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Carlson AP, Mayer AR, Cole C, van der Horn HJ, Marquez J, Stevenson TC, Shuttleworth CW. Cerebral autoregulation, spreading depolarization, and implications for targeted therapy in brain injury and ischemia. Rev Neurosci 2024; 35:651-678. [PMID: 38581271 DOI: 10.1515/revneuro-2024-0028] [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: 02/22/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Cerebral autoregulation is an intrinsic myogenic response of cerebral vasculature that allows for preservation of stable cerebral blood flow levels in response to changing systemic blood pressure. It is effective across a broad range of blood pressure levels through precapillary vasoconstriction and dilation. Autoregulation is difficult to directly measure and methods to indirectly ascertain cerebral autoregulation status inherently require certain assumptions. Patients with impaired cerebral autoregulation may be at risk of brain ischemia. One of the central mechanisms of ischemia in patients with metabolically compromised states is likely the triggering of spreading depolarization (SD) events and ultimately, terminal (or anoxic) depolarization. Cerebral autoregulation and SD are therefore linked when considering the risk of ischemia. In this scoping review, we will discuss the range of methods to measure cerebral autoregulation, their theoretical strengths and weaknesses, and the available clinical evidence to support their utility. We will then discuss the emerging link between impaired cerebral autoregulation and the occurrence of SD events. Such an approach offers the opportunity to better understand an individual patient's physiology and provide targeted treatments.
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Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
- Department of Neurosciences, 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Andrew R Mayer
- 168528 Mind Research Network , 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Chad Cole
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - Harm J van der Horn
- 168528 Mind Research Network , 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Joshua Marquez
- 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Taylor C Stevenson
- Department of Neurosurgery, 12288 University of New Mexico School of Medicine , MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - C William Shuttleworth
- Department of Neurosciences, 12288 University of New Mexico School of Medicine , 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
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Guensch DP, Utz CD, Jung B, Dozio S, Huettenmoser SP, Friess JO, Terbeck S, Erdoes G, Huber AT, Eberle B, Fischer K. Introducing a free-breathing MRI method to assess peri-operative myocardial oxygenation and function: A volunteer cohort study. Eur J Anaesthesiol 2024; 41:480-489. [PMID: 38323332 PMCID: PMC11155273 DOI: 10.1097/eja.0000000000001964] [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: 02/08/2024]
Abstract
BACKGROUND Induction of general anaesthesia has many potential triggers for peri-operative myocardial ischaemia including the acute disturbance of blood gases that frequently follows alterations in breathing and ventilation patterns. Free-breathing oxygenation-sensitive cardiovascular magnetic resonance (OS-CMR) imaging may provide the opportunity to continuously quantify the impact of such triggers on myocardial oxygenation. OBJECTIVE To investigate the impact of breathing patterns that simulate induction of general anaesthesia on myocardial oxygenation in awake healthy adults using continuous OS-CMR imaging. DESIGN Prospective observational study. SETTING Single-centre university hospital. Recruitment from August 2020 to January 2022. PARTICIPANTS Thirty-two healthy volunteers younger than 45 years old were recruited. Data were analysed from n = 29 (69% male individuals). INTERVENTION Participants performed a simulated induction breathing manoeuvre consisting of 2.5 min paced breathing with a respiration rate of 14 breaths per minute, followed by 5 deep breaths, then apnoea for up to 60s inside a magnetic resonance imaging scanner (MRI). Cardiac images were acquired with the traditional OS-CMR sequence (OS bh-cine ), which requires apnoea for acquisition and with two free-breathing OS-CMR sequences: a high-resolution single-shot sequence (OS fb-ss ) and a real-time cine sequence (OS fb-rtcine ). MAIN OUTCOME MEASURES Myocardial oxygenation response at the end of the paced breathing period and at the 30 s timepoint during the subsequent apnoea, reflecting the time of successful intubation in a clinical setting. RESULTS The paced breathing followed by five deep breaths significantly reduced myocardial oxygenation, which was observed with all three techniques (OS bh-cine -6.0 ± 2.6%, OS fb-ss -12.0 ± 5.9%, OS fb-rtcine -5.4 ± 7.0%, all P < 0.05). The subsequent vasodilating stimulus of apnoea then significantly increased myocardial oxygenation (OS bh-cine 6.8 ± 3.1%, OS fb-ss 8.4 ± 5.6%, OS fb-rtcine 15.7 ± 10.0%, all P < 0.01). The free-breathing sequences were reproducible and were not inferior to the original sequence for any stage. CONCLUSION Breathing manoeuvres simulating induction of general anaesthesia cause dynamic alterations of myocardial oxygenation in young volunteers, which can be quantified continuously with free-breathing OS-CMR. Introducing these new imaging techniques into peri-operative studies may throw new light into the mechanisms of peri-operative perturbations of myocardial tissue oxygenation and ischaemia. VISUAL ABSTRACT http://links.lww.com/EJA/A922.
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Affiliation(s)
- Dominik P Guensch
- From the Department of Anaesthesiology and Pain Medicine (DPG, CDU, JOF, ST, GE, BE, KF) and Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (DPG, BJ, SD, SPH, ATH)
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3
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Worley ML, Reed EL, Klaes N, Schlader ZJ, Johnson BD. Cool head-out water immersion does not alter cerebrovascular reactivity to hypercapnia despite elevated middle cerebral artery blood velocity: A pilot study. PLoS One 2024; 19:e0298587. [PMID: 38478550 PMCID: PMC10936844 DOI: 10.1371/journal.pone.0298587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/28/2024] [Indexed: 03/24/2024] Open
Abstract
Episodic increases in cerebral blood flow (CBF) are thought to contribute to improved cerebrovascular function and health. Head-out water immersion (HOWI) may be a useful modality to increase CBF secondary to the hydrostatic pressure placed on the body. However, it is unclear whether water temperatures common to the general public elicit similar cerebrovascular responses. We tested the hypothesis that mean middle cerebral artery blood velocity (MCAvmean) and cerebrovascular reactivity to CO2 (CVRCO2) would be higher during an acute bout of thermoneutral (TN; 35°C) vs. cool (COOL; 25°C) HOWI. Ten healthy participants (age: 23±3 y; 4 women) completed two randomized HOWI visits. Right MCAvmean, end-tidal CO2 (PETCO2) mean arterial pressure (MAP), and MCA conductance (MCAvmean/MAP) were continuously recorded. CVRCO2 was assessed using a stepped hypercapnia protocol before (PRE), at 30 minutes of HOWI (HOWI), immediately after HOWI (POST-1), and 45 minutes after HOWI (POST-2). Absolute values are reported as mean ± SD. MCAvmean, PETCO2, MAP, and CVRCO2 were not different between conditions at any timepoint (all P≥0.17). In COOL, MCAvmean increased from PRE (61±9 cm/s) during HOWI (68±11 cm/s), at POST-1 (69±11 cm/s), and POST-2 (72±8 cm/s) (all P<0.01), and in TN from PRE to POST-1 (66±13 vs. 71±14 cm/s; P = 0.05). PETCO2 did not change over time in either condition. In COOL, MAP increased from PRE (85±5 mmHg) during HOWI (101±4 mmHg), at POST-1 (97±7 mmHg), and POST-2 (96±9 mmHg), and in TN from PRE (88±5 mmHg) at HOWI (98±7 mmHg) and POST-1 (99±8 mmHg) (all P<0.01). In COOL, CVRCO2 increased from PRE to HOWI (1.66±0.55 vs. 1.92±0.52 cm/s/mmHg; P = 0.04). MCA conductance was not different between or within conditions. These data indicate that 30 minutes of cool HOWI augments MCAvmean and that the increase in MCAvmean persists beyond cool HOWI. However, cool HOWI does not alter CVRCO2 in healthy young adults.
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Affiliation(s)
- Morgan L. Worley
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States of America
| | - Emma L. Reed
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States of America
- Department of Human Physiology, College of Arts and Sciences, University of Oregon, Eugene, OR, United States of America
| | - Nathan Klaes
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States of America
| | - Zachary J. Schlader
- Department of Kinesiology, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States of America
| | - Blair D. Johnson
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States of America
- Department of Kinesiology, School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States of America
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Mayer AR, Dodd AB, Robertson-Benta CR, Zotev V, Ryman SG, Meier TB, Campbell RA, Phillips JP, van der Horn HJ, Hogeveen J, Tarawneh R, Sapien RE. Multifaceted neural and vascular pathologies after pediatric mild traumatic brain injury. J Cereb Blood Flow Metab 2024; 44:118-130. [PMID: 37724718 PMCID: PMC10905640 DOI: 10.1177/0271678x231197188] [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: 03/06/2023] [Revised: 06/01/2023] [Accepted: 07/25/2023] [Indexed: 09/21/2023]
Abstract
Dynamic changes in neurodevelopment and cognitive functioning occur during adolescence, including a switch from reactive to more proactive forms of cognitive control, including response inhibition. Pediatric mild traumatic brain injury (pmTBI) affects these cognitions immediately post-injury, but the role of vascular versus neural injury in cognitive dysfunction remains debated. This study consecutively recruited 214 sub-acute pmTBI (8-18 years) and age/sex-matched healthy controls (HC; N = 186), with high retention rates (>80%) at four months post-injury. Multimodal imaging (functional MRI during response inhibition, cerebral blood flow and cerebrovascular reactivity) assessed for pathologies within the neurovascular unit. Patients exhibited increased errors of commission and hypoactivation of motor circuitry during processing of probes. Evidence of increased/delayed cerebrovascular reactivity within motor circuitry during hypercapnia was present along with normal perfusion. Neither age-at-injury nor post-concussive symptom load were strongly associated with imaging abnormalities. Collectively, mild cognitive impairments and clinical symptoms may continue up to four months post-injury. Prolonged dysfunction within the neurovascular unit was observed during proactive response inhibition, with preliminary evidence that neural and pure vascular trauma are statistically independent. These findings suggest pmTBI is characterized by multifaceted pathologies during the sub-acute injury stage that persist several months post-injury.
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Affiliation(s)
- Andrew R Mayer
- The Mind Research Network/LBERI, Albuquerque, NM, USA
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - Andrew B Dodd
- The Mind Research Network/LBERI, Albuquerque, NM, USA
| | | | - Vadim Zotev
- The Mind Research Network/LBERI, Albuquerque, NM, USA
| | | | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard A Campbell
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - John P Phillips
- The Mind Research Network/LBERI, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | | | - Jeremy Hogeveen
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | - Rawan Tarawneh
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
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5
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McPherson JI, Nazir MSZ, Willer BS, Leddy JJ, Haider MN. Does Physiologic Post-Concussion Disorder Cause Persistent Post-Traumatic Headache? Curr Pain Headache Rep 2023; 27:793-799. [PMID: 37831366 DOI: 10.1007/s11916-023-01176-5] [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] [Accepted: 09/27/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE OF REVIEW One system classifies patients with symptoms after concussion into physiologic, vestibulo-ocular, cervicogenic, and mood/cognition post-concussion disorders (PCD) based upon the preponderance of specific symptoms and physical impairments. This review discusses physiologic PCD and its potential relationship to the development of persistent post-traumatic headaches (PPTH). RECENT FINDINGS Headache is the most reported symptom after a concussion. Headaches in physiologic PCD are suspected to be due to abnormal cellular metabolism, subclinical neuroinflammation, and dysfunction of the autonomic nervous system (ANS). These abnormalities have been linked to the development of migraine-like and neuralgia-related PPTH. Physiologic PCD is a potential cause of PPTH after a concussion. Future research should focus on how to prevent PPTH in patients with physiologic PCD.
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Affiliation(s)
- Jacob I McPherson
- Department of Rehabilitation Science, School of Public Health and Health Professions, State University of New York at Buffalo, 534 Kimball Tower, Buffalo, NY, 14214, USA.
| | - Muhammad S Z Nazir
- Concussion Management Clinic and Research Center, UBMD Orthopedics and Sports Medicine, State University of New York at Buffalo, Buffalo, NY, 14214, USA
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, 14215, USA
| | - John J Leddy
- Department of Orthopedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, 14215, USA
| | - Mohammad N Haider
- Department of Orthopedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, 14215, USA
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6
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Yeates KO, Räisänen AM, Premji Z, Debert CT, Frémont P, Hinds S, Smirl JD, Barlow K, Davis GA, Echemendia RJ, Feddermann-Demont N, Fuller C, Gagnon I, Giza CC, Iverson GL, Makdissi M, Schneider KJ. What tests and measures accurately diagnose persisting post-concussive symptoms in children, adolescents and adults following sport-related concussion? A systematic review. Br J Sports Med 2023; 57:780-788. [PMID: 37316186 DOI: 10.1136/bjsports-2022-106657] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To determine what tests and measures accurately diagnose persisting post-concussive symptoms (PPCS) in children, adolescents and adults following sport-related concussion (SRC). DESIGN A systematic literature review. DATA SOURCES MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL and SPORTDiscus through March 2022. ELIGIBILITY CRITERIA Original, empirical, peer-reviewed findings (cohort studies, case-control studies, cross-sectional studies and case series) published in English and focused on SRC. Studies needed to compare individuals with PPCS to a comparison group or their own baseline prior to concussion, on tests or measures potentially affected by concussion or associated with PPCS. RESULTS Of 3298 records screened, 26 articles were included in the qualitative synthesis, including 1016 participants with concussion and 531 in comparison groups; 7 studies involved adults, 8 involved children and adolescents and 11 spanned both age groups. No studies focused on diagnostic accuracy. Studies were heterogeneous in participant characteristics, definitions of concussion and PPCS, timing of assessment and the tests and measures examined. Some studies found differences between individuals with PPCS and comparison groups or their own pre-injury assessments, but definitive conclusions were not possible because most studies had small convenience samples, cross-sectional designs and were rated high risk of bias. CONCLUSION The diagnosis of PPCS continues to rely on symptom report, preferably using standardised symptom rating scales. The existing research does not indicate that any other specific tool or measure has satisfactory accuracy for clinical diagnosis. Future research drawing on prospective, longitudinal cohort studies could help inform clinical practice.
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Affiliation(s)
- Keith Owen Yeates
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Anu M Räisänen
- Department of Physical Therapy Education - Oregon, Western University of Health Sciences, College of Health Sciences - Northwest, Lebanon, Oregon, USA
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Zahra Premji
- Libraries, University of Victoria, Victoria, British Columbia, Canada
| | - Chantel T Debert
- Department of Clinical Neuroscience, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pierre Frémont
- Department of Rehabilitation, Laval University, Quebec, Quebec, Canada
| | - Sidney Hinds
- Uniformed Services University, Bethesda, Maryland, USA
| | - Jonathan D Smirl
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Karen Barlow
- Child Health Research Centre, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Cabrini Health, Malvern, Victoria, Australia
| | - Ruben J Echemendia
- Department of Psychology, University of Missouri, Kansas City, Missouri, USA
- Psychological and Neurobehavioral Associates, Inc, State College, Pennsylvania, USA
| | - Nina Feddermann-Demont
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Sports Neuroscience, University of Zurich, Zurich, Switzerland
| | - Colm Fuller
- College of Medicine and Health, University College Cork, Cork, Ireland
- Sports Medicine Department, Sports Surgery Clinic, Dublin, Ireland
| | - Isabelle Gagnon
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Trauma Center, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Christopher C Giza
- Department of Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, California, USA
- Department of Pediatrics/Pediatric Neurology, Mattel Children's Hospital UCLA, Los Angeles, California, USA
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- Sports Concussion Program, MassGeneral Hospital for Children, Boston, Massachusetts, USA
| | - Michael Makdissi
- Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- Australian Football League, Melbourne, Victoria, Australia
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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Wang Y, Bartels HM, Nelson LD. A Systematic Review of ASL Perfusion MRI in Mild TBI. Neuropsychol Rev 2023; 33:160-191. [PMID: 32808244 PMCID: PMC7889778 DOI: 10.1007/s11065-020-09451-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 08/06/2020] [Indexed: 01/06/2023]
Abstract
Mild traumatic brain injury (mTBI) is a major public health concern. Cerebrovascular alterations play a significant role in the evolution of injury sequelae and in the process of post-traumatic brain repair. Arterial spin labeling (ASL) is an advanced perfusion magnetic resonance imaging technique that permits noninvasive quantification of cerebral blood flow (CBF). This is the first systematic review of ASL research findings in patients with mTBI. Our approach followed the American Academy of Neurology (AAN) and PRISMA guidelines. We searched Ovid/MEDLINE, Web of Science, Scopus, and the Cochrane Index for relevant articles published as of February 20, 2020. Full-text results were combined into Rayyan software for further evaluation. Data extraction, including risk of bias ratings, was performed using American Academy of Neurology's four-tiered classification scheme. Twenty-three articles met inclusion criteria comprising data on up to 566 mTBI patients and 654 control subjects. Of the 23 studies, 18 reported some type of regional CBF abnormality in mTBI patients at rest or during a cognitive task, with more findings of decreased than increased CBF. The evidence supports the conclusion that mTBI likely causes ASL-derived CBF anomalies. However, synthesis of findings was challenging due to substantial methodological variations across studies and few studies with low risk of bias. Thus, larger-scale prospective cohort studies are needed to more definitively chart the course of CBF changes in humans after mTBI and to understand how individual difference factors contribute to post-injury CBF changes.
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Affiliation(s)
- Yang Wang
- Department of Radiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Hannah M Bartels
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
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8
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Sheldrake E, Lam B, Al-Hakeem H, Wheeler AL, Goldstein BI, Dunkley BT, Ameis S, Reed N, Scratch SE. A Scoping Review of Magnetic Resonance Modalities Used in Detection of Persistent Postconcussion Symptoms in Pediatric Populations. J Child Neurol 2022; 38:85-102. [PMID: 36380680 DOI: 10.1177/08830738221120741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Up to 30% of youth with concussion experience PPCSs (PPCS) lasting 4 weeks or longer, and can significantly impact quality of life. Magnetic resonance imaging (MRI) has the potential to increase understanding of causal mechanisms underlying PPCS. However, there are no clear modalities to assist in detecting PPCS. This scoping review aims to synthesize findings on utilization of MRI among children and youth with PPCS, and summarize progress and limitations. Thirty-six studies were included from 4907 identified papers. Many studies used multiple modalities, including (1) structural (n = 27) such as T1-weighted imaging, diffusion weighted imaging, and susceptibility weighted imaging; and (2) functional (n = 23) such as functional MRI and perfusion-weighted imaging. Findings were heterogeneous among modalities and regions of interest, which warrants future reviews that report on the patterns and potential advancements in the field. Consideration of modalities that target PPCS prediction and sensitive modalities that can supplement a biopsychosocial approach to PPCS would benefit future research.
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Affiliation(s)
- Elena Sheldrake
- Bloorview Research Institute, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Brendan Lam
- Bloorview Research Institute, Toronto, Ontario, Canada
| | | | - Anne L Wheeler
- Neuroscience and Mental Health Program, 7979Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin I Goldstein
- 7978Centre for Addiction and Mental Health, Toronto, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin T Dunkley
- Neuroscience and Mental Health Program, 7979Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie Ameis
- 7978Centre for Addiction and Mental Health, Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Nick Reed
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Shannon E Scratch
- Bloorview Research Institute, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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9
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Differential regional cerebrovascular reactivity to end-tidal gas combinations commonly seen during anaesthesia: A blood oxygenation level-dependent MRI observational study in awake adult subjects. Ugeskr Laeger 2022; 39:774-784. [PMID: 35852545 DOI: 10.1097/eja.0000000000001716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Regional cerebrovascular reactivity (rCVR) is highly variable in the human brain as measured by blood oxygenation level-dependent (BOLD) MRI to changes in both end-tidal CO 2 and O 2 . OBJECTIVES We examined awake participants under carefully controlled end-tidal gas concentrations to assess how regional CVR changes may present with end-tidal gas changes seen commonly with anaesthesia. DESIGN Observational study. SETTING Tertiary care centre, Winnipeg, Canada. The imaging for the study occurred in 2019. SUBJECTS Twelve healthy adult subjects. INTERVENTIONS Cerebral BOLD response was studied under two end-tidal gas paradigms. First end-tidal oxygen (ETO 2 ) maintained stable whereas ETCO 2 increased incrementally from hypocapnia to hypercapnia (CO 2 ramp); second ETCO 2 maintained stable whereas ETO 2 increased from normoxia to hyperoxia (O 2 ramp). BOLD images were modeled with end-tidal gas sequences split into two equal segments to examine regional CVR. MAIN OUTCOME MEASURES The voxel distribution comparing hypocapnia to mild hypercapnia and mild hyperoxia (mean F I O 2 = 0.3) to marked hyperoxia (mean F I O 2 = 0.7) were compared in a paired fashion ( P < 0.005 to reach threshold for voxel display). Additionally, type analysis was conducted on CO 2 ramp data. This stratifies the BOLD response to the CO 2 ramp into four categories of CVR slope based on segmentation (type A; +/+slope: normal response, type B +/-, type C -/-: intracranial steal, type D -/+.) Types B to D represent altered responses to the CO 2 stimulus. RESULTS Differential regional responsiveness was seen for both end-tidal gases. Hypocapnic regional CVR was more marked than hypercapnic CVR in 0.3% of voxels examined ( P < 0.005, paired comparison); the converse occurred in 2.3% of voxels. For O 2 , mild hyperoxia had more marked CVR in 0.2% of voxels compared with greater hyperoxia; the converse occurred in 0.5% of voxels. All subjects had altered regional CO 2 response based on Type Analysis ranging from 4 ± 2 to 7 ± 3% of voxels. CONCLUSION In awake subjects, regional differences and abnormalities in CVR were observed with changes in end-tidal gases common during the conduct of anaesthesia. On the basis of these findings, consideration could be given to minimising regional CVR fluctuations in patients-at-risk of neurological complications by tighter control of end-tidal gases near the individual's resting values.
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Wilde EA, Wanner I, Kenney K, Gill J, Stone JR, Disner S, Schnakers C, Meyer R, Prager EM, Haas M, Jeromin A. A Framework to Advance Biomarker Development in the Diagnosis, Outcome Prediction, and Treatment of Traumatic Brain Injury. J Neurotrauma 2022; 39:436-457. [PMID: 35057637 PMCID: PMC8978568 DOI: 10.1089/neu.2021.0099] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Elisabeth A. Wilde
- University of Utah, Neurology, 383 Colorow, Salt Lake City, Utah, United States, 84108
- VA Salt Lake City Health Care System, 20122, 500 Foothill Dr., Salt Lake City, Utah, United States, 84148-0002
| | - Ina Wanner
- UCLA, Semel Institute, NRB 260J, 635 Charles E. Young Drive South, Los Angeles, United States, 90095-7332, ,
| | - Kimbra Kenney
- Uniformed Services University of the Health Sciences, Neurology, Center for Neuroscience and Regenerative Medicine, 4301 Jones Bridge Road, Bethesda, Maryland, United States, 20814
| | - Jessica Gill
- National Institutes of Health, National Institute of Nursing Research, 1 cloister, Bethesda, Maryland, United States, 20892
| | - James R. Stone
- University of Virginia, Radiology and Medical Imaging, Box 801339, 480 Ray C. Hunt Dr. Rm. 185, Charlottesville, Virginia, United States, 22903, ,
| | - Seth Disner
- Minneapolis VA Health Care System, 20040, Minneapolis, Minnesota, United States
- University of Minnesota Medical School Twin Cities, 12269, 10Department of Psychiatry and Behavioral Sciences, Minneapolis, Minnesota, United States
| | - Caroline Schnakers
- Casa Colina Hospital and Centers for Healthcare, 6643, Pomona, California, United States
- Ronald Reagan UCLA Medical Center, 21767, Los Angeles, California, United States
| | - Restina Meyer
- Cohen Veterans Bioscience, 476204, New York, New York, United States
| | - Eric M Prager
- Cohen Veterans Bioscience, 476204, External Affairs, 535 8th Ave, New York, New York, United States, 10018
| | - Magali Haas
- Cohen Veterans Bioscience, 476204, 535 8th Avenue, 12th Floor, New York City, New York, United States, 10018,
| | - Andreas Jeromin
- Cohen Veterans Bioscience, 476204, Translational Sciences, Cambridge, Massachusetts, United States
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11
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Thibeault CM, Dorn AY, Radhakrishnan S, Hamilton RB. Longitudinal assessment of hemodynamic alterations after mild traumatic brain injury in adolescents: Selected case study review. JOURNAL OF CONCUSSION 2022. [DOI: 10.1177/20597002211065855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Alterations in the neurovasculature after traumatic brain injury (TBI) represents a significant sequelae. However, despite theoretical and empirical evidence supporting the near-ubiquity of vascular injury, its pathophysiology remains elusive. Although this has been shown for all grades of TBI, the vascular changes after injuries with the broad mild traumatic brain injuries (mTBI) classification, remain particularly difficult to describe. Our group has previously demonstrated hemodynamic alterations in mTBI by utilizing transcranial Doppler ultrasound and cerebrovascular reactivity in a cross-sectional study. That work identified a phasic progression of deviations over varying days post-injury. These phases were then characterized by a set of inverse models that provided a hypothetical process of hemodynamic dysfunction after mTBI. This model set provides a framework with the potential for guiding clinical treatment over the course of recovery. However, it is still unclear if individual patients will progress through the phases of dysfunction similar to that found at the population level. The work presented here explores six individual patients with high-density data collected during their post-injury recovery. Breath-hold index (BHI) was found to be the most robust feature related to mTBI longitudinally. All six subjects exhibited BHI recovery curves that followed the population model's progression. The changes in pulsatile features lacked the universality of BHI, but were present in subjects with higher self-reported symptom scores and longer periods of recovery. This work suggests neurovascular dysfunction after an mTBI may be a robust phenomenon. Additionally, the capabilities of TCD in capturing these changes highlights its potential for aiding clinicians in monitoring patient's recovery post mTBI.
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12
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Wu L, Chan ST, Edmiston WJ, Jin G, Levy ES, Kwong KK, Mannix R, Meehan WP, Chifamba FF, Lipton JO, Whalen MJ, Chen YCI. Persistent CO 2 reactivity deficits are associated with neurological dysfunction up to one year after repetitive mild closed head injury in adolescent mice. J Cereb Blood Flow Metab 2021; 41:3260-3272. [PMID: 34229511 PMCID: PMC8669283 DOI: 10.1177/0271678x211021771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cerebrovascular reactivity (CVR) deficits in adolescents with concussion may persist after resolution of neurological symptoms. Whether or not CVR deficits predict long term neurological function is unknown. We used adolescent mice closed head injury (CHI) models (54 g, 107 cm or 117 cm drop height), followed by blood oxygenation level dependent (BOLD)-functional MRI with CO2 challenge to assess CVR and brain connectivity. At one week, 3HD 107 cm mice showed delayed BOLD responses (p = 0.0074), normal striatal connectivity, and an impaired respiratory rate response to CO2 challenge (p = 0.0061 in ΔRmax). The 107 cm group developed rotarod deficits at 6 months (p = 0.02) and altered post-CO2 brain connectivity (3-fold increase in striatum to motor cortex correlation coefficient) by one year, but resolved their CVR and respiratory rate impairments, and did not develop cognitive or circadian activity deficits. In contrast, the 117 cm group had persistent CVR (delay time: p = 0.016; washout time: p = 0.039) and circadian activity deficits (free-running period: 23.7 hr in sham vs 23.9 hr in 3HD; amplitude: 0.15 in sham vs 0.2 in 3HD; peak activity: 18 in sham vs 21 in 3HD) at one year. Persistent CVR deficits after concussion may portend long-term neurological dysfunction. Further studies are warranted to determine the utility of CVR to predict chronic neurological outcome after mild traumatic brain injury.
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Affiliation(s)
- Limin Wu
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Suk-Tak Chan
- Department of Radiology, A. Martino's Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - William J Edmiston
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gina Jin
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily S Levy
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth K Kwong
- Department of Radiology, A. Martino's Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Rebekah Mannix
- Department of Emergency Medicine, Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA
| | - William P Meehan
- Department of Emergency Medicine, Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA.,Department of Orthopedics, Division of Sports Medicine, Boston, MA, USA
| | - Fortunate F Chifamba
- Department of Neurology, Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA
| | - Jonathan O Lipton
- Department of Neurology, Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, USA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Michael J Whalen
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yin-Ching I Chen
- Department of Radiology, A. Martino's Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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13
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Chan ST, Ordway C, Calvanio RJ, Buonanno FS, Rosen BR, Kwong KK. Cerebrovascular Responses to O 2-CO 2 Exchange Ratio under Brief Breath-Hold Challenge in Patients with Chronic Mild Traumatic Brain Injury. J Neurotrauma 2021; 38:2851-2861. [PMID: 34210158 PMCID: PMC8820289 DOI: 10.1089/neu.2021.0166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Breath-by-breath oxygen-carbon dioxide (O2-CO2) exchange ratio (bER) is a respiratory gas exchange (RGE) metric, which is the ratio of the changes in the partial pressure of O2 (ΔPO2) to CO2 (ΔPCO2) between end-inspiration and end-expiration, has been demonstrated to characterize the cerebrovascular responses to breath-hold challenge in healthy individuals. We aimed to explore whether bER could characterize cerebrovascular responses in patients with chronic mild traumatic brain injury (mTBI) under breath-hold challenge. We also investigated the correlation between bER and the severity of post-concussion symptoms. Blood-oxygenation-level-dependent (BOLD) images were acquired using functional magnetic resonance imaging (fMRI) on 10 patients with chronic mTBI and 10 controls without brain injury history when performing a breath-hold task. Time series of RGE metrics of ΔPO2, ΔPCO2, and bER were computed, and their cross-correlation with regional change in BOLD (ΔBOLD) was calculated. Symptom burden was assessed using the Rivermead Post Concussion Questionnaire (RPQ), and its correlation with RGE changes was also measured. Compared with controls, a diffuse decrease in the correlation between regional ΔBOLD and bER was found in the brain of patients with mTBI (pfdr < 0.05). No significant difference was found between patients and controls for the correlation of regional ΔBOLD with ΔPO2 and ΔPCO2. Symptom severity indicated by RPQ scores increased with a decrease in the averaged changes of bER (ρ = 0.79, p = 0.01) and ΔPO2 (ρ = 0.70, p = 0.03) in breath-hold epochs. Our imaging and symptom severity findings suggest that bER can be used to characterize cerebrovascular responses to breath hold in patients with mTBI. The RGE may contribute to the post-concussive symptom severity.
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Affiliation(s)
- Suk-Tak Chan
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Cora Ordway
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Ronald J. Calvanio
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Bruce R. Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Kenneth K. Kwong
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, USA
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14
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Barlow KM, Iyer K, Yan T, Scurfield A, Carlson H, Wang Y. Cerebral Blood Flow Predicts Recovery in Children with Persistent Post-Concussion Symptoms after Mild Traumatic Brain Injury. J Neurotrauma 2021; 38:2275-2283. [PMID: 33430707 PMCID: PMC9009764 DOI: 10.1089/neu.2020.7566] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Persistent post-concussion symptoms (PPCS) following pediatric mild traumatic brain injury (mTBI) are associated with differential changes in cerebral blood flow (CBF). Given its potential as a therapeutic target, we examined CBF changes during recovery in children with PPCS. We hypothesized that CBF would decrease and that such decreases would mirror clinical recovery. In a prospective cohort study, 61 children and adolescents (mean age 14 [standard deviation = 2.6] years; 41% male) with PPCS were imaged with three-dimensional (3D) pseudo-continuous arterial spin-labelled (pCASL) magnetic resonance imaging (MRI) at 4-6 and 8-10 weeks post-injury. Exclusion criteria included any significant past medical history and/or previous concussion within the past 3 months. Twenty-three participants had clinically recovered at the time of the second scan. We found that relative and mean absolute CBF were higher in participants with poor recovery, 44.0 (95% confidence interval [CI]: 43.32, 44.67) than in those with good recovery, 42.19 (95% CI: 41.77, 42.60) mL/min/100 g gray tissue and decreased over time (β = -1.75; p < 0.001). The decrease was greater in those with good recovery (β = 2.29; p < 0.001) and predicted outcome in 77% of children with PPCS (odds ratio [OR] 0.54, 95% CI: 0.36, 0.80; p = 0.002). Future studies are warranted to validate the utility of CBF as a useful predictive biomarker of outcome in PPCS.
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Affiliation(s)
- Karen M. Barlow
- Children's Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
- Queensland Children's Hospital, Children's Health Queensland, Brisbane, Queensland, Australia
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Kartik Iyer
- Children's Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Tingting Yan
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alex Scurfield
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Helen Carlson
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Yang Wang
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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15
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Differential regional cerebral blood flow reactivity to alterations in end-tidal gases in healthy volunteers. Can J Anaesth 2021; 68:1497-1506. [PMID: 34105067 DOI: 10.1007/s12630-021-02042-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/05/2021] [Accepted: 04/09/2021] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Anesthesia is associated with alterations in end-tidal (ET) respiratory gases from the awake state. These alterations result in marked vasoactive changes in regional cerebral blood flow (rCBF). Altered regional cerebrovascular reactivity (rCVR) is linked to neurologic dysfunction. We examined these differences in reactivity from prior work by focusing on the ratio of vasoconstriction with hyperoxia/hypocapnia (HO/hc):vasodilation with hypercapnia (HC) using magnetic resonance imaging pseudo-continuous arterial spin labelling (pCASL) to measure rCBF and compare rCVR The distribution and magnitude of these ratios could provide insights into rCBF during clinical anesthesia and inform future research into the origins of postoperative delirium (POD). METHODS Ten healthy subjects underwent cerebral blood flow (CBF) studies using pCASL with computer-controlled delivery of ET gases to assess flow effects of hyperoxia, hypercapnia, and hyperoxia/hypocapnia as part of a larger study into cerebrovascular reactivity. The vasoconstrictor stimulus was compared with the vasodilator stimulus by the ratio HO/hc:HC. RESULTS Hyperoxia minimally decreased whole brain CBF by - 0.6%/100 mm Hg increase in ETO2. Hypercapnia increased CBF by +4.6%/mm Hg carbon dioxide (CO2) and with HO/hc CBF decreased by - 5.1%/mm Hg CO2. The brain exhibited markedly different rCVR-regional HO/hc:HC ratios varied from 7.2:1 (greater response to vasoconstriction) to 0.49:1 (greater response to vasodilation). Many of the ratios greater than 1, where vasoconstriction predominated, were seen in regions associated with memory, cognition, and executive function, including the entorhinal cortex, hippocampus, parahippocampus, and dorsolateral prefrontal cortex. CONCLUSIONS In awake humans, marked rCBF changes occurred with alterations in ET respiratory gases common under anesthesia. Such heterogeneous reactivity may be relevant to future studies to identify those at risk of POD.
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16
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Lynch CE, Eisenbaum M, Algamal M, Balbi M, Ferguson S, Mouzon B, Saltiel N, Ojo J, Diaz-Arrastia R, Mullan M, Crawford F, Bachmeier C. Impairment of cerebrovascular reactivity in response to hypercapnic challenge in a mouse model of repetitive mild traumatic brain injury. J Cereb Blood Flow Metab 2021; 41:1362-1378. [PMID: 33050825 PMCID: PMC8142124 DOI: 10.1177/0271678x20954015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Incidences of repetitive mild TBI (r-mTBI), like those sustained by contact sports athletes and military personnel, are thought to be a risk factor for development of neurodegenerative disorders. Those suffering from chronic TBI-related illness demonstrate deficits in cerebrovascular reactivity (CVR), the ability of the cerebral vasculature to respond to a vasoactive stimulus. CVR is thus an important measure of traumatic cerebral vascular injury (TCVI), and a possible in vivo endophenotype of TBI-related neuropathogenesis. We combined laser speckle imaging of CVR in response to hypercapnic challenge with neurobehavioral assessment of learning and memory, to investigate if decreased cerebrovascular responsiveness underlies impaired cognitive function in our mouse model of chronic r-mTBI. We demonstrate a profile of blunted hypercapnia-evoked CVR in the cortices of r-mTBI mice like that of human TBI, alongside sustained memory and learning impairment, without biochemical or immunohistopathological signs of cerebral vessel laminar or endothelium constituent loss. Transient decreased expression of alpha smooth muscle actin and platelet-derived growth factor receptor β, indicative of TCVI, is obvious only at the time of the most pronounced CVR deficit. These findings implicate CVR as a valid preclinical measure of TCVI, perhaps useful for developing therapies targeting TCVI after recurrent mild head trauma.
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Affiliation(s)
- Cillian E Lynch
- The Roskamp Institute, Sarasota, FL, USA.,Department of Life Sciences, The Open University, Milton Keynes, UK.,James A. Haley Veteran's Administration, Tampa, FL, USA.,Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maxwell Eisenbaum
- The Roskamp Institute, Sarasota, FL, USA.,Department of Life Sciences, The Open University, Milton Keynes, UK
| | - Moustafa Algamal
- The Roskamp Institute, Sarasota, FL, USA.,Department of Life Sciences, The Open University, Milton Keynes, UK
| | - Matilde Balbi
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Scott Ferguson
- The Roskamp Institute, Sarasota, FL, USA.,Department of Life Sciences, The Open University, Milton Keynes, UK
| | - Benoit Mouzon
- The Roskamp Institute, Sarasota, FL, USA.,Department of Life Sciences, The Open University, Milton Keynes, UK.,James A. Haley Veteran's Administration, Tampa, FL, USA
| | | | - Joseph Ojo
- The Roskamp Institute, Sarasota, FL, USA.,Department of Life Sciences, The Open University, Milton Keynes, UK.,James A. Haley Veteran's Administration, Tampa, FL, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mike Mullan
- The Roskamp Institute, Sarasota, FL, USA.,Department of Life Sciences, The Open University, Milton Keynes, UK
| | - Fiona Crawford
- The Roskamp Institute, Sarasota, FL, USA.,Department of Life Sciences, The Open University, Milton Keynes, UK.,James A. Haley Veteran's Administration, Tampa, FL, USA
| | - Corbin Bachmeier
- The Roskamp Institute, Sarasota, FL, USA.,Department of Life Sciences, The Open University, Milton Keynes, UK.,Bay Pines VA Healthcare System, Bay Pines, FL, USA
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17
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Amyot F, Lynch CE, Ollinger J, Werner JK, Silverman E, Moore C, Davis C, Turtzo LC, Diaz-Arrastia R, Kenney K. Cerebrovascular Reactivity Measures Are Associated With Post-traumatic Headache Severity in Chronic TBI; A Retrospective Analysis. Front Physiol 2021; 12:649901. [PMID: 34054569 PMCID: PMC8155500 DOI: 10.3389/fphys.2021.649901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/17/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To characterize the relationship between persistent post-traumatic headache (pPTH) and traumatic cerebrovascular injury (TCVI) in chronic traumatic brain injury (TBI). Cerebrovascular reactivity (CVR), a measure of the cerebral microvasculature and endothelial cell function, is altered both in individuals with chronic TBI and migraine headache disorder (Amyot et al., 2017; Lee et al., 2019b). The pathophysiologies of pPTH and migraine are believed to be associated with chronic microvascular dysfunction. We therefore hypothesize that TCVI may contribute to the underlying migraine-like mechanism(s) of pPTH. MATERIALS AND METHODS 22 moderate/severe TBI participants in the chronic stage (>6 months) underwent anatomic and functional magnetic resonance imaging (fMRI) scanning with hypercapnia gas challenge to measure CVR as well as the change in CVR (ΔCVR) after single-dose treatment of a specific phosphodiesterase-5 (PDE-5) inhibitor, sildenafil, which potentiates vasodilation in response to hypercapnia in impaired endothelium, as part of a Phase2a RCT of sildenafil in chronic TBI (NCT01762475). CVR and ΔCVR measures of each participant were compared with the individual's pPTH severity measured by the headache impact test-6 (HIT-6) survey. RESULTS There was a moderate correlation between HIT-6 and both CVR and ΔCVR scores [Spearman's correlation = -0.50 (p = 0.018) and = 0.46 (p = 0.03), respectively], indicating that a higher headache burden is associated with decreased endothelial function in our chronic TBI population. CONCLUSION There is a correlation between PTH and CVR in chronic moderate-severe TBI. This relationship suggests that chronic TCVI may underlie the pathobiology of pPTH. Further, our results suggest that novel treatment strategies that target endothelial function and vascular health may be beneficial in refractory pPTH.
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Affiliation(s)
- Franck Amyot
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Cillian E. Lynch
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - John Ollinger
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - J. Kent Werner
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - E. Silverman
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Carol Moore
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Cora Davis
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - L. Christine Turtzo
- National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Ramon Diaz-Arrastia
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kimbra Kenney
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD, United States
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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18
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Sobczyk O, Sayin ES, Sam K, Poublanc J, Duffin J, Fisher JA, Mikulis DJ. The Reproducibility of Cerebrovascular Reactivity Across MRI Scanners. Front Physiol 2021; 12:668662. [PMID: 34025455 PMCID: PMC8134667 DOI: 10.3389/fphys.2021.668662] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Cerebrovascular reactivity (CVR) is defined as the ratio of the cerebral blood flow (CBF) response to an increase in a vasoactive stimulus. We used changes in blood oxygenation level-dependent (BOLD) MRI as surrogates for changes of CBF, and standardized quantitative changes in arterial partial pressure of carbon dioxide as the stimulus. Despite uniform stimulus and test conditions, differences in voxel-wise BOLD changes between testing sites may remain, attributable to physiologic and machine variability. We generated a reference atlas of normal CVR metrics (voxel-wise mean and SD) for each of two sites. We hypothesized that there would be no significant differences in CVR between the two atlases enabling each atlas to be used at any site. A total of 69 healthy subjects were tested to create site-specific atlases, with 20 of those individuals tested at both sites. 38 subjects were scanned at Site 1 (17F, 37.5 ± 16.8 y) and 51 subjects were tested at Site 2 (22F, 40.9 ± 17.4 y). MRI platforms were: Site 1, 3T Magnetom Skyra Siemens scanner with 20-channel head and neck coil; and Site 2, 3T HDx Signa GE scanner with 8-channel head coil. To construct the atlases, test results of individual subjects were co-registered into a standard space and voxel-wise mean and SD CVR metrics were calculated. Map comparisons of z scores found no significant differences between white matter or gray matter in the 20 subjects scanned at both sites when analyzed with either atlas. We conclude that individual CVR testing, and atlas generation are compatible across sites provided that standardized respiratory stimuli and BOLD MRI scan parameters are used. This enables the use of a single atlas to score the normality of CVR metrics across multiple sites.
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Affiliation(s)
- Olivia Sobczyk
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory, University Health Network, Toronto, ON, Canada.,Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Ece Su Sayin
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Kevin Sam
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Julien Poublanc
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory, University Health Network, Toronto, ON, Canada
| | - James Duffin
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Joseph A Fisher
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - David J Mikulis
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory, University Health Network, Toronto, ON, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
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19
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Champagne AA, Coverdale NS, Fernandez-Ruiz J, Mark CI, Cook DJ. Compromised resting cerebral metabolism after sport-related concussion: A calibrated MRI study. Brain Imaging Behav 2021; 15:133-146. [PMID: 32307673 DOI: 10.1007/s11682-019-00240-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Altered resting cerebral blood flow (CBF0) in the acute phase post-concussion may contribute to neurobehavioral deficiencies, often reported weeks after the injury. However, in addition to changes in CBF0, little is known about other physiological mechanisms that may be disturbed within the cerebrovasculature. The aim of this study was to assess whether changes in baseline perfusion following sport-related concussion (SRC) were co-localized with changes in cerebral metabolic demand. Forty-two subjects (15 SRC patients 8.0 ± 4.6 days post-injury and 27 age-matched healthy control athletes) were studied cross-sectionally. CBF0, cerebrovascular reactivity (CVR), resting oxygen extraction (OEF0) and cerebral metabolic rate of oxygen consumption (CMRO2|0) were measured using a combination of hypercapnic and hyperoxic breathing protocols, and the biophysical model developed in calibrated MRI. Blood oxygenation level dependent and perfusion data were acquired simultaneously using a dual-echo arterial spin labelling sequence. SRC patients showed significant decreases in CBF0 spread across the grey-matter (P < 0.05, corrected), and these differences were also confounded by the effects of baseline end-tidal CO2 (P < 0.0001). Lower perfusion was co-localized with reductions in regional CMRO2|0 (P = 0.006) post-SRC, despite finding no group-differences in OEF0 (P = 0.800). Higher CVR within voxels showing differences in CBF was also observed in the SRC group (P = 0.001), compared to controls. Reductions in metabolic demand despite no significant changes in OEF0 suggests that hypoperfusion post-SRC may reflect compromised metabolic function after the injury. These results provide novel insight about the possible pathophysiological mechanisms underlying concussion that may affect the clinical recovery of athletes after sport-related head injuries.
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Affiliation(s)
- Allen A Champagne
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Nicole S Coverdale
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Juan Fernandez-Ruiz
- Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de México, 04510, Ciudad de México, Mexico
| | - Clarisse I Mark
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, K7L 3N6, Canada
| | - Douglas J Cook
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, K7L 3N6, Canada.
- Department of Surgery, Queen's University, Room 232, 18 Stuart St., Kingston, ON, K7L 3N6, Canada.
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20
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Hemodialysis Patients Have Impaired Cerebrovascular Reactivity to CO 2 Compared to Chronic Kidney Disease Patients and Healthy Controls: A Pilot Study. Kidney Int Rep 2021; 6:1868-1877. [PMID: 34307981 PMCID: PMC8258459 DOI: 10.1016/j.ekir.2021.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/11/2021] [Accepted: 04/05/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction Recurrent hemodialysis (HD)–induced ischemia has emerged as a mechanism responsible for cognitive impairment in HD patients. Impairment of cerebrovascular function in HD patients may render the brain vulnerable to HD-induced ischemic injury. Cerebrovascular reactivity to CO2 (CVR) is a noninvasive marker of cerebrovascular function. Whether CVR is impaired in HD patients is unknown. In this study, we compared CVR between healthy participants, HD patients, and chronic kidney disease (CKD) patients not yet requiring dialysis. Methods This was a single-center prospective observational study carried out at Kidney Clinical Research Unit in London, Canada. We used carefully controlled hypercapnia to interrogate brain vasomotor control. Transcranial Doppler was combined with 10–mm Hg step changes in CO2 from baseline to hypercapnia (intervention) and back to baseline (recovery) to assess CVR in 8 HD, 10 CKD, and 17 heathy participants. Results HD patients had lower CVR than CKD or healthy participants during both intervention and recovery (P < 0.0001). There were no differences in CVR between healthy and CKD participants during either intervention (P = 0.88) or recovery (P = 0.99). The impaired CVR in HD patients was independent of CO2-induced changes in blood pressure, heart rate, cardiac output, or dialysis vintage. In the CKD group, CVR was not associated with the estimated glomerular filtration rate. Conclusions Our study shows that HD patients have impaired CVR relative to CKD and healthy participants. This renders HD patients vulnerable to ischemic injury during circulatory stress of dialysis and may contribute to the pathogenesis of cognitive impairment.
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21
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Fisher JA, Mikulis DJ. Cerebrovascular Reactivity: Purpose, Optimizing Methods, and Limitations to Interpretation - A Personal 20-Year Odyssey of (Re)searching. Front Physiol 2021; 12:629651. [PMID: 33868001 PMCID: PMC8047146 DOI: 10.3389/fphys.2021.629651] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 03/10/2021] [Indexed: 11/18/2022] Open
Abstract
The brain is a neurovascular organ. A stimulus-response approach is effective in interrogating the physiology of its vasculature. Ideally, the stimulus is standardized across patients, and in a single patient over time. We developed a standard stimulus and attempted to measure, classify, and interpret the many forms of responses. Over the past 20 years, our work has delivered nuanced insights into normal cerebral vascular physiology, as well as adaptive physiological responses in the presence of disease. The trajectory of our understanding did not follow a logical linear progression; rather, it emerged as a coalescence of new, old, and previously dismissed, ideas that had accumulated over time. In this essay, we review what we believe were our most valuable - and sometimes controversial insights during our two decades-long journey.
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Affiliation(s)
- Joseph A. Fisher
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Department of Anaesthesia and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
| | - David J. Mikulis
- Joint Department of Medical Imaging and the Functional Neuroimaging Lab, University Health Network, Toronto, ON, Canada
- The Joint Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
- Techna Institute & Koerner Scientist in MR Imaging, University Health Network, Toronto, ON, Canada
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22
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Sleight E, Stringer MS, Marshall I, Wardlaw JM, Thrippleton MJ. Cerebrovascular Reactivity Measurement Using Magnetic Resonance Imaging: A Systematic Review. Front Physiol 2021; 12:643468. [PMID: 33716793 PMCID: PMC7947694 DOI: 10.3389/fphys.2021.643468] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/01/2021] [Indexed: 12/27/2022] Open
Abstract
Cerebrovascular reactivity (CVR) magnetic resonance imaging (MRI) probes cerebral haemodynamic changes in response to a vasodilatory stimulus. CVR closely relates to the health of the vasculature and is therefore a key parameter for studying cerebrovascular diseases such as stroke, small vessel disease and dementias. MRI allows in vivo measurement of CVR but several different methods have been presented in the literature, differing in pulse sequence, hardware requirements, stimulus and image processing technique. We systematically reviewed publications measuring CVR using MRI up to June 2020, identifying 235 relevant papers. We summarised the acquisition methods, experimental parameters, hardware and CVR quantification approaches used, clinical populations investigated, and corresponding summary CVR measures. CVR was investigated in many pathologies such as steno-occlusive diseases, dementia and small vessel disease and is generally lower in patients than in healthy controls. Blood oxygen level dependent (BOLD) acquisitions with fixed inspired CO2 gas or end-tidal CO2 forcing stimulus are the most commonly used methods. General linear modelling of the MRI signal with end-tidal CO2 as the regressor is the most frequently used method to compute CVR. Our survey of CVR measurement approaches and applications will help researchers to identify good practice and provide objective information to inform the development of future consensus recommendations.
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Affiliation(s)
- Emilie Sleight
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom,UK Dementia Research Institute, Edinburgh, United Kingdom
| | - Michael S. Stringer
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom,UK Dementia Research Institute, Edinburgh, United Kingdom,*Correspondence: Michael S. Stringer
| | - Ian Marshall
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom,UK Dementia Research Institute, Edinburgh, United Kingdom
| | - Joanna M. Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom,UK Dementia Research Institute, Edinburgh, United Kingdom
| | - Michael J. Thrippleton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom,UK Dementia Research Institute, Edinburgh, United Kingdom
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23
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Shafi R, Poublanc J, Venkatraghavan L, Crawley AP, Sobczyk O, McKetton L, Bayley M, Chandra T, Foster E, Ruttan L, Comper P, Tartaglia MC, Tator CH, Duffin J, Mutch WA, Fisher J, Mikulis DJ. A Promising Subject-Level Classification Model for Acute Concussion Based on Cerebrovascular Reactivity Metrics. J Neurotrauma 2020; 38:1036-1047. [PMID: 33096952 DOI: 10.1089/neu.2020.7272] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Concussion imaging research has primarily focused on neuronal disruption with lesser emphasis directed toward vascular dysfunction. However, blood flow metrics may be more sensitive than measures of neuronal integrity. Vascular dysfunction can be assessed by measuring cerebrovascular reactivity (CVR)-the change in cerebral blood flow per unit change in vasodilatory stimulus. CVR metrics, including speed and magnitude of flow responses to a standardized well-controlled vasoactive stimulus, are potentially useful for assessing individual subjects following concussion given that blood flow dysregulation is known to occur with traumatic brain injury. We assessed changes in CVR metrics to a standardized vasodilatory stimulus during the acute phase of concussion. Using a case control design, 20 concussed participants and 20 healthy controls (HCs) underwent CVR assessment measuring blood oxygen-level dependent (BOLD) magnetic resonance imaging using precise changes in end-tidal partial pressure of CO2 (PETCO2). Metrics were calculated for the whole brain, gray matter (GM), and white matter (WM) using sex-stratification. A leave-one-out receiver operating characteristic (ROC) analysis classified concussed from HCs based on CVR metrics. CVR magnitude was greater and speed of response faster in concussed participants relative to HCs, with WM showing higher classification accuracy compared with GM. ROC analysis for WM-CVR metrics revealed an area under the curve of 0.94 in males and 0.90 in females for speed and magnitude of response respectively. These greater than normal responses to a vasodilatory stimulus warrant further investigation to compare the predictive ability of CVR metrics against structural injury metrics for diagnosis and prognosis in acute concussion.
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Affiliation(s)
- Reema Shafi
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Julien Poublanc
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Lashmi Venkatraghavan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adrian P Crawley
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Olivia Sobczyk
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Larissa McKetton
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Mark Bayley
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Tharshini Chandra
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Evan Foster
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Lesley Ruttan
- Graduate Department of Psychological Clinical Science, University of Toronto, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Canadian Concussion Center, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Paul Comper
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Maria Carmela Tartaglia
- Department of Medicine (Neurology), University of Toronto, Toronto, Ontario, Canada.,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Tanz Center for Research in Neurodegenerative Diseases, Toronto, Ontario, Canada.,Canadian Concussion Center, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Charles H Tator
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Canadian Concussion Center, Toronto Western Hospital, Toronto, Ontario, Canada
| | - James Duffin
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - W Alan Mutch
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joseph Fisher
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - David J Mikulis
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.,Canadian Concussion Center, Toronto Western Hospital, Toronto, Ontario, Canada
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24
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Dodd AB, Lu H, Wertz CJ, Ling JM, Shaff NA, Wasserott BC, Meier TB, Park G, Oglesbee SJ, Phillips JP, Campbell RA, Liu P, Mayer AR. Persistent alterations in cerebrovascular reactivity in response to hypercapnia following pediatric mild traumatic brain injury. J Cereb Blood Flow Metab 2020; 40:2491-2504. [PMID: 31903838 PMCID: PMC7820694 DOI: 10.1177/0271678x19896883] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Much attention has been paid to the effects of mild traumatic brain injury (mTBI) on cerebrovascular reactivity in adult populations, yet it remains understudied in pediatric injury. In this study, 30 adolescents (12-18 years old) with pediatric mTBI (pmTBI) and 35 age- and sex-matched healthy controls (HC) underwent clinical and neuroimaging assessments during sub-acute (6.9 ± 2.2 days) and early chronic (120.4 ± 11.7 days) phases of injury. Relative to controls, pmTBI reported greater initial post-concussion symptoms, headache, pain, and anxiety, resolving by four months post-injury. Patients reported increased sleep issues and exhibited deficits in processing speed and attention across both visits. In grey-white matter interface areas throughout the brain, pmTBI displayed increased maximal fit/amplitude of a time-shifted end-tidal CO2 regressor to blood oxygen-level dependent response relative to HC, as well as increased latency to maximal fit. The alterations persisted through the early chronic phase of injury, with maximal fit being associated with complaints of ongoing sleep disturbances during post hoc analyses but not cognitive measures of processing speed or attention. Collectively, these findings suggest that deficits in the speed and degree of cerebrovascular reactivity may persist longer than current conceptualizations about clinical recovery within 30 days.
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Affiliation(s)
- Andrew B Dodd
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, USA
| | - Hanzhang Lu
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher J Wertz
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, USA
| | - Josef M Ling
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, USA
| | - Nicholas A Shaff
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, USA
| | - Benjamin C Wasserott
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, USA
| | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Departments of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Grace Park
- Department of Pediatric Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Scott J Oglesbee
- Department of Pediatric Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
| | - John P Phillips
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Richard A Campbell
- Department of Psychiatry, University of New Mexico, Albuquerque, NM, USA
| | - Peiying Liu
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew R Mayer
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
- Department of Psychiatry, University of New Mexico, Albuquerque, NM, USA
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
- Andrew R Mayer, The Mind Research Network, Pete & Nancy Domenici Hall, 1101 Yale Blvd. NE, Albuquerque, NM 87106, USA.
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25
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Rausa VC, Shapiro J, Seal ML, Davis GA, Anderson V, Babl FE, Veal R, Parkin G, Ryan NP, Takagi M. Neuroimaging in paediatric mild traumatic brain injury: a systematic review. Neurosci Biobehav Rev 2020; 118:643-653. [PMID: 32905817 DOI: 10.1016/j.neubiorev.2020.08.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 08/02/2020] [Accepted: 08/29/2020] [Indexed: 01/05/2023]
Abstract
Neuroimaging is being increasingly applied to the study of paediatric mild traumatic brain injury (mTBI) to uncover the neurobiological correlates of delayed recovery post-injury. The aims of this systematic review were to: (i) evaluate the neuroimaging research investigating neuropathology post-mTBI in children and adolescents from 0-18 years, (ii) assess the relationship between advanced neuroimaging abnormalities and PCS in children, (iii) assess the quality of the evidence by evaluating study methodology and reporting against best practice guidelines, and (iv) provide directions for future research. A literature search of MEDLINE, PsycINFO, EMBASE, and PubMed was conducted. Abstracts and titles were screened, followed by full review of remaining articles where specific eligibility criteria were applied. This systematic review identified 58 imaging studies which met criteria. Based on several factors including methodological heterogeneity and relatively small sample sizes, the literature currently provides insufficient evidence to draw meaningful conclusions about the relationship between MRI findings and clinical outcomes. Future research is needed which incorporates prospective, longitudinal designs, minimises potential confounds and utilises multimodal imaging techniques.
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Affiliation(s)
- Vanessa C Rausa
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
| | - Jesse Shapiro
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia.
| | - Marc L Seal
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia.
| | - Gavin A Davis
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
| | - Vicki Anderson
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia; Psychology Service, The Royal Children's Hospital, Melbourne, Australia.
| | - Franz E Babl
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia.
| | - Ryan Veal
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
| | - Georgia Parkin
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
| | - Nicholas P Ryan
- Department of Paediatrics, University of Melbourne, Victoria, Australia; Cognitive Neuroscience Unit, Deakin University, Geelong, Australia.
| | - Michael Takagi
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Melbourne School of Psychological Sciences, University of Melbourne, Victoria, Australia.
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26
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27
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Puig J, Ellis MJ, Kornelsen J, Figley TD, Figley CR, Daunis-i-Estadella P, Mutch WAC, Essig M. Magnetic Resonance Imaging Biomarkers of Brain Connectivity in Predicting Outcome after Mild Traumatic Brain Injury: A Systematic Review. J Neurotrauma 2020; 37:1761-1776. [DOI: 10.1089/neu.2019.6623] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Josep Puig
- Department of Radiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Radiology (IDI), Girona Biomedical Research Institute (IDIBGI), Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain
| | - Michael J. Ellis
- Canada North Concussion Network, Winnipeg, Manitoba, Canada
- Department of Surgery and Pediatrics and Child Health, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Pan Am Concussion Program, Winnipeg, Manitoba, Canada
- Childrens Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Jennifer Kornelsen
- Department of Radiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg Health Sciences Center, Winnipeg, Manitoba, Canada
- Department of Physiology and Pathophysiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Teresa D. Figley
- Department of Radiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg Health Sciences Center, Winnipeg, Manitoba, Canada
| | - Chase R. Figley
- Department of Radiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg Health Sciences Center, Winnipeg, Manitoba, Canada
- Department of Physiology and Pathophysiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Pepus Daunis-i-Estadella
- Department of Computer Science, Applied Mathematics and Statistics, Universitat de Girona, Girona, Spain
| | - W. Alan C. Mutch
- Canada North Concussion Network, Winnipeg, Manitoba, Canada
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg Health Sciences Center, Winnipeg, Manitoba, Canada
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marco Essig
- Department of Radiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Canada North Concussion Network, Winnipeg, Manitoba, Canada
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg Health Sciences Center, Winnipeg, Manitoba, Canada
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28
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Churchill NW, Hutchison MG, Graham SJ, Schweizer TA. Cerebrovascular Reactivity After Sport Concussion: From Acute Injury to 1 Year After Medical Clearance. Front Neurol 2020; 11:558. [PMID: 32760336 PMCID: PMC7371921 DOI: 10.3389/fneur.2020.00558] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/15/2020] [Indexed: 01/26/2023] Open
Abstract
Neuroimaging has identified significant disturbances in cerebrovascular reactivity (CVR) in the early symptomatic phase of sport-related concussion. However, less is known about how whole-brain alterations in CVR evolve after concussion and whether they remain present beyond medical clearance to return to play (RTP). In the present study, CVR was evaluated using blood-oxygenation-level-dependent functional magnetic resonance imaging (BOLD fMRI) during a respiratory challenge. Imaging data were collected for 110 university-level athletes, including 39 concussed athletes and 71 athletic controls. The concussed athletes were imaged at the acute phase of injury (1–7 days post-injury), the subacute phase (8-14 days post-injury), medical clearance to RTP, 1 month post-RTP, and 1 year post-RTP. Enhanced negative BOLD response to controlled breathing was seen at acute injury, with attenuation of the effect mainly occurring by 1 year post-RTP. Secondary analyses showed that greater symptom severity and prolonged recovery were associated with enhanced BOLD response in the acute phase of injury, but a more attenuated BOLD response in the subacute phase. This study provides novel information characterizing the CVR response after concussion and shows CVR to be a sensitive technique for evaluating long-term brain recovery.
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Affiliation(s)
- Nathan W Churchill
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada.,Neuroscience Research Program, St. Michael's Hospital, Toronto, ON, Canada
| | - Michael G Hutchison
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Simon J Graham
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.,Physical Sciences Platform, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Tom A Schweizer
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, ON, Canada.,Neuroscience Research Program, St. Michael's Hospital, Toronto, ON, Canada.,Faculty of Medicine (Neurosurgery) University of Toronto, Toronto, ON, Canada.,The Institute of Biomaterials & Biomedical Engineering (IBBME) at the University of Toronto, Toronto, ON, Canada
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29
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Mutch WAC, El-Gabalawy R, Ryner L, Puig J, Essig M, Kilborn K, Fidler K, Graham MR. Brain BOLD MRI O 2 and CO 2 stress testing: implications for perioperative neurocognitive disorder following surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:76. [PMID: 32131878 PMCID: PMC7057494 DOI: 10.1186/s13054-020-2800-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 02/18/2020] [Indexed: 12/17/2022]
Abstract
Background Mechanical ventilation to alter and improve respiratory gases is a fundamental feature of critical care and intraoperative anesthesia management. The range of inspired O2 and expired CO2 during patient management can significantly deviate from values in the healthy awake state. It has long been appreciated that hyperoxia can have deleterious effects on organs, especially the lung and retina. Recent work shows intraoperative end-tidal (ET) CO2 management influences the incidence of perioperative neurocognitive disorder (POND). The interaction of O2 and CO2 on cerebral blood flow (CBF) and oxygenation with alterations common in the critical care and operating room environments has not been well studied. Methods We examine the effects of controlled alterations in both ET O2 and CO2 on cerebral blood flow (CBF) in awake adults using blood oxygenation level-dependent (BOLD) and pseudo-continuous arterial spin labeling (pCASL) MRI. Twelve healthy adults had BOLD and CBF responses measured to alterations in ET CO2 and O2 in various combinations commonly observed during anesthesia. Results Dynamic alterations in regional BOLD and CBF were seen in all subjects with expected and inverse brain voxel responses to both stimuli. These effects were incremental and rapid (within seconds). The most dramatic effects were seen with combined hyperoxia and hypocapnia. Inverse responses increased with age suggesting greater risk. Conclusions Human CBF responds dramatically to alterations in ET gas tensions commonly seen during anesthesia and in critical care. Such alterations may contribute to delirium following surgery and under certain circumstances in the critical care environment. Trial registration ClincialTrials.gov NCT02126215 for some components of the study. First registered April 29, 2014.
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Affiliation(s)
- W Alan C Mutch
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, 2nd Floor, Harry Medovy House, 671 William Ave., Winnipeg, MB, R3E 0Z2, Canada. .,Canada North Concussion Network, .
| | - Renée El-Gabalawy
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, 2nd Floor, Harry Medovy House, 671 William Ave., Winnipeg, MB, R3E 0Z2, Canada.,Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Canada
| | - Lawrence Ryner
- Canada North Concussion Network.,Department of Radiology, University of Manitoba, Winnipeg, Canada.,Department of Physics, University of Manitoba, Winnipeg, Canada
| | - Josep Puig
- Department of Radiology, University of Manitoba, Winnipeg, Canada
| | - Marco Essig
- Canada North Concussion Network.,Department of Radiology, University of Manitoba, Winnipeg, Canada
| | - Kayla Kilborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, 2nd Floor, Harry Medovy House, 671 William Ave., Winnipeg, MB, R3E 0Z2, Canada
| | - Kelsi Fidler
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, 2nd Floor, Harry Medovy House, 671 William Ave., Winnipeg, MB, R3E 0Z2, Canada
| | - M Ruth Graham
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, 2nd Floor, Harry Medovy House, 671 William Ave., Winnipeg, MB, R3E 0Z2, Canada.,Canada North Concussion Network
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30
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Champagne AA, Coverdale NS, Ross A, Chen Y, Murray CI, Dubowitz D, Cook DJ. Multi-modal normalization of resting-state using local physiology reduces changes in functional connectivity patterns observed in mTBI patients. Neuroimage Clin 2020; 26:102204. [PMID: 32058317 PMCID: PMC7013121 DOI: 10.1016/j.nicl.2020.102204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 12/25/2022]
Abstract
Blood oxygenation level dependent (BOLD) resting-state functional magnetic resonance imaging (rs-fMRI) may serve as a sensitive marker to identify possible changes in the architecture of large-scale networks following mild traumatic brain injury (mTBI). Differences in functional connectivity (FC) measurements derived from BOLD rs-fMRI may however be confounded by changes in local cerebrovascular physiology and neurovascular coupling mechanisms, without changes in the underlying neuronally driven connectivity of networks. In this study, multi-modal neuroimaging data including BOLD rs-fMRI, baseline cerebral blood flow (CBF0) and cerebrovascular reactivity (CVR; acquired using a hypercapnic gas breathing challenge) were collected in 23 subjects with reported mTBI (14.6±14.9 months post-injury) and 27 age-matched healthy controls. Despite no group differences in CVR within the networks of interest (P > 0.05, corrected), significantly higher CBF0 was documented in the mTBI subjects (P < 0.05, corrected), relative to the controls. A normalization method designed to account for differences in CBF0 post-mTBI was introduced to evaluate the effects of such an approach on reported group differences in network connectivity. Inclusion of regional perfusion measurements in the computation of correlation coefficients within and across large-scale networks narrowed the differences in FC between the groups, suggesting that this approach may elucidate unique changes in connectivity post-mTBI while accounting for shared variance with CBF0. Altogether, our results provide a strong paradigm supporting the need to account for changes in physiological modulators of BOLD in order to expand our understanding of the effects of brain injury on large-scale FC of cortical networks.
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Affiliation(s)
- Allen A Champagne
- Centre for Neuroscience Studies, Room 260, Queen's University, Kingston ON K7L 3N6 Canada.
| | - Nicole S Coverdale
- Centre for Neuroscience Studies, Room 260, Queen's University, Kingston ON K7L 3N6 Canada.
| | - Andrew Ross
- Performance Phenomics, 180 John St., Toronto ON M5T 1 × 5 Canada.
| | - Yining Chen
- Centre for Neuroscience Studies, Room 260, Queen's University, Kingston ON K7L 3N6 Canada.
| | | | - David Dubowitz
- Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand.
| | - Douglas J Cook
- Centre for Neuroscience Studies, Room 260, Queen's University, Kingston ON K7L 3N6 Canada; Department of Surgery, Queen's University, Kingston, ON, Canada.
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Co-localized impaired regional cerebrovascular reactivity in chronic concussion is associated with BOLD activation differences during a working memory task. Brain Imaging Behav 2020; 14:2438-2449. [PMID: 31903527 DOI: 10.1007/s11682-019-00194-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The purpose of this study was to quantify differences in blood oxygen level dependent (BOLD) activation on a working memory task, baseline cerebral blood flow (CBF0), and cerebrovascular reactivity (CVR) between participants with and without a history of concussion. A dual-echo pseudo-continuous arterial spin labelling (pCASL) sequence was performed on a group of 10 subjects with a previous concussion (126 ± 15 days prior) and on a control group (n = 10) during a visual working memory protocol. A separate dual-echo pCASL sequence was used to derive CVR and CBF0 measurements from a boxcar hypercapnic breathing protocol. Brain areas with significant activation differences on the working memory task between groups were identified and combined as an aggregate region of interest for CBF and CVR analyses. Areas of reduced BOLD activation during the working memory task in the concussed group included the ventral anterior cingulate cortex (ACC), the medial temporal gyrus (MTG), and the lateral occipital cortex in two loci. A single area of increased activation was located in the parietal operculum. Further analyses of CBF0 and CVR in these regions revealed reduced CVR in the concussed group in the MTG and ACC, while CBF0 did not differ. The differences in CVR between the two groups in these regions suggest that concussive injury may result in microvascular dysfunction. In turn, the decreased BOLD response during the task could be due to altered neurovascular coupling, rather than an impairment in neural activation alone. However, in other regions associated with working memory, unchanged CBF0 and CVR suggests that neural injury also persists after concussion. In the future, BOLD results should be normalized to CVR in order achieve a clearer understanding of the neural and vascular contributions to the differences in the signal.
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Amyot F, Kenney K, Spessert E, Moore C, Haber M, Silverman E, Gandjbakhche A, Diaz-Arrastia R. Assessment of cerebrovascular dysfunction after traumatic brain injury with fMRI and fNIRS. Neuroimage Clin 2019; 25:102086. [PMID: 31790877 PMCID: PMC6909332 DOI: 10.1016/j.nicl.2019.102086] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 11/07/2019] [Accepted: 11/09/2019] [Indexed: 11/26/2022]
Abstract
Traumatic cerebral vascular injury (TCVI) is a frequent, but under-recognized, endophenotype of traumatic brain injury (TBI). It likely contributes to functional deficits after TBI and TBI-related chronic disability, and represents an attractive target for targeted therapeutic interventions. The aim of this prospective study is to assess microvascular injury/dysfunction in chronic TBI by measuring cerebral vascular reactivity (CVR) by 2 methods, functional magnetic resonance imaging (fMRI) and functional Near InfraRed Spectroscopy (fNIRS) imaging, as each has attractive features relevant to clinical utility. 42 subjects (27 chronic TBI, 15 age- and gender-matched non-TBI volunteers) were enrolled and underwent outpatient CVR testing by 2 methods, MRI-BOLD and fNIRS, each with hypercapnia challenge, a neuropsychological testing battery, and symptom survey questionnaires. Chronic TBI subjects showed a significant reduction in global CVR compared to HC (p < 0.0001). Mean CVR measures by fMRI were 0.225 ± 0.014 and 0.183 ± 0.026 %BOLD/mmHg for non-TBI and TBI subjects respectively and 12.3 ± 1.8 and 9.2 ± 1.7 mM/mmHg by fNIRS for non-TBI versus TBI subjects respectively. Global CVR measured by fNIRS imaging correlates with results by MRI-BOLD (R = 0.5). Focal CVR deficits seen on CVR maps by fMRI are also observed in the same areas by fNIRS in the frontal regions. Global CVR is significantly lower in chronic TBI patients and is reliably measured by both fMRI and fNIRS, the former with better spatial and the latter with better temporal resolution. Both methods show promise as non-invasive measures of CVR function and microvascular integrity after TBI.
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Affiliation(s)
- Franck Amyot
- Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Center for Neuroscience and Regenerative Medicine, Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Kimbra Kenney
- Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Center for Neuroscience and Regenerative Medicine, Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Emily Spessert
- Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Center for Neuroscience and Regenerative Medicine, Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Carol Moore
- Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Center for Neuroscience and Regenerative Medicine, Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Margalit Haber
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Erika Silverman
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Amir Gandjbakhche
- Section on Analytical and Functional Biophotonics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Ramon Diaz-Arrastia
- Center for Neuroscience and Regenerative Medicine, Department of Neurology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia
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33
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Wu L, Chung JY, Saith S, Tozzi L, Buckley EM, Sanders B, Franceschini MA, Lule S, Izzy S, Lok J, Edmiston WJ, McAllister LM, Mebane S, Jin G, Lu J, Sherwood JS, Willwerth S, Hickman S, Khoury JE, Lo EH, Kaplan D, Whalen MJ. Repetitive head injury in adolescent mice: A role for vascular inflammation. J Cereb Blood Flow Metab 2019; 39:2196-2209. [PMID: 30001646 PMCID: PMC6827111 DOI: 10.1177/0271678x18786633] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/07/2018] [Accepted: 05/25/2018] [Indexed: 12/14/2022]
Abstract
Repetitive mild traumatic brain injury during adolescence can induce neurological dysfunction through undefined mechanisms. Interleukin-1 (IL-1) contributes to experimental adult diffuse and contusion TBI models, and IL-1 antagonists have entered clinical trials for severe TBI in adults; however, no such data exist for adolescent TBI. We developed an adolescent mouse repetitive closed head injury (rCHI) model to test the role of IL-1 family members in post-injury neurological outcome. Compared to one CHI, three daily injuries (3HD) produced acute and chronic learning deficits and emergence of hyperactivity, without detectable gliosis, neurodegeneration, brain atrophy, and white matter loss at one year. Mature IL-1β and IL-18 were induced in brain endothelium in 3HD but not 1HD, three hit weekly, or sham animals. IL-1β processing was induced cell-autonomously in three-dimensional human endothelial cell cultures subjected to in vitro concussive trauma. Mice deficient in IL-1 receptor-1 or caspase-1 had improved post-injury Morris water maze performance. Repetitive mild CHI in adolescent mice may induce behavioral deficits in the absence of significant histopathology. The endothelium is a potential source of IL-1β and IL-18 in rCHI, and IL-1 family members may be therapeutic targets to reduce or prevent neurological dysfunction after repetitive mild TBI in adolescents.
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Affiliation(s)
- Limin Wu
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Joon Y Chung
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Shivani Saith
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Lorenzo Tozzi
- Department of Biomedical Engineering,
Tufts University, Medford, MA, USA
| | - Erin M Buckley
- Wallace H. Coulter Department of
Biomedical Engineering, Georgia Institute of Technology and
Emory
University, Atlanta, GA, USA
- Department of Pediatrics,
Emory
University, Atlanta, GA, USA
| | - Bharat Sanders
- Wallace H. Coulter Department of
Biomedical Engineering, Georgia Institute of Technology and
Emory
University, Atlanta, GA, USA
| | | | - Sevda Lule
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Saef Izzy
- Department of Neurology, Brigham and
Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Josephine Lok
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - William J Edmiston
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Lauren M McAllister
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Sloane Mebane
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Gina Jin
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jiaxi Lu
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - John S Sherwood
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah Willwerth
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne Hickman
- Department of Medicine, Center for
Immunology and Inflammatory Diseases, Harvard Medical School, Massachusetts General
Hospital, Boston, MA, USA
| | - Joseph El Khoury
- Department of Medicine, Center for
Immunology and Inflammatory Diseases, Harvard Medical School, Massachusetts General
Hospital, Boston, MA, USA
| | - Eng H Lo
- Department of Radiology, Massachusetts
General Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts
General Hospital, Boston, MA, USA
| | - David Kaplan
- Department of Biomedical Engineering,
Tufts University, Medford, MA, USA
| | - Michael J Whalen
- Neuroscience Center, Harvard Medical
School, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Pediatrics, Harvard
Medical School, Massachusetts General Hospital, Boston, MA, USA
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Sandsmark DK, Bashir A, Wellington CL, Diaz-Arrastia R. Cerebral Microvascular Injury: A Potentially Treatable Endophenotype of Traumatic Brain Injury-Induced Neurodegeneration. Neuron 2019; 103:367-379. [PMID: 31394062 PMCID: PMC6688649 DOI: 10.1016/j.neuron.2019.06.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/10/2019] [Accepted: 06/03/2019] [Indexed: 02/08/2023]
Abstract
Traumatic brain injury (TBI) is one the most common human afflictions, contributing to long-term disability in survivors. Emerging data indicate that functional improvement or deterioration can occur years after TBI. In this regard, TBI is recognized as risk factor for late-life neurodegenerative disorders. TBI encompasses a heterogeneous disease process in which diverse injury subtypes and multiple molecular mechanisms overlap. To develop precision medicine approaches where specific pathobiological processes are targeted by mechanistically appropriate therapies, techniques to identify and measure these subtypes are needed. Traumatic microvascular injury is a common but relatively understudied TBI endophenotype. In this review, we describe evidence of microvascular dysfunction in human and animal TBI, explore the role of vascular dysfunction in neurodegenerative disease, and discuss potential opportunities for vascular-directed therapies in ameliorating TBI-related neurodegeneration. We discuss the therapeutic potential of vascular-directed therapies in TBI and the use and limitations of preclinical models to explore these therapies.
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Affiliation(s)
| | - Asma Bashir
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada; Graduate Program in Neuroscience, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl L Wellington
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada; Djavad Mowafaghian Centre for Brain Health, School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
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35
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Champagne AA, Coverdale NS, Germuska M, Cook DJ. Multi-parametric analysis reveals metabolic and vascular effects driving differences in BOLD-based cerebrovascular reactivity associated with a history of sport concussion. Brain Inj 2019; 33:1479-1489. [PMID: 31354054 PMCID: PMC7115911 DOI: 10.1080/02699052.2019.1644375] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 07/12/2019] [Indexed: 12/19/2022]
Abstract
Objective: Identify alterations in cerebrovascular reactivity (CVR) based on the history of sport-related concussion (SRC). Further explore possible mechanisms underlying differences in vascular physiology using hemodynamic parameters modeled using calibrated magnetic resonance imaging (MRI). Method: End-tidal targeting and dual-echo MRI were combined to probe hypercapnic and hyperoxic challenges in athletes with (n = 32) and without (n = 31) a history of SRC. Concurrent blood oxygenation level dependent (BOLD) and arterial spin labeling (ASL) data were used to compute BOLD-CVR, ASL-CVR, and other physiological parameters including resting oxygen extraction fraction (OEF0) and cerebral blood volume (CBV0). Multiple linear and logistic regressions were then used to identify dominant parameters driving group-differences in BOLD-CVR. Results: Robust evidence for elevated BOLD-CVR were found in athletes with SRC history spreading over parts of the cortical hemispheres. Follow-up analyses showed co-localized differences in ASL-CVR (representing modulation of cerebral blood flow) and hemodynamic factors representing static vascular (i.e., CBV0) and metabolic (i.e., OEF0) effects suggesting that group-based differences in BOLD-CVR may be driven by a mixed effect from factors with vascular and metabolic origins. Conclusion: These results emphasize that while BOLD-CVR offers promises as a surrogate non-specific biomarker for cerebrovascular health following SRC, multiple hemodynamic parameters can affect its relative measurements. Abbreviations: [dHb]: concentration of deoxyhemoglobin; AFNI: Analysis of Functional NeuroImages ( https://afni.nimh.nih.gov ); ASL: arterial spin labeling; BIG: position group: defensive and offensive linemen; BIG-SKILL: position group: full backs, linebackers, running backs, tight-ends; BOLD: blood oxygen level dependent; CBF: cerebral blood flow; CMRO2: cerebral metabolic rate of oxygen consumption; CTL: group of control subjects; CVR: cerebrovascular reactivity; fMRI: functional magnetic resonance imaging; FSL: FMRIB software library ( https://fsl.fmrib.ox.ac.uk/fsl/fslwiki/ ); HC: hypercapnia; HO: hyperoxia; HX: group with history of concussion; M: maximal theoretical BOLD signal upon complete removal of venous dHb; pCASL: pseudo-continuous arterial spin labeling; PETCO2: end-tidal carbon dioxide; PETO2: end-tidal oxygen; SCAT: sport-concussion assessment tool; SKILL: position group: defensive backs, kickers, quarterbacks, safeties, wide-receivers; SRC: sport-related concussion.
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Affiliation(s)
- Allen A. Champagne
- Centre for Neuroscience Studies, Queen’s University, Kingston, ON, Canada
| | | | - Michael Germuska
- Cardiff University Brain Research Imaging Center, Cardiff University, Cardiff, United Kingdom
| | - Douglas J. Cook
- Centre for Neuroscience Studies, Queen’s University, Kingston, ON, Canada
- Department of Surgery, Queen’s University, Kingston, ON, Canada
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36
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Stephens JA, Liu P, Lu H, Suskauer SJ. Cerebral Blood Flow after Mild Traumatic Brain Injury: Associations between Symptoms and Post-Injury Perfusion. J Neurotrauma 2019; 35:241-248. [PMID: 28967326 DOI: 10.1089/neu.2017.5237] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Arterial spin labeling (ASL) has emerged as a technique for assessing mild traumatic brain injury (mTBI), as it can noninvasively evaluate cerebrovascular physiology. To date, there is substantial variability in methodology and findings of ASL studies of mTBI. While both increased and decreased perfusion are reported after mTBI, more consistency is emerging when perfusion is examined with regard to symptomology. We evaluated 15 teenage athletes two and six weeks after sports-related concussion (SRC group) using pseudo-continuous ASL. We acquired comparison data from 15 matched controls from a single time point. At each time point, we completed whole-brain contrasts to evaluate differences between the SRC group and controls in relative cerebral blood flow (rCBF). Cluster-level findings directed region of interest (ROI) analyses to test for group differences in rCBF across the left dorsal anterior cingulate cortex (ACC) and left insula. Finally, we evaluated ROI rCBF and symptomology in the SRC group. At two weeks post-injury, the SRC group had significantly higher rCBF in the left dorsal ACC and left insula than controls; at six weeks post-injury, elevated rCBF persisted in the SRC group in the left dorsal ACC. Perfusion in the left dorsal ACC was higher in athletes reporting physical symptoms six weeks post-injury compared with asymptomatic athletes and controls. Overall, these findings are inconsistent with reports of reduced rCBF after mTBI but coherent with studies that report increased perfusion in persons with greater or persistent mTBI-related symptomology. Future work should continue to assess how CBF perfusion relates to symptomology and recovery after mTBI.
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Affiliation(s)
- Jaclyn A Stephens
- 1 Kennedy Krieger Institute , Baltimore, Maryland.,2 Department of Occupational Therapy at Colorado State University , Fort Collins, Colorado.,3 Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine , Baltimore, Maryland
| | - Peiying Liu
- 4 Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine , Baltimore, Maryland
| | - Hanzhang Lu
- 4 Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins School of Medicine , Baltimore, Maryland
| | - Stacy J Suskauer
- 1 Kennedy Krieger Institute , Baltimore, Maryland.,3 Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine , Baltimore, Maryland.,5 Department of Pediatrics, Johns Hopkins School of Medicine , Baltimore, Maryland
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37
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Churchill NW, Hutchison MG, Graham SJ, Schweizer TA. Evaluating Cerebrovascular Reactivity during the Early Symptomatic Phase of Sport Concussion. J Neurotrauma 2019; 36:1518-1525. [DOI: 10.1089/neu.2018.6024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Nathan W. Churchill
- Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario, Canada
- Neuroscience Research Program, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michael G. Hutchison
- Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Simon J. Graham
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences, Toronto, Ontario, Canada
| | - Tom A. Schweizer
- Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario, Canada
- Neuroscience Research Program, St. Michael's Hospital, Toronto, Ontario, Canada
- Faculty of Medicine (Neurosurgery), University of Toronto, Toronto, Ontario, Canada
- The Institute of Biomaterials & Biomedical Engineering (IBBME) at the University of Toronto, Toronto, Ontario, Canada
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38
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Svaldi DO, Joshi C, McCuen EC, Music JP, Hannemann R, Leverenz LJ, Nauman EA, Talavage TM. Accumulation of high magnitude acceleration events predicts cerebrovascular reactivity changes in female high school soccer athletes. Brain Imaging Behav 2018; 14:164-174. [DOI: 10.1007/s11682-018-9983-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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39
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Bigler ED. Structural neuroimaging in sport-related concussion. Int J Psychophysiol 2018; 132:105-123. [DOI: 10.1016/j.ijpsycho.2017.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 09/03/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
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40
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Adams C, Bazzigaluppi P, Beckett TL, Bishay J, Weisspapir I, Dorr A, Mester JR, Steinman J, Hirschler L, Warnking JM, Barbier EL, McLaurin J, Sled JG, Stefanovic B. Neurogliovascular dysfunction in a model of repeated traumatic brain injury. Am J Cancer Res 2018; 8:4824-4836. [PMID: 30279740 PMCID: PMC6160760 DOI: 10.7150/thno.24747] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 08/02/2018] [Indexed: 12/13/2022] Open
Abstract
Traumatic brain injury (TBI) research has focused on moderate to severe injuries as their outcomes are significantly worse than those of a mild TBI (mTBI). However, recent epidemiological evidence has indicated that a series of even mild TBIs greatly increases the risk of neurodegenerative and psychiatric disorders. Neuropathological studies of repeated TBI have identified changes in neuronal ionic concentrations, axonal injury, and cytoskeletal damage as important determinants of later life neurological and mood compromise; yet, there is a paucity of data on the contribution of neurogliovascular dysfunction to the progression of repeated TBI and alterations of brain function in the intervening period. Methods: Here, we established a mouse model of repeated TBI induced via three electromagnetically actuated impacts delivered to the intact skull at three-day intervals and determined the long-term deficits in neurogliovascular functioning in Thy1-ChR2 mice. Two weeks post the third impact, cerebral blood flow and cerebrovascular reactivity were measured with arterial spin labelling magnetic resonance imaging. Neuronal function was investigated through bilateral intracranial electrophysiological responses to optogenetic photostimulation. Vascular density of the site of impacts was measured with in vivo two photon fluorescence microscopy. Pathological analysis of neuronal survival and astrogliosis was performed via NeuN and GFAP immunofluorescence. Results: Cerebral blood flow and cerebrovascular reactivity were decreased by 50±16% and 70±20%, respectively, in the TBI cohort relative to sham-treated animals. Concomitantly, electrophysiological recordings revealed a 97±1% attenuation in peri-contusional neuronal reactivity relative to sham. Peri-contusional vascular volume was increased by 33±2% relative to sham-treated mice. Pathological analysis of the peri-contusional cortex demonstrated astrogliosis, but no changes in neuronal survival. Conclusion: This work provides the first in-situ characterization of the long-term deficits of the neurogliovascular unit following repeated TBI. The findings will help guide the development of diagnostic markers as well as therapeutics targeting neurogliovascular dysfunction.
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Fisher JA, Venkatraghavan L, Mikulis DJ. Magnetic Resonance Imaging–Based Cerebrovascular Reactivity and Hemodynamic Reserve. Stroke 2018; 49:2011-2018. [DOI: 10.1161/strokeaha.118.021012] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Joseph A. Fisher
- From the Department of Anesthesia and Pain Management and the Toronto General Hospital Research Institute (J.A.F., L.V.)
- Department of Anesthesiology (J.A.F., L.V.)
- Institute of Medical Sciences (J.A.F., D.J.M.)
- Department of Physiology (J.A.F.), University of Toronto, Canada
| | - Lashmi Venkatraghavan
- From the Department of Anesthesia and Pain Management and the Toronto General Hospital Research Institute (J.A.F., L.V.)
- Department of Anesthesiology (J.A.F., L.V.)
| | - David J. Mikulis
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory (D.J.M.), University Health Network, Toronto, Canada
- Institute of Medical Sciences (J.A.F., D.J.M.)
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Haider MN, Leddy JJ, Hinds AL, Aronoff N, Rein D, Poulsen D, Willer BS. Intracranial pressure changes after mild traumatic brain injury: a systematic review. Brain Inj 2018; 32:809-815. [PMID: 29701515 PMCID: PMC6192525 DOI: 10.1080/02699052.2018.1469045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 02/12/2018] [Accepted: 04/21/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Intracranial pressure (ICP) after mild traumatic brain injury (mTBI) is poorly studied due to lack of sensitive non-invasive methods. The purpose of this review was to summarize the existing knowledge of changes in ICP after mTBI. Literature selection: PubMed, Embase, CINAHL, and Scopus were searched by three reviewers independently up to December 2016. INCLUSION CRITERIA animal and human studies measuring ICP and brain oedema after an mTBI. EXCLUSION CRITERIA moderate and severe forms of traumatic brain injury, repeat samples, and studies that measured ICP at the time of impact but not after. Study quality was assessed using Downs and Black criteria. RESULTS Of 1067 papers, 9 studies were included. In human studies, one provided direct evidence on increased, one provided indirect evidence of increased, and two provided indirect evidence of decreased ICP. In animal studies, three studies provided direct evidence of increased, one provided indirect evidence of increased, and one provided indirect evidence of no change in ICP. CONCLUSION The existing research suggests that there may be increased ICP after mTBI and animal studies suggest an elevation for days which returns to baseline, which corresponds with functional and symptomatic recovery. Future human studies using sensitive indirect methods to measure ICP longitudinally after mTBI are needed.
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Affiliation(s)
- Mohammad N Haider
- Department of Orthopedics and Sports Medicine, State University of New York at Buffalo
- Department of Neuroscience, State University of New York at Buffalo
| | - John J Leddy
- Department of Orthopedics and Sports Medicine, State University of New York at Buffalo
| | - Andrea L Hinds
- Department of Orthopedics and Sports Medicine, State University of New York at Buffalo
| | - Nell Aronoff
- Health Sciences Library, State University of New York at Buffalo
| | - Diane Rein
- Health Sciences Library, State University of New York at Buffalo
| | - David Poulsen
- Department of Neurosurgery, State University of New York at Buffalo
| | - Barry S Willer
- Department of Psychiatry, State University of New York at Buffalo
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43
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Chamard E, Lichtenstein JD. A systematic review of neuroimaging findings in children and adolescents with sports-related concussion. Brain Inj 2018; 32:816-831. [PMID: 29648462 DOI: 10.1080/02699052.2018.1463106] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Sport-related concussion (SRC) generally does not result in structural anomalies revealed through clinical imaging techniques such as MRI and CT. While advanced neuroimaging techniques offer another avenue to investigate the subtle alterations following SRC, the current pediatric literature in this area has yet to be reviewed. The aim of this review is to systematically explore the literature on magnetic resonance spectroscopy (MRS), diffusion tensor imaging (DTI), functional magnetic resonance imaging (fMRI), and cortical thickness following SRC in children and adolescents. METHODS A systematic Pubmed search using the preferred reporting items for systematic reviews and meta-analysis guidelines was conducted independently for each neuroimaging method. Studies were screened for inclusion based on pre-determined criteria. RESULTS A total of 26 studies were included (MRS = 4, DTI = 10, fMRI = 11, cortical thickness = 1). A total of 16 studies were conducted solely with male athletes, while 10 studies recruited an unequal number of male and female athletes. CONCLUSIONS While MRI and CT are generally unrevealing, advanced neuroimaging techniques demonstrated neurometabolic, microstructural, and functional alterations following SRC in athletes younger than 19 years of age in the acute, subacute, and chronic phases of recovery. However, more studies are needed to fully understand the impact of SRC on the developing brain in children and adolescents.
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Affiliation(s)
- Emilie Chamard
- a Department of Psychiatry, Geisel School of Medicine at Dartmouth , Dartmouth-Hitchcock Medical Center , Lebanon , NH , USA
| | - Jonathan D Lichtenstein
- a Department of Psychiatry, Geisel School of Medicine at Dartmouth , Dartmouth-Hitchcock Medical Center , Lebanon , NH , USA
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Ellis M, Krisko C, Selci E, Russell K. Effect of concussion history on symptom burden and recovery following pediatric sports-related concussion. J Neurosurg Pediatr 2018; 21:401-408. [PMID: 29393810 DOI: 10.3171/2017.9.peds17392] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to examine differences in symptom burden and duration until physician-documented clinical recovery among pediatric patients with sports-related concussion (SRC) with and without a history of concussion. METHODS A retrospective chart review was performed for all pediatric patients (7-19 years old) referred to the Pan Am Concussion Program in Winnipeg, Canada, with an SRC and evaluated < 30 days postinjury between September 1, 2013, and August 1, 2015. RESULTS A total of 322 patients with SRC (64.91% male, mean age 13.96 years) who were evaluated a median of 7 days (interquartile range [IQR] 5-11 days) postinjury were included. Patients without a history of concussion endorsed significantly fewer concussion symptoms at initial assessment (median 5.5 symptoms, IQR 1-10 symptoms) than those with a previous concussion (median 7 symptoms, IQR 2-13.25 symptoms; p = 0.036). The median Post-Concussion Symptom Scale scores were 9 (IQR 1-23) for patients with no concussion history and 13 (IQR 3-33) for those with a history of concussion (p = 0.032). For patients with no previous concussion, the median number of days until physician-documented clinical recovery was 23 (IQR 15-44 days) compared with 25 days (IQR 18-43 days) for those with a history of concussion (p = 0.281). There was no significant difference in the proportion of patients who experienced delayed time until physician-documented clinical recovery (> 1 month postinjury) between the groups (p = 0.584). CONCLUSIONS Although a history of concussion may be associated with increased symptom burden following pediatric SRC, there was no difference in the time until physician-documented clinical recovery. Pediatric patients with SRC who have a history of concussion should be managed on an individualized basis. Future work is needed to examine the short- and long-term effects of multiple concussions in children and adolescents.
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Affiliation(s)
- Michael Ellis
- Departments of1Surgery and.,3Section of Neurosurgery, and.,5Pan Am Concussion Program.,7Canada North Concussion Network, Winnipeg, Manitoba, Canada
| | | | - Erin Selci
- 2Pediatrics and Child Health.,6Children's Hospital Research Institute of Manitoba; and
| | - Kelly Russell
- 2Pediatrics and Child Health.,6Children's Hospital Research Institute of Manitoba; and.,7Canada North Concussion Network, Winnipeg, Manitoba, Canada
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Amyot F, Kenney K, Moore C, Haber M, Turtzo LC, Shenouda C, Silverman E, Gong Y, Qu BX, Harburg L, Lu HY, Wassermann EM, Diaz-Arrastia R. Imaging of Cerebrovascular Function in Chronic Traumatic Brain Injury. J Neurotrauma 2018; 35:1116-1123. [PMID: 29065769 DOI: 10.1089/neu.2017.5114] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic cerebrovascular injury (TCVI) is a common pathologic mechanism of traumatic brain injury (TBI) and presents an attractive target for intervention. The aims of this study were to assess cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) using magnetic resonance imaging (MRI) to assess their value as biomarkers of TCVI in chronic TBI, characterize the spatial distribution of TCVI, and assess the relationships between each biomarker and neuropsychological and clinical assessments. Forty-two subjects (27 chronic TBI, 15 age- and gender-matched healthy volunteers) were studied cross-sectionally. CBF was measured by arterial spin labeling and CVR by assessing the MRI-blood oxygen level-dependent signal with hypercapnia challenge. A focused neuropsychological battery adapted from the TBI Common Data Elements and neurobehavioral symptom questionnaires were administered at the time of the imaging session. Chronic TBI subjects showed a significant reduction in mean global, gray matter (GM), and white matter (WM) CVR, compared with healthy volunteers (p < 0.001). Mean GM CVR had the greatest effect size (Cohen's d = 0.9). CVR maps in chronic TBI subjects showed patchy, multifocal CVR deficits. CBF discriminated poorly between TBI subjects and healthy volunteers and did not correlate with CVR. Mean global CVR correlated best with chronic neurobehavioral symptoms among TBI subjects. Global, GM, and WM CVR are reliable and potentially useful biomarkers of TCVI in the chronic stage after moderate-to-severe TBI. CBF is less useful as biomarker of TCVI. CVR correlates best with chronic TBI symptoms. CVR has potential as a predictive and pharmacodynamic biomarker for interventions targeting TCVI.
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Affiliation(s)
- Franck Amyot
- 1 Department of Neurology, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Kimbra Kenney
- 1 Department of Neurology, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Carol Moore
- 1 Department of Neurology, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Margalit Haber
- 2 Department of Neurology, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - L Christine Turtzo
- 3 Center for Neuroscience and Regenerative Medicine, National Institute of Neurological Disorder and Stroke, National Institutes of Health , Bethesda, Maryland
| | - Christian Shenouda
- 3 Center for Neuroscience and Regenerative Medicine, National Institute of Neurological Disorder and Stroke, National Institutes of Health , Bethesda, Maryland
| | - Erika Silverman
- 2 Department of Neurology, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Yunhua Gong
- 2 Department of Neurology, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Bao-Xi Qu
- 1 Department of Neurology, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Leah Harburg
- 1 Department of Neurology, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Hanzhang Y Lu
- 4 Department of Radiology and Radiological Science, Johns Hopkins University Baltimore , Maryland
| | - Eric M Wassermann
- 5 National Institute of Neurological Disorders and Stroke, National Institutes of Health , Bethesda, Maryland
| | - Ramon Diaz-Arrastia
- 2 Department of Neurology, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
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Abstract
PURPOSE OF REVIEW As clinicians preparing patients for general anesthesia, should we consider the possibility of concussion in our elective operative patients? If so, why is this necessary? Is it possible that exposure to an anesthetic is detrimental to recovery from concussion? If so, what should we do about the imperative/urgency for surgery? No answers are promised in this review. Rather, the focus is on the questions and approaches taken in the recent literature, as well as highlighting a need for more research. RECENT FINDINGS Surgery, pain and general anesthesia all influence autonomic nervous system responses. Intravenous and inhalational anesthetic agents are also known to have variable effects on the cerebrovascular reactivity (CVR) to carbon dioxide (CO2). This review adds to this general information the recent, specific physiologic alterations seen after concussion in autonomic system function and the CVR to CO2. SUMMARY This review provides a perspective about autonomic nervous system function and cerebrovascular effects of concussion, and some relevant clinical issues that warrant further clinical study.
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Mutch WAC, Ellis MJ, Ryner LN, McDonald PJ, Morissette MP, Pries P, Essig M, Mikulis DJ, Duffin J, Fisher JA. Patient-Specific Alterations in CO 2 Cerebrovascular Responsiveness in Acute and Sub-Acute Sports-Related Concussion. Front Neurol 2018; 9:23. [PMID: 29416525 PMCID: PMC5787575 DOI: 10.3389/fneur.2018.00023] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 01/11/2018] [Indexed: 01/06/2023] Open
Abstract
Background Preliminary studies suggest that sports-related concussion (SRC) is associated with alterations in cerebral blood flow (CBF) regulation. Here, we use advanced magnetic resonance imaging (MRI) techniques to measure CBF and cerebrovascular responsiveness (CVR) in individual SRC patients and healthy control subjects. Methods 15 SRC patients (mean age = 16.3, range 14–20 years) and 27 healthy control subjects (mean age = 17.6, range 13–21 years) underwent anatomical MRI, pseudo-continuous arterial spin labeling (pCASL) MRI and model-based prospective end-tidal targeting (MPET) of CO2 during blood oxygenation level-dependent (BOLD) MRI. Group differences in global mean resting CBF were examined. Voxel-by-voxel group and individual differences in regional CVR were examined using statistical parametric mapping (SPM). Leave-one-out receiver operating characteristic curve analysis was used to evaluate the utility of brain MRI CO2 stress testing biomarkers to correctly discriminate between SRC patients and healthy control subjects. Results All studies were tolerated with no complications. Traumatic structural findings were identified in one SRC patient. No significant group differences in global mean resting CBF were observed. There were no significant differences in the CO2 stimulus and O2 targeting during BOLD MRI. Significant group and patient-specific differences in CVR were observed with SRC patients demonstrating a predominant pattern of increased CVR. Leave-one-out ROC analysis for voxels demonstrating a significant increase in CVR was found to reliably discriminate between SRC patients and healthy control subjects (AUC of 0.879, p = 0.0001). The optimal cutoff for increased CVR declarative for SRC was 1,899 voxels resulting in a sensitivity of 0.867 and a specificity of 0.778 for this specific ROC analysis. There was no correlation between abnormal voxel counts and Postconcussion Symptom Scale scores among SRC patients. Conclusion Acute and subacute SRCs are associated with alterations in CVR that can be reliably detected by brain MRI CO2 stress testing in individual patients.
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Affiliation(s)
- W Alan C Mutch
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada.,University of Manitoba, Winnipeg, MB, Canada.,Canada North Concussion Network, University of Manitoba, Winnipeg, MB, Canada
| | - Michael J Ellis
- University of Manitoba, Winnipeg, MB, Canada.,Canada North Concussion Network, University of Manitoba, Winnipeg, MB, Canada.,Department of Surgery and Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada.,Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada.,Pan Am Concussion Program, University of Manitoba, Winnipeg, MB, Canada.,Childrens Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada
| | - Lawrence N Ryner
- University of Manitoba, Winnipeg, MB, Canada.,Canada North Concussion Network, University of Manitoba, Winnipeg, MB, Canada.,Department of Radiology Diagnostic Imaging, University of Manitoba, Winnipeg, MB, Canada
| | - Patrick J McDonald
- Canada North Concussion Network, University of Manitoba, Winnipeg, MB, Canada.,Division of Neurosurgery, BC Children's Hospital, National Core for Neuroethics, University of British Columbia, Vancouver, BC, Canada
| | | | - Philip Pries
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marco Essig
- University of Manitoba, Winnipeg, MB, Canada.,Canada North Concussion Network, University of Manitoba, Winnipeg, MB, Canada.,Pan Am Concussion Program, University of Manitoba, Winnipeg, MB, Canada.,Department of Radiology Diagnostic Imaging, University of Manitoba, Winnipeg, MB, Canada
| | - David J Mikulis
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada.,University Health Network Cerebrovascular Reactivity Research Group, Toronto, ON, Canada
| | - James Duffin
- University of Toronto, Toronto, ON, Canada.,University Health Network Cerebrovascular Reactivity Research Group, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Joseph A Fisher
- University of Toronto, Toronto, ON, Canada.,University Health Network Cerebrovascular Reactivity Research Group, Toronto, ON, Canada.,Department of Anesthesia, University of Toronto, Toronto, ON, Canada
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Pertab JL, Merkley TL, Cramond AJ, Cramond K, Paxton H, Wu T. Concussion and the autonomic nervous system: An introduction to the field and the results of a systematic review. NeuroRehabilitation 2018; 42:397-427. [PMID: 29660949 PMCID: PMC6027940 DOI: 10.3233/nre-172298] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent evidence suggests that autonomic nervous dysfunction may be one of many potential factors contributing to persisting post-concussion symptoms. OBJECTIVE This is the first systematic review to explore the impact of concussion on multiple aspects of autonomic nervous system functioning. METHODS The methods employed are in compliance with the American Academy of Neurology (AAN) and PRISMA standards. Embase, MEDLINE, PsychINFO, and Science Citation Index literature searches were performed using relevant indexing terms for articles published prior to the end of December 2016. Data extraction was performed by two independent groups, including study quality indicators to determine potential risk for bias according to the 4-tiered classification scheme of the AAN. RESULTS Thirty-six articles qualified for inclusion in the analysis. Only three studies (one Class II and two Class IV) did not identify anomalies in measures of ANS functioning in concussed populations. CONCLUSIONS The evidence supports the conclusion that it is likely that concussion causes autonomic nervous system anomalies. An awareness of this relationship increases our understanding of the physical impact of concussion, partially explains the overlap of concussion symptoms with other medical conditions, presents opportunities for further research, and has the potential to powerfully inform treatment decisions.
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Affiliation(s)
- Jon L. Pertab
- Neurosciences Institute, Intermountain Healthcare, Murray, UT, USA
| | - Tricia L. Merkley
- Department of Clinical Neuropsychology, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | - Kelly Cramond
- Summit Neuropsychology, Reno, NV, USA
- VA Sierra Nevada Healthcare System, Reno, NV, USA
| | - Holly Paxton
- Hauenstein Neurosciences of Mercy Health and Department of Translational Science and Molecular Medicine, Michigan State University, MI, USA
| | - Trevor Wu
- Hauenstein Neurosciences of Mercy Health and Department of Translational Science and Molecular Medicine, Michigan State University, MI, USA
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Wing BH, Tucker BJ, Fong AK, Allen MD. Developing the Standard of Care for Post-Concussion Treatment: Neuroimaging-Guided Rehabilitation of Neurovascular Coupling. Open Neuroimag J 2017; 11:58-71. [PMID: 29299085 PMCID: PMC5725584 DOI: 10.2174/1874440001711010058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/02/2017] [Accepted: 09/04/2017] [Indexed: 12/20/2022] Open
Abstract
Background Emerging research proposes the imbalance between microvascular supply and metabolic demand as a contributing factor in the pathophysiology of mild traumatic brain injury. Prolonged effects on the dysregulation of neurovascular coupling may explain persistent symptomatic models such as Post-Concussion Syndrome. Objective Increased knowledge of what we refer to as neurovascular uncoupling provides a template for establishing a new concussion treatment standard in the assessment and therapeutic guidance of concussion. Methods The degree and localization of neurovascular uncoupling were statistically contextualized against a normative-based atlas in 270 concussed patients. Functional NeuroCognitive ImagingTM was used to establish pre-treatment benchmarks and guide neurotherapy. Conventional and functional neurocognitive imaging-directed measures were used to evaluate post-rehabilitative outcomes. Results Functional neurocognitive imaging was successful in identifying regions of Neurovascular uncoupling unique to each patient's brain and concussion profile. Longitudinal objective outcome measures demonstrated timely and lasting improvement of neurovascular coupling functioning in a significant majority of patients. Conclusion We present practice-based evidence supporting the clinical administration of functional neurocognitive imaging with particular efficacy in the neurorehabilitation of concussion. We advocate the reliability of functional neurocognitive imaging in assessing severity and localization of neurovascular uncoupling, and promote its use in the therapeutic guidance and neurorehabilitation of mild traumatic brain injury. We further support the continual exploration of other potential pathophysiological alterations resulting from concussion.
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Affiliation(s)
- Benjamin H Wing
- Cognitive FX, Provo, UT, USA.,American University of the Caribbean School of Medicine, Cupecoy, St. Maarten, USA
| | - Braden J Tucker
- Cognitive FX, Provo, UT, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alina K Fong
- Cognitive FX, Provo, UT, USA.,Utah Valley Regional Medical Center, Provo, UT, USA
| | - Mark D Allen
- Cognitive FX, Provo, UT, USA.,Notus Neuropsychological Imaging, Orem, UT, USA
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El-Gabalawy R, Patel R, Kilborn K, Blaney C, Hoban C, Ryner L, Funk D, Legaspi R, Fisher JA, Duffin J, Mikulis DJ, Mutch WAC. A Novel Stress-Diathesis Model to Predict Risk of Post-operative Delirium: Implications for Intra-operative Management. Front Aging Neurosci 2017; 9:274. [PMID: 28868035 PMCID: PMC5563326 DOI: 10.3389/fnagi.2017.00274] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/28/2017] [Indexed: 12/24/2022] Open
Abstract
Introduction: Risk assessment for post-operative delirium (POD) is poorly developed. Improved metrics could greatly facilitate peri-operative care as costs associated with POD are staggering. In this preliminary study, we develop a novel stress-diathesis model based on comprehensive pre-operative psychiatric and neuropsychological testing, a blood oxygenation level-dependent (BOLD) magnetic resonance imaging (MRI) carbon dioxide (CO2) stress test, and high fidelity measures of intra-operative parameters that may interact facilitating POD. Methods: The study was approved by the ethics board at the University of Manitoba and registered at clinicaltrials.gov as NCT02126215. Twelve patients were studied. Pre-operative psychiatric symptom measures and neuropsychological testing preceded MRI featuring a BOLD MRI CO2 stress test whereby BOLD scans were conducted while exposing participants to a rigorously controlled CO2 stimulus. During surgery the patient had hemodynamics and end-tidal gases downloaded at 0.5 hz. Post-operatively, the presence of POD and POD severity was comprehensively assessed using the Confusion Assessment Measure -Severity (CAM-S) scoring instrument on days 0 (surgery) through post-operative day 5, and patients were followed up at least 1 month post-operatively. Results: Six of 12 patients had no evidence of POD (non-POD). Three patients had POD and 3 had clinically significant confusional states (referred as subthreshold POD; ST-POD) (score ≥ 5/19 on the CAM-S). Average severity for delirium was 1.3 in the non-POD group, 3.2 in ST-POD, and 6.1 in POD (F-statistic = 15.4, p < 0.001). Depressive symptoms, and cognitive measures of semantic fluency and executive functioning/processing speed were significantly associated with POD. Second level analysis revealed an increased inverse BOLD responsiveness to CO2 pre-operatively in ST-POD and marked increase in the POD groups when compared to the non-POD group. An association was also noted for the patient population to manifest leucoaraiosis as assessed with advanced neuroimaging techniques. Results provide preliminary support for the interacting of diatheses (vulnerabilities) and intra-operative stressors on the POD phenotype. Conclusions: The stress-diathesis model has the potential to aid in risk assessment for POD. Based on these initial findings, we make some recommendations for intra-operative management for patients at risk of POD.
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Affiliation(s)
- Renée El-Gabalawy
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada.,Department of Clinical Health Psychology, Rady Faculty of Health Sciences, University of ManitobaWinnipeg, MB, Canada
| | - Ronak Patel
- Department of Clinical Health Psychology, Rady Faculty of Health Sciences, University of ManitobaWinnipeg, MB, Canada
| | - Kayla Kilborn
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - Caitlin Blaney
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - Christopher Hoban
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - Lawrence Ryner
- Department of Physics and Astronomy, Faculty of Science, University of ManitobaWinnipeg, MB, Canada
| | - Duane Funk
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - Regina Legaspi
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada
| | - Joseph A Fisher
- Department of Anesthesia, Faculty of Medicine, University of TorontoToronto, ON, Canada
| | - James Duffin
- Department of Physiology, Faculty of Medicine, University of TorontoToronto, ON, Canada
| | - David J Mikulis
- Department of Medical Imaging, Faculty of Medicine, University of TorontoToronto, ON, Canada
| | - W Alan C Mutch
- Department of Anesthesia and Perioperative Medicine, Max Rady College of Medicine, University of ManitobaWinnipeg, MB, Canada.,Canada North Concussion NetworkWinnipeg, MB, Canada
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