variability calculations were found to be correlated with in-patient mortality. The consecutive absolute percentage change, however, was most predictive: OR 5.2 [1.4-19.8, CI 95%] for percentage change and 8.8 [1.8-43.6] for median change, when controlling for the defined predictors. Survival to ICU discharge was associated with lower glucose variability (consecutive absolute percentage change 17% ± 9%) compared with the group that did not survive to discharge (20% ± 15%, p < 0.01). Interestingly, this finding was not significant in patients with pre-admission poorly controlled diabetes as indicated by HbA1c (OR 0.45 [0.04-7.18], by percentage change). The effect is driven mostly by non-diabetic patients or those with well-controlled diabetes. CONCLUSIONS Reduced glucose variability is highly correlated with in-patient survival and long-term mortality in aSAH patients. This finding was observed in the non-diabetic and well-controlled diabetic patients, suggesting a possible benefit for personalized glucose targets based on baseline HbA1c and minimizing variability. The inter-measure percentage change as an indicator of glucose variability is not only predictive of outcome, but is an easy-to-use tool that could be implemented in future clinical trials.
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10
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Okazaki T, Kuroda Y. Aneurysmal subarachnoid hemorrhage: intensive care for improving neurological outcome. J Intensive Care 2018; 6:28. [PMID: 29760928 PMCID: PMC5941608 DOI: 10.1186/s40560-018-0297-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/29/2018] [Indexed: 12/18/2022] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage is a life-threatening disease requiring neurocritical care. Delayed cerebral ischemia is a well-known complication that contributes to unfavorable neurological outcomes. Cerebral vasospasm has been thought to be the main cause of delayed cerebral ischemia, and although several studies were able to decrease cerebral vasospasm, none showed improved neurological outcomes. Our target is not cerebral vasospasm but improving neurological outcomes. The purpose of this review is to discuss what intensivists should know and can do to improve clinical outcomes in subarachnoid hemorrhage patients. Main body of the abstract Delayed cerebral ischemia is thought to be due to not only vasospasm but also multifactorial mechanisms. Additionally, the concept of early brain injury, which occurs within the first 72 h after the hemorrhage, has become an important concern. Increasing sympathetic activity after the hemorrhage is associated with cardiopulmonary complications and poor outcomes. Serum lactate measurement may be a valuable marker reflecting the severity of sympathetic activity. The transpulmonary thermodilution method will bring about an advanced understanding of hemodynamic management. Fever is a well-recognized symptom and targeted temperature management is an anticipated intervention. To avoid hyperglycemia and hypoglycemia, performing moderate glucose control and minimizing glucose variability are important concepts in glycemic management, but the optimal target range remains unknown. Dysnatremia seems to be associated with negative outcomes. It is not clear yet that maintaining normonatremia actively improves neurological outcomes. Optimal duration of intensive care management has not been determined. Short conclusion Although we have an advanced understanding of the pathophysiology and clinical characteristics of subarachnoid hemorrhage, there are many controversies in the intensive care unit management of subarachnoid hemorrhage. With an awareness of not only delayed cerebral ischemia but also early brain injury, more attention should be given to various aspects to improve neurological outcomes.
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Affiliation(s)
- Tomoya Okazaki
- 1Emergency Medical Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793 Japan
| | - Yasuhiro Kuroda
- 2Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Miki, Kita, Kagawa 761-0793 Japan
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Kofler M, Schiefecker AJ, Beer R, Gaasch M, Rhomberg P, Stover J, Pfausler B, Thomé C, Schmutzhard E, Helbok R. Enteral nutrition increases interstitial brain glucose levels in poor-grade subarachnoid hemorrhage patients. J Cereb Blood Flow Metab 2018; 38:518-527. [PMID: 28322077 PMCID: PMC5851142 DOI: 10.1177/0271678x17700434] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Low brain tissue glucose levels after acute brain injury are associated with poor outcome. Whether enteral nutrition (EN) reliably increases cerebral glucose levels remains unclear. In this retrospective analysis of prospectively collected observational data, we investigate the effect of EN on brain metabolism in 17 poor-grade subarachnoid hemorrhage (SAH) patients undergoing cerebral microdialysis (CMD) monitoring. CMD-values were obtained hourly. A nutritional intervention was defined as the clinical routine administration of EN without supplemental parenteral nutrition. Sixty-three interventions were analyzed. The mean amount of EN per intervention was 472.4 ± 10.7 kcal. CMD-glucose levels significantly increased from 1.59 ± 0.13 mmol/l at baseline to a maximum of 2.03 ± 0.2 mmol/l after 5 h (p < 0.001), independently of insulin-treatment, baseline serum glucose, baseline brain metabolic distress (CMD-lactate-to-pyruvate-ratio (LPR) > 40) and the microdialysis probe location. The increase in CMD-glucose was directly dependent on the magnitude of increase of serum glucose levels (p = 0.007). No change in CMD-lactate, CMD-pyruvate, CMD-LPR, or CMD-glutamate (p > 0.4) was observed. Routine EN also increased CMD-glucose even if baseline concentrations were critically low ( < 0.7 mmol/l, neuroglucopenia; p < 0.001). These results may have treatment implications regarding glucose management of poor-grade aneurysmal SAH patients.
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Affiliation(s)
- Mario Kofler
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois J Schiefecker
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Maxime Gaasch
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul Rhomberg
- 2 Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - John Stover
- 3 Fresenius Kabi, Bad Homburg vor der Höhe, Germany
| | - Bettina Pfausler
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- 4 Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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12
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Helbok R, Kofler M, Schiefecker AJ, Gaasch M, Rass V, Pfausler B, Beer R, Schmutzhard E. Clinical Use of Cerebral Microdialysis in Patients with Aneurysmal Subarachnoid Hemorrhage-State of the Art. Front Neurol 2017; 8:565. [PMID: 29163332 PMCID: PMC5676489 DOI: 10.3389/fneur.2017.00565] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 10/09/2017] [Indexed: 01/04/2023] Open
Abstract
Objective To review the published literature on the clinical application of cerebral microdialysis (CMD) in aneurysmal subarachnoid hemorrhage (SAH) patients and to summarize the evidence relating cerebral metabolism to pathophysiology, secondary brain injury, and outcome. Methods Study selection: Two reviewers identified all manuscripts reporting on the clinical use of CMD in aneurysmal SAH patients from MEDLINE. All identified studies were grouped according to their focus on brain metabolic changes during the early and subacute phase after SAH, their association with mechanisms of secondary brain injury and outcome. Results The review demonstrated: (1) limited literature is available in the very early phase before the aneurysm is secured. (2) Brain metabolic changes related to early and delayed secondary injury mechanisms may be used in addition to other neuromonitoring parameters in the critical care management of SAH patients. (3) CMD markers of ischemia may detect delayed cerebral ischemia early (up to 16 h before onset), underlining the importance of trend analysis. (4) Various CMD-derived parameters may be associated with patient outcome at 3–12 months, including CMD-lactate-to-pyruvate-ratio, CMD-glucose, and CMD-glutamate. Conclusion The clinical use of CMD is an emerging area in the literature of aneurysmal SAH patients. Larger prospective multi-center studies on interventions based on CMD findings are needed.
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Affiliation(s)
- Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois Josef Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Maxime Gaasch
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Abstract
Microdialysis enables the chemistry of the extracellular interstitial space to be monitored. Use of this technique in patients with acute brain injury has increased our understanding of the pathophysiology of several acute neurological disorders. In 2004, a consensus document on the clinical application of cerebral microdialysis was published. Since then, there have been significant advances in the clinical use of microdialysis in neurocritical care. The objective of this review is to report on the International Microdialysis Forum held in Cambridge, UK, in April 2014 and to produce a revised and updated consensus statement about its clinical use including technique, data interpretation, relationship with outcome, role in guiding therapy in neurocritical care and research applications.
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Young B, Kalanuria A, Kumar M, Burke K, Balu R, Amendolia O, McNulty K, Marion B, Beckmann B, Ciocco L, Miller K, Schuele D, Maloney-Wilensky E, Frangos S, Wright D. Cerebral Microdialysis. Crit Care Nurs Clin North Am 2016; 28:109-24. [DOI: 10.1016/j.cnc.2015.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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15
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de Lima Oliveira M, Kairalla AC, Fonoff ET, Martinez RCR, Teixeira MJ, Bor-Seng-Shu E. Cerebral microdialysis in traumatic brain injury and subarachnoid hemorrhage: state of the art. Neurocrit Care 2015; 21:152-62. [PMID: 24072457 DOI: 10.1007/s12028-013-9884-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cerebral microdialysis (CMD) is a laboratory tool that provides on-line analysis of brain biochemistry via a thin, fenestrated, double-lumen dialysis catheter that is inserted into the interstitium of the brain. A solute is slowly infused into the catheter at a constant velocity. The fenestrated membranes at the tip of the catheter permit free diffusion of molecules between the brain interstitium and the perfusate, which is subsequently collected for laboratory analysis. The major molecules studied using this method are glucose, lactate, pyruvate, glutamate, and glycerol. The collected substances provide insight into the neurochemical features of secondary injury following traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) and valuable information about changes in brain metabolism within a short time frame. In this review, the authors detail the CMD technique and its associated markers and then describe pertinent findings from the literature about the clinical application of CMD in TBI and SAH.
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Affiliation(s)
- Marcelo de Lima Oliveira
- Division of Neurological Surgery, Hospital das Clinicas, School of Medicine, University of São Paulo, Rua Loefgreen, 1.272 - Vila Clementino, São Paulo, SP, 04040-001, Brazil
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16
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Arfvidsson B, Nilsson TK, Norgren L. S100B concentrations increase perioperatively in jugular vein blood despite limited metabolic and inflammatory response to clinically uneventful carotid endarterectomy. ACTA ACUST UNITED AC 2015; 53:111-7. [DOI: 10.1515/cclm-2014-0283] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 07/11/2014] [Indexed: 11/15/2022]
Abstract
AbstractOur aim was to test the hypothesis that metabolic and inflammatory responses of the brain perioperatively during carotid endarterectomy (CEA) might affect blood brain barrier (BBB) integrity.Twenty patients with >70% stenosis of internal carotid artery (ICA) were prospectively included. Surgery was performed under general anaesthesia. Blood was sampled from ipsilateral internal jugular vein and radial artery: just before, during, and after ICA clamping S100B protein, glucose, lactate, 20 amino acids, and key cytokines were analysed.Jugular vein S100B increased during clamping and reperfusion, while a marginal systemic increase was recorded, unrelated to stump pressure during clamping. Glucose increased during clamping in jugular vein blood and even more systemically, while jugular lactate values were higher than systemic values initially. Most amino acids did not differ significantly between jugular vein and systemic levels: glutamic acid and aspartic acid decreased during surgery while asparagine increased. Jugular vein interleukin (IL)-6 showed a transient non-significant increase during clamping and decreased systemically. IL-8 and IL-10 increased over time.Rising jugular vein S100B concentrations indicated reduced BBB integrity, and marginal secondary increase of S100B systemically. Limited ischaemic effects on the brain during cross-clamping, unrelated to S100B concentrations, were confirmed by lower brain glucose levels and higher lactate levels than in systemic blood. The lack of increased jugular vein glutamic acid disproves any major ischaemic brain injury following CEA. The inflammatory response was limited, did not differ greatly between jugular and systemic blood, and was unrelated to S100B.
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17
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Chen J, Lee HJ, Wu X, Huo L, Kim SJ, Xu L, Wang Y, He J, Bollu LR, Gao G, Su F, Briggs J, Liu X, Melman T, Asara JM, Fidler IJ, Cantley LC, Locasale JW, Weihua Z. Gain of glucose-independent growth upon metastasis of breast cancer cells to the brain. Cancer Res 2014; 75:554-65. [PMID: 25511375 DOI: 10.1158/0008-5472.can-14-2268] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Breast cancer brain metastasis is resistant to therapy and a particularly poor prognostic feature in patient survival. Altered metabolism is a common feature of cancer cells, but little is known as to what metabolic changes benefit breast cancer brain metastases. We found that brain metastatic breast cancer cells evolved the ability to survive and proliferate independent of glucose due to enhanced gluconeogenesis and oxidations of glutamine and branched chain amino acids, which together sustain the nonoxidative pentose pathway for purine synthesis. Silencing expression of fructose-1,6-bisphosphatases (FBP) in brain metastatic cells reduced their viability and improved the survival of metastasis-bearing immunocompetent hosts. Clinically, we showed that brain metastases from human breast cancer patients expressed higher levels of FBP and glycogen than the corresponding primary tumors. Together, our findings identify a critical metabolic condition required to sustain brain metastasis and suggest that targeting gluconeogenesis may help eradicate this deadly feature in advanced breast cancer patients.
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Affiliation(s)
- Jinyu Chen
- Department of Biochemistry and Biology, College of Natural Science and Mathematics, University of Houston, Houston, Texas
| | - Ho-Jeong Lee
- Department of Cancer Biology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Xuefeng Wu
- Department of Biochemistry and Biology, College of Natural Science and Mathematics, University of Houston, Houston, Texas
| | - Lei Huo
- Department of Pathology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Sun-Jin Kim
- Department of Cancer Biology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Lei Xu
- Department of Biochemistry and Biology, College of Natural Science and Mathematics, University of Houston, Houston, Texas
| | - Yan Wang
- Department of Pathology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Junqing He
- Department of Cancer Biology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Lakshmi R Bollu
- Department of Biochemistry and Biology, College of Natural Science and Mathematics, University of Houston, Houston, Texas
| | - Guang Gao
- Department of Biochemistry and Biology, College of Natural Science and Mathematics, University of Houston, Houston, Texas
| | - Fei Su
- Department of Biochemistry and Biology, College of Natural Science and Mathematics, University of Houston, Houston, Texas
| | - James Briggs
- Department of Biochemistry and Biology, College of Natural Science and Mathematics, University of Houston, Houston, Texas
| | - Xiaojing Liu
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Tamar Melman
- Division of Signal Transduction, Beth Israel Deaconess Medical Center and Department of Medicine, Harvard Medical School Boston, Massachusetts
| | - John M Asara
- Division of Signal Transduction, Beth Israel Deaconess Medical Center and Department of Medicine, Harvard Medical School Boston, Massachusetts. Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Isaiah J Fidler
- Department of Cancer Biology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Lewis C Cantley
- Meyer Cancer Center, Weill Cornell Medical College, New York, New York
| | - Jason W Locasale
- Division of Nutritional Sciences, Cornell University, Ithaca, New York
| | - Zhang Weihua
- Department of Biochemistry and Biology, College of Natural Science and Mathematics, University of Houston, Houston, Texas.
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Rostami E. Glucose and the injured brain-monitored in the neurointensive care unit. Front Neurol 2014; 5:91. [PMID: 24936196 PMCID: PMC4047514 DOI: 10.3389/fneur.2014.00091] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/23/2014] [Indexed: 12/16/2022] Open
Abstract
Brain has a continuous demand for energy that is met by oxidative metabolism of oxygen and glucose. This demand is compromised in the injured brain and if the inadequate supply persists it will lead to permanent tissue damage. Zero values of cerebral glucose have been associated with infarction and poor neurological outcome. Furthermore, hyperglycemia is common in patients with neurological insults and associated with poor outcome. Intensive insulin therapy (IIT) to control blood glucose has been suggested and used in neurointensive care with conflicting results. This review covers the studies reporting on monitoring of cerebral glucose with microdialysis in patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH) and ischemic stroke. Studies investigating IIT are also discussed. Available data suggest that low cerebral glucose in patients with TBI and SAH provides valuable information on development of secondary ischemia and has been correlated with worse outcome. There is also indication that the location of the catheter is important for correlation between plasma and brain glucose. In conclusion considering catheter location, monitoring of brain glucose in the neurointensive care not only provides information on imminent secondary ischemia it also reveals the effect of peripheral treatment on the injured brain.
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Affiliation(s)
- Elham Rostami
- Department of Neuroscience, Section of Neurosurgery, Uppsala University , Uppsala , Sweden ; Department of Neuroscience, Karolinska Institutet , Stockholm , Sweden
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19
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Kubo Y, Koji T, Kashimura H, Otawara Y, Ogawa A, Ogasawara K. Adrenomedullin concentration in the cerebrospinal fluid is related to appetite loss and delayed ischemic neurological deficits after subarachnoid hemorrhage. Neurol Res 2013; 35:713-8. [DOI: 10.1179/1743132813y.0000000222] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Yoshitaka Kubo
- Department of NeurosurgeryIwate Medical University, Morioka, Japan
| | - Takahiro Koji
- Department of NeurosurgeryIwate Medical University, Morioka, Japan
| | | | - Yasunari Otawara
- Department of NeurosurgeryIwate Medical University, Morioka, Japan
| | - Akira Ogawa
- Department of NeurosurgeryIwate Medical University, Morioka, Japan
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Kubo Y, Koji T, Kashimura H, Otawara Y, Ogawa A, Ogasawara K. Appetite loss may be induced by lower serum ghrelin and higher serum leptin concentrations in subarachnoid hemorrhage patients. Nutr Neurosci 2013; 17:230-3. [PMID: 24075245 DOI: 10.1179/1476830513y.0000000086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Patients with aneurysmal subarachnoid hemorrhage (SAH) typically develop appetite loss. However, the mechanisms regulating appetite are not understood. Ghrelin and leptin, both of which signal nutritional status and energy storage levels to the hypothalamus, are essential elements of the appetite system. Thus, the goal of this study was to investigate the relationship between appetite and ghrelin and leptin concentrations in patients with SAH. METHODS Blood plasma or serum profiles and appetite status were measured in 19 patients with SAH who underwent aneurysmal clipping within 48 hours of SAH onset. Appetite status was measured using dietary oral calorie intake. All outcome variables were measured at an early (day 3) and late (day 8) time point after SAH onset (day 0). RESULTS Of the 19 patients studied, 6 (31.6%) showed lower dietary oral calorie intake at the late time point than at the early time point. In these patients with appetite loss, plasma hemoglobin (P < 0.02), albumin (P < 0.01), glucose (P < 0.01), plasma insulin (P < 0.04), and serum ghrelin (P < 0.03) concentrations were lower at the late time point than at the early time point. Serum leptin was higher at the late time point than at the early time point (P < 0.02). CONCLUSION In SAH patients, appetite loss may be induced by lower serum ghrelin and higher serum leptin concentrations resulting from high plasma glucose and insulin levels due to a catecholamine surge following SAH.
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21
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Somatotropic and thyroid hormones in the acute phase of subarachnoid haemorrhage. Acta Neurochir (Wien) 2013; 155:2053-62. [PMID: 23494135 DOI: 10.1007/s00701-013-1670-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 02/24/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Somatotropic and thyroid hormones are probably important for the recovery after acute brain injury. Still, the dynamics of these hormones after spontaneous subarachnoid haemorrhage (SAH) is not well described. The purpose of this study was to investigate the relation between somatotropic and thyroid hormones and clinical factors after SAH. METHODS Twenty patients with spontaneous SAH were included prospectively. Serum concentrations of TSH, fT4, T3, IGF-1 and GH were measured once a day for 7 days after SAH. Hormone patterns and serum concentrations were compared to the severity of SAH, neurological condition at admission, clinical course and outcome of the patients. RESULTS During the first week after SAH, all patients showed increased GH and IGF-1 concentrations. In the whole group, concentrations of TSH increased, whereas T3 and fT4 decreased. There were no relations of serum concentrations of IGF-1 or GH to clinical condition at admission, clinical course or outcome of the patients. Half of the patients showed low T3 serum concentrations. A complicated course was associated with a deeper fall in TSH and T3 concentrations. There were negative correlations for mean concentrations of TSH and T3 versus WFNS grade and a positive correlation for T3 versus GOS after 6 months, indicating that low concentrations of TSH and T3 were connected to worse SAH grade and poor outcome. CONCLUSIONS All patients showed increased GH and IGF-1 concentrations irrespective of the grade of SAH or clinical course. Patients with a complicated clinical course showed a more pronounced fall in TSH and T3 concentrations and low serum T3 concentrations were related to a more serious SAH and poor patient outcome. These results need to be studied further and they may contribute to the accumulated knowledge needed to understand the complex mechanisms influencing the unpredictable clinical course after SAH.
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Kramer AH, Roberts DJ, Zygun DA. Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R203. [PMID: 23082798 PMCID: PMC3682305 DOI: 10.1186/cc11812] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 08/29/2012] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hyper- and hypoglycemia are strongly associated with adverse outcomes in critical care. Neurologically injured patients are a unique subgroup, where optimal glycemic targets may differ, such that the findings of clinical trials involving heterogeneous critically ill patients may not apply. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing intensive insulin therapy with conventional glycemic control among patients with traumatic brain injury, ischemic or hemorrhagic stroke, anoxic encephalopathy, central nervous system infections or spinal cord injury. RESULTS Sixteen RCTs, involving 1248 neurocritical care patients, were included. Glycemic targets with intensive insulin ranged from 70-140 mg/dl (3.9-7.8 mmol/L), while conventional protocols aimed to keep glucose levels below 144-300 mg/dl (8.0-16.7 mmol/L). Tight glycemic control had no impact on mortality (RR 0.99; 95% CI 0.83-1.17; p = 0.88), but did result in fewer unfavorable neurological outcomes (RR 0.91; 95% CI 0.84-1.00; p = 0.04). However, improved outcomes were only observed when glucose levels in the conventional glycemic control group were permitted to be relatively high [threshold for insulin administration > 200 mg/dl (> 11.1 mmol/L)], but not with more intermediate glycemic targets [threshold for insulin administration 140-180 mg/dl (7.8-10.0 mmol/L)]. Hypoglycemia was far more common with intensive therapy (RR 3.10; 95% CI 1.54-6.23; p = 0.002), but there was a large degree of heterogeneity in the results of individual trials (Q = 47.9; p<0.0001; I2 = 75%). Mortality was non-significantly higher with intensive insulin in studies where the proportion of patients developing hypoglycemia was large (> 33%) (RR 1.17; 95% CI 0.79-1.75; p = 0.44). CONCLUSIONS Intensive insulin therapy significantly increases the risk of hypoglycemia and does not influence mortality among neurocritical care patients. Very loose glucose control is associated with worse neurological recovery and should be avoided. These results suggest that intermediate glycemic goals may be most appropriate.
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Relationship between systemic glucose and cerebral glucose is preserved in patients with severe traumatic brain injury, but glucose delivery to the brain may become limited when oxidative metabolism is impaired: implications for glycemic control. Crit Care Med 2012; 40:1785-91. [PMID: 22610183 DOI: 10.1097/ccm.0b013e318246bd45] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To clarify the dynamics of glucose delivery to the brain and the effects of changes in blood glucose after severe traumatic brain injury. DESIGN Retrospective analysis of a prospective observational cohort study. SETTING Neurosurgical intensive care unit of a university hospital. PATIENTS Seventeen patients with acute traumatic brain injury monitored with cerebral and subcutaneous microdialysis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For continuous, accurate systemic monitoring, glucose was measured in the interstitial space of subcutaneous adipose tissue using microdialysis, and 39 specific episodes of spontaneous rises in glucose were identified. During these episodes, there was a significant positive linear relationship between systemic glucose levels and brain glucose concentrations measured by microdialysis (p < .0001). The basal lactate/pyruvate ratio, with a threshold of 25, was adopted to distinguish between disturbed and presumably preserved cerebral oxidative metabolism. Using normal vs. elevated lactate/pyruvate ratio as variable factor, the relationship between brain and systemic glucose during the episodes could be described by two significantly distinct parallel lines (p = .0001), which indicates a strong additive effect of subcutaneous glucose and lactate/pyruvate ratio in determining brain glucose. The line describing the relationship under disturbed metabolic conditions was lower than in presumably intact metabolic conditions, with a significant difference of 0.648 ± 0.192 mM (p = .002). This let us to accurately predict that in this situation systemic glucose concentrations in the lower range of normality would result in critical brain glucose levels. CONCLUSIONS The linear relationship between systemic and brain glucose in healthy subjects is preserved in traumatic brain-injured patients. As a consequence, in brain tissue where oxidative metabolism is disturbed, brain glucose concentrations might possibly drop below the critical threshold of 0.8 mM to 1.0 mM when there is a reduction in systemic glucose toward the lower limits of the "normal" range.
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How much glucose does the injured brain need?*. Crit Care Med 2012; 40:1973-4. [DOI: 10.1097/ccm.0b013e31824e18ec] [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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Schmidt JM, Claassen J, Ko SB, Lantigua H, Presciutti M, Lee K, Connolly ES, Mayer SA, Seres DS, Badjatia N. Nutritional support and brain tissue glucose metabolism in poor-grade SAH: a retrospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R15. [PMID: 22277085 PMCID: PMC3396251 DOI: 10.1186/cc11160] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 11/01/2011] [Accepted: 01/25/2012] [Indexed: 01/04/2023]
Abstract
Introduction We sought to determine the effect of nutritional support and insulin infusion therapy on serum and brain glucose levels and cerebral metabolic crisis after aneurysmal subarachnoid hemorrhage (SAH). Methods We used a retrospective observational cohort study of 50 mechanically ventilated poor-grade (Hunt-Hess 4 or 5) aneurysmal SAH patients who underwent brain microdialysis monitoring for an average of 109 hours. Enteral nutrition was started within 72 hours of admission whenever feasible. Intensive insulin therapy was used to maintain serum glucose levels between 5.5 and 7.8 mmol/l. Serum glucose, insulin and caloric intake from enteral tube feeds, dextrose and propofol were recorded hourly. Cerebral metabolic distress was defined as a lactate to pyruvate ratio (LPR) > 40. Time-series data were analyzed using a general linear model extended by generalized estimation equations (GEE). Results Daily mean caloric intake received was 13.8 ± 6.9 cal/kg and mean serum glucose was 7.9 ± 1 mmol/l. A total of 32% of hourly recordings indicated a state of metabolic distress and < 1% indicated a state of critical brain hypoglycemia (< 0.2 mmol/l). Calories received from enteral tube feeds were associated with higher serum glucose concentrations (Wald = 6.07, P = 0.048), more insulin administered (Wald = 108, P < 0.001), higher body mass index (Wald = 213.47, P < 0.001), and lower body temperature (Wald = 4.1, P = 0.043). Enteral feeding (Wald = 1.743, P = 0.418) was not related to brain glucose concentrations after accounting for serum glucose concentrations (Wald = 67.41, P < 0.001). In the presence of metabolic distress, increased insulin administration was associated with a relative reduction of interstitial brain glucose concentrations (Wald = 8.26, P = 0.017), independent of serum glucose levels. Conclusions In the presence of metabolic distress, insulin administration is associated with reductions in brain glucose concentration that are independent of serum glucose levels. Further study is needed to understand how nutritional support and insulin administration can be optimized to minimize secondary injury after subarachnoid hemorrhage.
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Affiliation(s)
- J Michael Schmidt
- Columbia University, Department of Neurology, Milstein Hospital, 177 Fort Washington, Suite 8-300, New York, NY 10032, USA.
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