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Zhang C, Tang W, Cheng L, Yang C, Wang T, Wang J, Miao Z, Zhao X, Fang X, Zhou Y. Early and delayed blood-brain barrier permeability predicts delayed cerebral ischemia and outcomes following aneurysmal subarachnoid hemorrhage. Eur Radiol 2024; 34:5287-5296. [PMID: 38221580 DOI: 10.1007/s00330-023-10571-w] [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: 08/18/2023] [Revised: 11/27/2023] [Accepted: 12/12/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVES This study aimed to monitor blood-brain barrier permeability within 24 h and during the delayed cerebral ischemia (DCI) time window (DCITW) spanning 4-14 days after aneurysmal subarachnoid hemorrhage (aSAH) and to investigate its correlation with both DCI occurrence and outcomes at three months. METHODS A total of 128 patients were stratified based on the DCI occurrence and three-month modified Rankin scale scores. Comparison of Ktrans at admission (admission Ktrans) and during DCITW (DCITW Ktrans) was conducted between DCI and non-DCI groups, as well as between groups with good and poor outcomes. Changes in Ktrans were also analyzed. Multivariate logistic regression analysis was performed to identify independent predictors of DCI and poor outcomes. RESULTS Admission Ktrans (0.58 ± 0.18 vs 0.47 ± 0.12, p = 0.002) and DCITW Ktrans (0.54 ± 0.19 vs 0.41 ± 0.14, p < 0.001) were significantly higher in the DCI group compared with the non-DCI group. Although both were higher in the poor outcome group than the good outcome group, the difference was not statistically significant at admission (0.53 ± 0.18 vs 0.49 ± 0.14, p = 0.198). Ktrans in the non-DCI group (0.47 ± 0.12 vs 0.41 ± 0.14, p = 0.004) and good outcome group (0.49 ± 0.14 vs 0.41 ± 0.14, p < 0.001) decreased significantly from the admission to DCITW. Multivariate analysis identified DCITW Ktrans and admission Ktrans as independent predictors of poor outcomes (OR = 1.73, 95%CI: 1.24-2.43, p = 0.001) and DCI (OR = 1.75, 95%CI: 1.25-2.44, p = 0.001), respectively. CONCLUSION Elevated Ktrans at admission is associated with the occurrence of DCI. Continuous monitoring of Ktrans from admission to DCITW can accurately identify reversible and irreversible changes and can predict outcomes at 3 months. CLINICAL RELEVANCE STATEMENT Ktrans measured with CT perfusion is a valuable tool for predicting both delayed cerebral ischemia and three-month outcomes following aneurysmal subarachnoid hemorrhage. Monitoring changes in Ktrans from admission to time window of delayed cerebral ischemia can guide treatment and management decisions for aneurysmal subarachnoid hemorrhage patients. KEY POINTS • Ktrans measured at admission and during the delayed cerebral ischemia time window (4-14 days) holds distinct clinical significance following aneurysmal subarachnoid hemorrhage. • Admission Ktrans serves as a predictor for delayed cerebral ischemia, while continuous assessment of Ktrans from admission to the delayed cerebral ischemia time window can predict three-month outcomes. • Monitoring Ktrans at different stages improves instrumental in enhancing decision-making and treatment planning for patients with aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Chao Zhang
- Department of Radiology, Yijishan Hospital of Wannan Medical College, No.2 Zheshan West Road, Wuhu, 241001, Anhui, China
| | - Wenjuan Tang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liang Cheng
- Department of Radiology, Yijishan Hospital of Wannan Medical College, No.2 Zheshan West Road, Wuhu, 241001, Anhui, China
| | - Chen Yang
- Department of Radiology, Yijishan Hospital of Wannan Medical College, No.2 Zheshan West Road, Wuhu, 241001, Anhui, China
| | - Ting Wang
- Department of Radiology, Yijishan Hospital of Wannan Medical College, No.2 Zheshan West Road, Wuhu, 241001, Anhui, China
| | - Juan Wang
- Department of Radiology, Yijishan Hospital of Wannan Medical College, No.2 Zheshan West Road, Wuhu, 241001, Anhui, China
| | - Zhuang Miao
- Department of Radiology, Yijishan Hospital of Wannan Medical College, No.2 Zheshan West Road, Wuhu, 241001, Anhui, China
| | - Xintong Zhao
- Department of Neurosurgery, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Xinggen Fang
- Department of Neurosurgery, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Yunfeng Zhou
- Department of Radiology, Yijishan Hospital of Wannan Medical College, No.2 Zheshan West Road, Wuhu, 241001, Anhui, China.
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Andersen S, Western E, Sorteberg W, Sorteberg A. The impact of pre-ictal statin use on vasospasm and outcome in aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:3325-3338. [PMID: 37792050 PMCID: PMC10624707 DOI: 10.1007/s00701-023-05812-2] [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: 05/29/2023] [Accepted: 09/12/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Pleiotropic effects of statins may be beneficial in alleviating cerebral vasospasm (VS) and improving outcome after aneurysmal subarachnoid hemorrhage (aSAH). Initiation of statin treatment at aSAH is not recommended; however, the effect of pre-ictal and continued statin use is not fully investigated. METHODS Retrospective study comparing aSAH patients admitted in 2012 to 2021 with pre-ictal statin use versus those not using statins. Patient entry variables, radiological/sonological VS, symptomatic VS, and radiologically documented delayed cerebral ischemia (DCI) were registered. Outcome was scored in terms of mortality, modified Rankin score, Glasgow outcome score extended, and levels of fatigue. Patients were compared on group level and in a case-control design. RESULTS We included 961 patients, with 204 (21.2%) statin users. Statin users were older and had more often hypertension. Severe radiological/sonological VS, symptomatic VS, and DCI were less frequent in statin users, and their length of stay was shorter. Mortality, functional outcome, and levels of fatigue were similar in both groups. When analyzing 89 pairs of statin users and non-statin users matched for age, aSAH severity, gender, and hypertension, we confirmed decreased radiological/sonological and symptomatic VS as well as shorter length of stay in statin users. They also had more often a favorable functional outcome and lower levels of fatigue. CONCLUSIONS Patients with pre-ictal and continued use of statins have a reduced occurrence of radiological/sonological and symptomatic VS, shorter length of stay, and more often favorable functional outcome, whereas mortality is similar to non-statin users. Even though larger multicenter studies with common, strict protocols for prevention, diagnosis, and treatment of vasospasm are needed to finally establish the value of statins in aSAH, continuation of pre-ictal statin use seems worthwhile.
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Affiliation(s)
- S Andersen
- Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway
| | - E Western
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Nydalen, P.B. 4950, 0424, Oslo, Norway
| | - W Sorteberg
- Department of Neurosurgery, Oslo University Hospital, Nydalen, P.B. 0454, 0424, Oslo, Norway
| | - A Sorteberg
- Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway.
- Department of Neurosurgery, Oslo University Hospital, Nydalen, P.B. 0454, 0424, Oslo, Norway.
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Zhang A, Liu Y, Wang X, Xu H, Fang C, Yuan L, Wang K, Zheng J, Qi Y, Chen S, Zhang J, Shao A. Clinical Potential of Immunotherapies in Subarachnoid Hemorrhage Treatment: Mechanistic Dissection of Innate and Adaptive Immune Responses. Aging Dis 2023; 14:1533-1554. [PMID: 37196120 PMCID: PMC10529760 DOI: 10.14336/ad.2023.0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/26/2023] [Indexed: 05/19/2023] Open
Abstract
Subarachnoid hemorrhage (SAH), classified as a medical emergency, is a devastating and severe subtype of stroke. SAH induces an immune response, which further triggers brain injury; however, the underlying mechanisms need to be further elucidated. The current research is predominantly focused on the production of specific subtypes of immune cells, especially innate immune cells, post-SAH onset. Increasing evidence suggests the critical role of immune responses in SAH pathophysiology; however, studies on the role and clinical significance of adaptive immunity post-SAH are limited. In this present study, we briefly review the mechanistic dissection of innate and adaptive immune responses post-SAH. Additionally, we summarized the experimental studies and clinical trials of immunotherapies for SAH treatment, which may form the basis for the development of improved therapeutic approaches for the clinical management of SAH in the future.
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Affiliation(s)
- Anke Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Houshi Xu
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Chaoyou Fang
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Ling Yuan
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - KaiKai Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Jingwei Zheng
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Yangjian Qi
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Anwen Shao
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, China.
- Key Laboratory of Precise Treatment and Clinical Translational Research of Neurological Diseases, Hangzhou, Zhejiang, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
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Koopman I, van Dijk BJ, Zuithoff NPA, Sluijs JA, van der Kamp MJ, Baldew ZAV, Frijns CJM, Rinkel GJE, Hol EM, Vergouwen MDI. Glial cell response and microthrombosis in aneurysmal subarachnoid hemorrhage patients: An autopsy study. J Neuropathol Exp Neurol 2023; 82:798-805. [PMID: 37478478 PMCID: PMC10440719 DOI: 10.1093/jnen/nlad050] [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] [Indexed: 07/23/2023] Open
Abstract
Neuroinflammation and microthrombosis may be underlying mechanisms of brain injury after aneurysmal subarachnoid hemorrhage (aSAH), but they have not been studied in relation to each other. In postmortem brain tissue, we investigated neuroinflammation by studying the microglial and astrocyte response in the frontal cortex of 11 aSAH and 10 control patients. In a second study, we investigated the correlation between microthrombosis and microglia by studying the microglial surface area around vessels with and without microthrombosis in the frontal cortex and hippocampus of 8 other aSAH patients. In comparison with controls, we found increased numbers of microglia (mean ± SEM 50 ± 8 vs 20 ± 5 per 0.0026 mm³, p < 0.01), an increased surface area (%) of microglia (mean ± SEM 4.2 ± 0.6 vs 2.2 ± 0.4, p < 0.05), a higher intensity of the astrocytic intermediate filament protein glial fibrillary acidic protein (GFAP) (mean ± SEM 184 ± 28 vs 92 ± 23 arbitrary units, p < 0.05), and an increased GFAP surface area (%) (mean ± SEM 21.2 ± 2.6 vs 10.7 ± 2.1, p < 0.01) in aSAH tissue. Microglia surface area was approximately 40% larger around vessels with microthrombosis than those without microthrombosis (estimated marginal means [95% CI]; 6.1 [5.4-6.9] vs 4.3 [3.6-5.0], p < 0.001). Our results show that the microglial and astrocyte surface areas increased after aSAH and that microthrombosis and microglia are interrelated.
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Affiliation(s)
- Inez Koopman
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Bart J van Dijk
- Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nicolaas P A Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jacqueline A Sluijs
- Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marije J van der Kamp
- Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Zelonna A V Baldew
- Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Catharina J M Frijns
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Elly M Hol
- Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Levinson S, Pendharkar AV, Gauden AJ, Heit JJ. Modern Imaging of Aneurysmal Subarachnoid Hemorrhage. Radiol Clin North Am 2023; 61:457-465. [PMID: 36931762 DOI: 10.1016/j.rcl.2023.01.004] [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] [Indexed: 02/21/2023]
Abstract
In this review, we discuss the imaging of aneurysmal subarachnoid hemorrhage (SAH). We discuss emergency brain imaging, aneurysm detection techniques, and the management of CTA-negative SAH. We also review the concepts of cerebral vasospasm and delayed cerebral ischemia that occurs after aneurysm rupture and their impact on patient outcomes. These pathologies are distinct, and the use of multimodal imaging modalities is essential for prompt diagnosis and management to minimize morbidity from these conditions. Lastly, new advances in artificial intelligence and advanced imaging modalities such as PET and MR imaging scans have been shown to improve the detection of aneurysms and potentially predict outcomes early in the course of SAH.
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Affiliation(s)
- Simon Levinson
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew J Gauden
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Stanford School of Medicine, 453 Quarry Road, Palo Alto, CA 94304, USA.
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6
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Pedrosa L, Hoyos J, Reyes L, Llull L, Santana D, de Riva N, Mellado R, Sala X, Rodríguez-Hernández A, Enseñat J, Amaro S, Torné R. MicroRNA cerebrospinal fluid profile during the early brain injury period as a biomarker in subarachnoid hemorrhage patients. Front Cell Neurosci 2022; 16:1016814. [PMID: 36505512 PMCID: PMC9732100 DOI: 10.3389/fncel.2022.1016814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Delayed cerebral ischemia (DCI) is a dreadful complication present in up to 30% of patients with spontaneous subarachnoid hemorrhage (SAH). Indeed, DCI is one of the main causes of long-term disability in SAH, yet its prediction and prevention are troublesome in poor-grade SAH cases. In this prospective study, we explored the potential role of micro ribonucleic acid (microRNA, abbreviated miRNAs)-small non-coding RNAs involved in clue gene regulation at the post-transcriptional level-as biomarkers of neurological outcomes in SAH patients. Methods We analyzed the expression of several miRNAs present in the cerebrospinal fluid (CSF) of SAH patients during the early stage of the disease (third-day post-hemorrhage). NanoString Technologies were used for the characterization of the CSF samples. Results We found an overexpression of miRNAs in the acute stage of 57 SAH in comparison with 10 non-SAH controls. Moreover, a differential expression of specific miRNAs was detected according to the severity of clinical onset, but also regarding the development of DCI and the midterm functional outcomes. Conclusion These observations reinforce the potential utility of miRNAs as prognostic and diagnostic biomarkers in SAH patients. In addition, the identification of specific miRNAs related to SAH evolution might provide insights into their regulatory functions of pathophysiological pathways, such as the TGF-β inflammatory pathway and blood-brain barrier disruption.
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Affiliation(s)
- Leire Pedrosa
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Jhon Hoyos
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Luis Reyes
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Daniel Santana
- Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Nicolás de Riva
- Neuroanesthesia Division, Department of Anesthesiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Ricard Mellado
- Department of Anesthesiology and Critical Care, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Xavier Sala
- Neuroanesthesia Division, Department of Anesthesiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Joaquim Enseñat
- Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergio Amaro
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain,Comprehensive Stroke Center, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain,Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain,*Correspondence: Sergio Amaro,
| | - Ramon Torné
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain,Department of Neurosurgery, Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain,Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain,Ramon Torné,
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7
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Ma YC, Chen AQ, Guo F, Yu J, Xu M, Shan DD, Zhang SH. The value of whole-brain CT perfusion imaging combined with dynamic CT angiography in the evaluation of pial collateral circulation with middle cerebral artery occlusion. Technol Health Care 2022; 30:967-979. [PMID: 35275581 DOI: 10.3233/thc-213118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Middle cerebral artery (MCA) occlusion is extremely common, especially unilateral artery, which can result in a significant incidence of cerebral infarction. OBJECTIVE To assess the value of whole-brain computed tomography perfusion (CTP) imaging combined with dynamic CT angiography (dCTA) in the evaluation of pial collateral circulation in patients with MCA occlusion. METHODS Whole-brain CTP and dCTA images were acquired in 58 patients with unilateral MCA occlusion. All patients were divided into three groups according to the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral score (by CTA). The CTP parameters were analysed, including relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), relative mean transit time (rMTT), and relative time to peak (rTTP). Patients were followed up with the modified Rankin scale (mRS). All cases in this study were confirmed by DSA. RESULTS The CTP parameters of the MCA blood supply area on the affected side of patients with different degrees of stenosis were significantly different from those on the unaffected side. There are significant differences in the CTP parameters and openings of the Willis circle in patients with different degrees of stenosis. Significant differences were found in the number of patients with good prognosis. CONCLUSIONS Whole-brain CT perfusion combined with dynamic CTA can structurally and functionally evaluate the establishment of pial collateral circulation and its effect on cerebral hemodynamic changes.
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Affiliation(s)
- Yi-Chuan Ma
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Ai-Qi Chen
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Fei Guo
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Juan Yu
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Min Xu
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Dan-Dan Shan
- Department of Radiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Shun-Hua Zhang
- School of Medical Imaging, Bengbu Medical College, Bengbu, Anhui, China
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Solár P, Zamani A, Lakatosová K, Joukal M. The blood-brain barrier and the neurovascular unit in subarachnoid hemorrhage: molecular events and potential treatments. Fluids Barriers CNS 2022; 19:29. [PMID: 35410231 PMCID: PMC8996682 DOI: 10.1186/s12987-022-00312-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/24/2022] [Indexed: 12/12/2022] Open
Abstract
The response of the blood-brain barrier (BBB) following a stroke, including subarachnoid hemorrhage (SAH), has been studied extensively. The main components of this reaction are endothelial cells, pericytes, and astrocytes that affect microglia, neurons, and vascular smooth muscle cells. SAH induces alterations in individual BBB cells, leading to brain homeostasis disruption. Recent experiments have uncovered many pathophysiological cascades affecting the BBB following SAH. Targeting some of these pathways is important for restoring brain function following SAH. BBB injury occurs immediately after SAH and has long-lasting consequences, but most changes in the pathophysiological cascades occur in the first few days following SAH. These changes determine the development of early brain injury as well as delayed cerebral ischemia. SAH-induced neuroprotection also plays an important role and weakens the negative impact of SAH. Supporting some of these beneficial cascades while attenuating the major pathophysiological pathways might be decisive in inhibiting the negative impact of bleeding in the subarachnoid space. In this review, we attempt a comprehensive overview of the current knowledge on the molecular and cellular changes in the BBB following SAH and their possible modulation by various drugs and substances.
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Affiliation(s)
- Peter Solár
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Pekařská 53, 656 91, Brno, Czech Republic
| | - Alemeh Zamani
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Klaudia Lakatosová
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Marek Joukal
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic.
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Whole-Brain Permeability Analysis on Admission Improves Prediction of Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2022; 31:106312. [PMID: 35093628 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106312] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To evaluate the changes of blood-brain barrier permeability (BBBP) after aneurysmal subarachnoid hemorrhage (aSAH) and find out whether BBBP within 24 h after onset can further improve prediction of delayed cerebral ischemia (DCI). METHODS CT perfusion (CTP) was performed within 24 h after onset and in the DCI time window (DCITW). Whole brain average values of flow extraction product (mKtrans), qualitative and quantitative CTP parameters, and clinical data were compared between DCI and non-DCI groups. The changes of mKtrans were analysed using a Paired t test. Multivariate logistic regression analysis and ROC analyses were performed to identify predictors of DCI and evaluate the predictive performance. RESULTS One hundred and forty of 179 consecutive patients were included, 45 of whom (32%) developed DCI. mKtrans was higher in the DCI group both on admission and in the DCITW (P<0.001). mKtrans decreased significantly in the non-DCI group (P=0.003), but not in DCI group (P=0.285). Multivariate logistic regression analysis showed that mKtrans (OR=1.07, 95%CI: 1.03-1.11, P<0.001), World Federation of Neurosurgery Scale (OR=6.73, 95%CI: 1.09-41.41, P=0.040), Hunt-Hess grade (OR=0.16, 95%CI: 0.02-1.19, P=0.073), modified Fisher Score (OR=3.74, 95%CI: 1.30-10.75, P=0.014), and qualitative CTP (OR=4.31, 95%CI: 1.49-12.47, P=0.007) were independent predictors of DCI. The model with Ktrans produced a larger AUC of 0.88 (95%CI: 0.81-0.95), with corresponding sensitivity and specificity of 84% and 86%, respectively. CONCLUSION BBBP measurement within 24 h after onset can improve the prediction of DCI. Early moderate BBB disruption may be reversible, whereas severe BBBP disruption indicates the risk of DCI.
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Dhir N, Attri SV, Pattanaik S, Kumar MP, Gill NK, Patial A, Rathore N, Saha L, Mohindra S. Aneurysmal Subarachnoid Hemorrhage: Impact on Phenytoin Permeability across the Blood-Brain Barrier. Neurol India 2021; 68:588-592. [PMID: 32643669 DOI: 10.4103/0028-3886.288987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Phenytoin (PHT) is a routinely prescribed prophylactic antiepileptic following aneurysmal subarachnoid hemorrhage (aSAH). However, its prophylactic use in aSAH is controversial as emerging evidence suggests worsening of the neurological and functional outcomes. In addition, there is profound damage to the blood-brain barrier (BBB) in aSAH, posing uncertainty about the permeability of PHT across BBB in these patients. This pilot study was designed to evaluate the alteration in PHT permeability across BBB in aSAH patients. Materials and Methods For conducting the study, 20 patients (control n = 10; aSAH (grade 3 or 4) n = 10) were recruited from a tertiary care hospital. The patients undergoing cranial surgery for pathology with intracerebral mass lesions on MRI were chosen as control for aSAH group. Both groups were administered PHT loading dose (20 mg/kg), infused in 5% dextrose, at a rate not more than 50 mg/min, followed by a maintenance dose (5 mg/kg). Quantification of PHT concentration was performed in brain tissue, plasma, and cerebrospinal fluid (CSF) by LC-MS/MS. Results The median PHT concentration in brain was found to be significantly decreased (64.8%) in aSAH group (3.78 μg/g) as compared to control (10.73 μg/g), P = 0.010. Similarly, median PHT brain concentration as fraction of plasma was significantly decreased in aSAH group (36.72%) compared to that of control (89.55%), P = 0.003. There was no significant difference in PHT concentration in plasma, CSF, and CSF as a fraction of plasma between both the groups. Conclusion There is a definite decrease in the penetration of PHT to the brain in patients with grade 3 and 4 aSAH.
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Affiliation(s)
- Neha Dhir
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Savita Verma Attri
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Smita Pattanaik
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - M Praveen Kumar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navjit Kaur Gill
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ajay Patial
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nidhi Rathore
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Lekha Saha
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sandeep Mohindra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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11
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Ivanidze J, Sanelli PC. Vasospasm: Role of Imaging in Detection and Monitoring Treatment. Neuroimaging Clin N Am 2021; 31:147-155. [PMID: 33902870 DOI: 10.1016/j.nic.2021.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cerebral vasospasm (VS) and delayed cerebral ischemia (DCI) are important complications of aneurysmal subarachnoid hemorrhage (ASAH). Imaging approaches to VS monitoring include noninvasive bedside assessment with transcranial Doppler ultrasonography, angiographic evaluation with digital subtraction angiography, and computed tomography (CT) angiography. DCI is a clinical diagnosis and is not fully explained by the presence of angiographic VS. CT perfusion has shown clinical utility and implications for future research in the evaluation of DCI in patients with ASAH. This review article discusses the common approaches to diagnosis and monitoring of VS and DCI, current treatment strategies, and future research directions.
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Affiliation(s)
- Jana Ivanidze
- Department of Radiology, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10021, USA.
| | - Pina C Sanelli
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, 300 Community Drive, Manhasset, NY 11030, USA
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12
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Amoo M, Henry J, Pender N, Brennan P, Campbell M, Javadpour M. Blood-brain barrier permeability imaging as a predictor for delayed cerebral ischaemia following subarachnoid haemorrhage. A narrative review. Acta Neurochir (Wien) 2021; 163:1457-1467. [PMID: 33404877 DOI: 10.1007/s00701-020-04670-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/01/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage is associated with significant morbidity and mortality due to the myriad of complications contributing to early brain injury and delayed cerebral ischaemia. There is increasing interest in the exploration of the association between blood-brain barrier integrity and risks of delayed cerebral ischaemia and poor outcomes. Despite recent advances in cerebral imaging, radiographic imaging of blood-brain barrier disruption, as a biomarker for outcome prediction, has not been adopted in clinical practice. METHODS We performed a narrative review by searching for articles describing molecular changes or radiological identification of changes in BBB permeability following subarachnoid haemorrhage (SAH) on MEDLINE. Preclinical studies were analysed if reported structural changes and clinical studies were included if they investigated for radiological markers of BBB disruption and its correlation with delayed cerebral ischaemia. RESULTS There is ample preclinical evidence to suggest that there are structural changes in BBB permeability following SAH. The available clinical literature has demonstrated correlations between permeability imaging and outcomes following aneurysmal subarachnoid haemorrhage (aSAH). CONCLUSION Radiological biomarkers offer a potential non-invasive prognostication tool and may also allow early identifications of patients who may be at risk of DCI.
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13
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Chen S, Xu P, Fang Y, Lenahan C. The Updated Role of the Blood Brain Barrier in Subarachnoid Hemorrhage: From Basic and Clinical Studies. Curr Neuropharmacol 2020; 18:1266-1278. [PMID: 32928088 PMCID: PMC7770644 DOI: 10.2174/1570159x18666200914161231] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a type of hemorrhagic stroke associated with high mortality and morbidity. The blood-brain-barrier (BBB) is a structure consisting primarily of cerebral microvascular endothelial cells, end feet of astrocytes, extracellular matrix, and pericytes. Post-SAH pathophysiology included early brain injury and delayed cerebral ischemia. BBB disruption was a critical mechanism of early brain injury and was associated with other pathophysiological events. These pathophysiological events may propel the development of secondary brain injury, known as delayed cerebral ischemia. Imaging advancements to measure BBB after SAH primarily focused on exploring innovative methods to predict clinical outcome, delayed cerebral ischemia, and delayed infarction related to delayed cerebral ischemia in acute periods. These predictions are based on detecting abnormal changes in BBB permeability. The parameters of BBB permeability are described by changes in computed tomography (CT) perfusion and magnetic resonance imaging (MRI). Kep seems to be a stable and sensitive indicator in CT perfusion, whereas Ktrans is a reliable parameter for dynamic contrast-enhanced MRI. Future prediction models that utilize both the volume of BBB disruption and stable parameters of BBB may be a promising direction to develop practical clinical tools. These tools could provide greater accuracy in predicting clinical outcome and risk of deterioration. Therapeutic interventional exploration targeting BBB disruption is also promising, considering the extended duration of post-SAH BBB disruption.
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Affiliation(s)
- Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - PengLei Xu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - YuanJian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou,
Zhejiang Province, China
| | - Cameron Lenahan
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA,Center for Neuroscience Research, School of Medicine, Loma Linda University, Loma Linda, CA, USA
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14
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Nadkarni NA, Maas MB, Batra A, Kim M, Manno EM, Sorond FA, Prabhakaran S, Naidech AM, Liotta EM. Elevated Cerebrospinal Fluid Protein Is Associated with Unfavorable Functional Outcome in Spontaneous Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104605. [PMID: 31932209 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104605] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 12/10/2019] [Accepted: 12/13/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND/OBJECTIVE Subarachnoid hemorrhage (SAH) is a devastating neurologic event for which markers to assess poor outcome are needed. Elevated cerebrospinal fluid (CSF) protein may result from inflammation and blood-brain barrier (BBB) disruption that occurs during SAH. We sought to determine if CSF protein level is associated with functional outcome after SAH. METHODS We prospectively collected single-center demographic and clinical data for consecutive patients admitted with spontaneous SAH. Inclusion required an external ventricular drain and daily CSF protein and cellular counts starting within 48 hours of symptom onset and extending through 7 days after onset. Seven-day average CSF protein was determined from daily measured values after correcting for contemporaneous CSF red blood cell (RBC) count. Three-month functional outcome was assessed by telephone interview with good outcome defined as modified Rankin score 0-3. Variables univariately associated with outcome at P less than .25 and measures of hemorrhage volume were included for binary logistic regression model development. RESULTS The study included 130 patients (88% aneurysmal SAH, 69% female, 54.8 ± 14.8 years, Glasgow Coma Scale [GCS] 14 [7-15]). Three-month outcome assessment was complete in 112 (86%) patients with good functional outcome in 74 (66%). CSF protein was lower in good outcome (35.3 [20.4-49.7] versus 80.5 [40.5-115.5] mg/dL; P < .001). CSF protein was not associated with cerebral vasospasm, but delayed radiographic infarction on 3 to 12-month neuroimaging was associated with higher CSF protein (46.3 [32.0-75.0] versus 30.2 [20.4-47.8] mg/dL; P = .023). Good 3-month outcome was independently associated with lower CSF protein (odds ratios [OR] .39 [.23-.70] for 75th versus 25th percentile of protein; P = .001) and higher admission GCS (OR 1.23 [1.10-1.37] for good outcome per GCS point increase; P < .001). Parenchymal hematoma predicted worse outcome (OR 6.31 [1.58-25.25]; P = .009). Results were similar after excluding nonaneurysmal SAH and after including CSF RBC count, CT score, and intraventricular hemorrhage volume in models. CONCLUSIONS Elevated average CSF protein is associated with poor outcome after spontaneous SAH. Further research should investigate if elevated CSF protein identifies patients in whom mechanisms such as BBB disruption contribute to poor outcome.
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Affiliation(s)
- Neil A Nadkarni
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Matthew B Maas
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Ayush Batra
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Minjee Kim
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Edward M Manno
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Farzaneh A Sorond
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Shyam Prabhakaran
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Andrew M Naidech
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Eric M Liotta
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois.
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15
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Forssten MP, Thelin EP, Nelson DW, Bellander BM. The Role of Glycerol-Containing Drugs in Cerebral Microdialysis: A Retrospective Study on the Effects of Intravenously Administered Glycerol. Neurocrit Care 2020; 30:590-600. [PMID: 30430381 PMCID: PMC6513829 DOI: 10.1007/s12028-018-0643-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cerebral microdialysis (CMD) is a valuable tool for monitoring compounds in the cerebral extracellular fluid (ECF). Glycerol is one such compound which is regarded as a marker of cell membrane decomposition. Notably, in some acutely brain-injured patients, CMD-glycerol levels rise without any other apparent indication of cerebral deterioration. The aim of this study was to investigate whether this could be due to an association between CMD-glycerol levels and the administration of glycerol-containing drugs. METHODS Microdialysis data were retrospectively retrieved from the hospital's intensive care unit patient data management system (PDMS). All patients who were monitored with CMD for ≥ 96 h were included. Administered drug doses were retrieved from the PDMS and converted to exact doses of glycerol. Cross-correlation analyses were performed between the free, metabolized as well as total administered dose of glycerol and the detrended and differenced CMD-glycerol concentration. These analyses were repeated for two sets of subgroups based upon the individual catheter's graphical trend and its location in relation to the lesion. RESULTS There was no significant correlation between the differenced CMD-glycerol levels and drug-administered glycerol. Furthermore, there was no significant correlation between CMD-glycerol and catheter location or graphical trend. However, if the CMD-glycerol levels were detrended, significant but clinically non-relevant correlations were identified (maximum correlation coefficient of 0.1 (0.04-0.15, 95% CI) at a lag of 7 h using the total administered dose of glycerol). CONCLUSIONS Glycerol-containing drugs routinely administered intravenously in the clinical setting appear to have a minimal and clinically insignificant effect on levels of glycerol in the cerebral ECF.
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Affiliation(s)
- Maximilian Peter Forssten
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - David W Nelson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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16
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Li Y, Wu P, Bihl JC, Shi H. Underlying Mechanisms and Potential Therapeutic Molecular Targets in Blood-Brain Barrier Disruption after Subarachnoid Hemorrhage. Curr Neuropharmacol 2020; 18:1168-1179. [PMID: 31903882 PMCID: PMC7770641 DOI: 10.2174/1570159x18666200106154203] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/18/2019] [Accepted: 01/04/2020] [Indexed: 01/01/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a subtype of hemorrhagic stroke with significant morbidity and mortality. Aneurysmal bleeding causes elevated intracranial pressure, decreased cerebral blood flow, global cerebral ischemia, brain edema, blood component extravasation, and accumulation of breakdown products. These post-SAH injuries can disrupt the integrity and function of the blood-brain barrier (BBB), and brain tissues are directly exposed to the neurotoxic blood contents and immune cells, which leads to secondary brain injuries including inflammation and oxidative stress, and other cascades. Though the exact mechanisms are not fully clarified, multiple interconnected and/or independent signaling pathways have been reported to be involved in BBB disruption after SAH. In addition, alleviation of BBB disruption through various pathways or chemicals has a neuroprotective effect on SAH. Hence, BBB permeability plays an important role in the pathological course and outcomes of SAH. This review discusses the recent understandings of the underlying mechanisms and potential therapeutic targets in BBB disruption after SAH, emphasizing the dysfunction of tight junctions and endothelial cells in the development of BBB disruption. The emerging molecular targets, including toll-like receptor 4, netrin-1, lipocalin-2, tropomyosin-related kinase receptor B, and receptor tyrosine kinase ErbB4, are also summarized in detail. Finally, we discussed the emerging treatments for BBB disruption after SAH and put forward our perspectives on future research.
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Affiliation(s)
| | | | - Ji C. Bihl
- Address correspondence to these authors at the Department of Pharmacology & Toxicology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, 45435, USA; Tel: 011-01-9377755243; Fax: 011-01-9377757221; E-mail: and Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China; Tel: +86-15545107889; E-mail:
| | - Huaizhang Shi
- Address correspondence to these authors at the Department of Pharmacology & Toxicology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, 45435, USA; Tel: 011-01-9377755243; Fax: 011-01-9377757221; E-mail: and Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China; Tel: +86-15545107889; E-mail:
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17
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Feng W, Zhang C, Yu T, Semyachkina-Glushkovskaya O, Zhu D. In vivo monitoring blood-brain barrier permeability using spectral imaging through optical clearing skull window. JOURNAL OF BIOPHOTONICS 2019; 12:e201800330. [PMID: 30485699 DOI: 10.1002/jbio.201800330] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/18/2018] [Accepted: 11/25/2018] [Indexed: 05/21/2023]
Abstract
The blood-brain barrier (BBB) plays a key role in the health of the central nervous system. Opening the BBB is very important for drug delivery to brain tissues to enhance the therapeutic effect on brain diseases. It is necessary to in vivo monitor the BBB permeability for assessing drug release with high resolution; however, an effective method is lacking. In this work, we developed a new method that combined spectral imaging with an optical clearing skull window to in vivo dynamically monitor BBB opening caused by 5-aminolevulinic acid (5-ALA)-mediated photodynamic therapy (PDT), in which the Evans blue dye (EBd) acted as an indicator of the BBB permeability. Using this method, we effectively monitored the cerebrovascular EBd leakage process. Moreover, the analysis of changes in the vascular and extravascular EBd concentrations demonstrated that the PDT-induced BBB opening exhibited spatiotemporal differences in the cortex. This spectral imaging method based on the optical clearing skull window provides a low-cost and simply operated tool for in vivo monitoring BBB opening process. This has a high potential for the visualization of drug delivery to the central nervous system. Thus, it is of tremendous significance in brain disease therapy. Monitoring the changes in PDT-induced BBB permeability by evaluating the EBd concentration using an optical clearing skull window. (A) Entire brains and coronal sections following treatment of PDT with/without an optical clearing skull window after injection of EBd. (B) Typical EBd distribution maps before and after laser irradiation captured by the spectral imaging method. (Colorbar represents the EBd concentration).
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Affiliation(s)
- Wei Feng
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics-Huazhong University of Science and Technology, Wuhan, Hubei, China
- MOE Key Laboratory for Biomedical Photonics, Collaborative Innovation Center for Biomedical Engineering, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chao Zhang
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics-Huazhong University of Science and Technology, Wuhan, Hubei, China
- MOE Key Laboratory for Biomedical Photonics, Collaborative Innovation Center for Biomedical Engineering, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Tingting Yu
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics-Huazhong University of Science and Technology, Wuhan, Hubei, China
- MOE Key Laboratory for Biomedical Photonics, Collaborative Innovation Center for Biomedical Engineering, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | | | - Dan Zhu
- Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics-Huazhong University of Science and Technology, Wuhan, Hubei, China
- MOE Key Laboratory for Biomedical Photonics, Collaborative Innovation Center for Biomedical Engineering, School of Engineering Sciences, Huazhong University of Science and Technology, Wuhan, Hubei, China
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18
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Blood-Brain Barrier Permeability in Aneurysmal Subarachnoid Hemorrhage: Correlation With Clinical Outcomes. AJR Am J Roentgenol 2018; 211:891-895. [DOI: 10.2214/ajr.17.18237] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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19
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Russin JJ, Montagne A, D’Amore F, He S, Shiroishi MS, Rennert RC, Depetris J, Zlokovic BV, Mack WJ. Permeability imaging as a predictor of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab 2018; 38:973-979. [PMID: 29611451 PMCID: PMC5998996 DOI: 10.1177/0271678x18768670] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Blood-brain barrier (BBB) dysfunction has been implicated in ischemic risk following aneurysmal subarachnoid hemorrhage (aSAH), but never directly imaged. We prospectively examined whether post-bleed day 4 dynamic contrast-enhanced magnetic resonance (DCE-MR) BBB permeability imaging could predict development of delayed cerebral ischemia (DCI). Global MR-derived BBB permeability ( Ktrans) was significantly higher in aSAH patients who subsequently developed DCI (five patients; 2.28 ± 0.09 × 10-3 min-1) compared to those who experienced radiographic vasospasm only (three patients; 1.85 ± 0.12 × 10-3 min-1; p < 0.05), or no vasospasm/ischemia (eight patients; 1.74 ± 0.07 × 10-3 min-1; p < 0.01). Ktrans > 2 × 10-3 min-1 predicted development of DCI (AUC = 0.98, 95% CI: 0.93-1). Global BBB dysfunction following aSAH is detectable with DCE-MR and predictive of ischemic risk.
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Affiliation(s)
- Jonathan J Russin
- USC Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Jonathan J Russin, USC Neurorestoration Center, Keck School of Medicine, University of Southern California, 1200 N State Street, Suite 3300, Los Angeles, CA 90033, USA.
| | - Axel Montagne
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Francesco D’Amore
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shuhan He
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Mark S Shiroishi
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert C Rennert
- USC Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jena Depetris
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Berislav V Zlokovic
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - William J Mack
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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20
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Li Q, Gao X, Yao Z, Feng X, He H, Xue J, Gao P, Yang L, Cheng X, Chen W, Yang Y. Permeability Surface of Deep Middle Cerebral Artery Territory on Computed Tomographic Perfusion Predicts Hemorrhagic Transformation After Stroke. Stroke 2017; 48:2412-2418. [PMID: 28775139 DOI: 10.1161/strokeaha.117.017486] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/22/2017] [Accepted: 07/10/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Permeability surface (PS) on computed tomographic perfusion reflects blood-brain barrier permeability and is related to hemorrhagic transformation (HT). HT of deep middle cerebral artery (MCA) territory can occur after recanalization of proximal large-vessel occlusion. We aimed to determine the relationship between HT and PS of deep MCA territory. METHODS We retrospectively reviewed 70 consecutive acute ischemic stroke patients presenting with occlusion of the distal internal carotid artery or M1 segment of the MCA. All patients underwent computed tomographic perfusion within 6 hours after symptom onset. Computed tomographic perfusion data were postprocessed to generate maps of different perfusion parameters. Risk factors were identified for increased deep MCA territory PS. Receiver operating characteristic curve analysis was performed to calculate the optimal PS threshold to predict HT of deep MCA territory. RESULTS Increased PS was associated with HT of deep MCA territory. After adjustments for age, sex, onset time to computed tomographic perfusion, and baseline National Institutes of Health Stroke Scale, poor collateral status (odds ratio, 7.8; 95% confidence interval, 1.67-37.14; P=0.009) and proximal MCA-M1 occlusion (odds ratio, 4.12; 95% confidence interval, 1.03-16.52; P=0.045) were independently associated with increased deep MCA territory PS. Relative PS most accurately predicted HT of deep MCA territory (area under curve, 0.94; optimal threshold, 2.89). CONCLUSIONS Increased PS can predict HT of deep MCA territory after recanalization therapy for cerebral proximal large-vessel occlusion. Proximal MCA-M1 complete occlusion and distal internal carotid artery occlusion in conjunction with poor collaterals elevate deep MCA territory PS.
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Affiliation(s)
- Qiao Li
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Xinyi Gao
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Zhenwei Yao
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Xiaoyuan Feng
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Huijin He
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.).
| | - Jing Xue
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Peiyi Gao
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Lumeng Yang
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Xin Cheng
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Weijian Chen
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Yunjun Yang
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
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21
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Heparin and Heparin-Derivatives in Post-Subarachnoid Hemorrhage Brain Injury: A Multimodal Therapy for a Multimodal Disease. Molecules 2017; 22:molecules22050724. [PMID: 28468328 PMCID: PMC6154575 DOI: 10.3390/molecules22050724] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 12/23/2022] Open
Abstract
Pharmacologic efforts to improve outcomes following aneurysmal subarachnoid hemorrhage (aSAH) remain disappointing, likely owing to the complex nature of post-hemorrhage brain injury. Previous work suggests that heparin, due to the multimodal nature of its actions, reduces the incidence of clinical vasospasm and delayed cerebral ischemia that accompany the disease. This narrative review examines how heparin may mitigate the non-vasospastic pathological aspects of aSAH, particularly those related to neuroinflammation. Following a brief review of early brain injury in aSAH and heparin’s general pharmacology, we discuss potential mechanistic roles of heparin therapy in treating post-aSAH inflammatory injury. These roles include reducing ischemia-reperfusion injury, preventing leukocyte extravasation, modulating phagocyte activation, countering oxidative stress, and correcting blood-brain barrier dysfunction. Following a discussion of evidence to support these mechanistic roles, we provide a brief discussion of potential complications of heparin usage in aSAH. Our review suggests that heparin’s use in aSAH is not only safe, but effectively addresses a number of pathologies initiated by aSAH.
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22
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Giardino A, Gupta S, Olson E, Sepulveda K, Lenchik L, Ivanidze J, Rakow-Penner R, Patel MJ, Subramaniam RM, Ganeshan D. Role of Imaging in the Era of Precision Medicine. Acad Radiol 2017; 24:639-649. [PMID: 28131497 DOI: 10.1016/j.acra.2016.11.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/07/2016] [Accepted: 11/29/2016] [Indexed: 12/17/2022]
Abstract
Precision medicine is an emerging approach for treating medical disorders, which takes into account individual variability in genetic and environmental factors. Preventive or therapeutic interventions can then be directed to those who will benefit most from targeted interventions, thereby maximizing benefits and minimizing costs and complications. Precision medicine is gaining increasing recognition by clinicians, healthcare systems, pharmaceutical companies, patients, and the government. Imaging plays a critical role in precision medicine including screening, early diagnosis, guiding treatment, evaluating response to therapy, and assessing likelihood of disease recurrence. The Association of University Radiologists Radiology Research Alliance Precision Imaging Task Force convened to explore the current and future role of imaging in the era of precision medicine and summarized its finding in this article. We review the increasingly important role of imaging in various oncological and non-oncological disorders. We also highlight the challenges for radiology in the era of precision medicine.
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Affiliation(s)
- Angela Giardino
- Department of Imaging, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Supriya Gupta
- Department of Radiology and Imaging, Medical College of Georgia, 1120 15th St, Augusta, GA 30912.
| | - Emmi Olson
- Radiology Resident, University of California San Diego, San Diego, California
| | | | - Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jana Ivanidze
- Department of Diagnostic Radiology, Weill Cornell Medicine, New York, New York
| | - Rebecca Rakow-Penner
- Department of Radiology, University of California San Diego, San Diego, California
| | - Midhir J Patel
- Department of Radiology, University of South Florida, Tampa, Florida
| | - Rathan M Subramaniam
- Cyclotron and Molecular Imaging Program, Department of Radiology, UT Southwestern Medical Center, Dallas, Texas
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23
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Ivanidze J, Charalel RA, Shuryak I, Brenner D, Pandya A, Kallas ON, Kesavabhotla K, Segal AZ, Simon MS, Sanelli PC. Effects of Radiation Exposure on the Cost-Effectiveness of CT Angiography and Perfusion Imaging in Aneurysmal Subarachnoid Hemorrhage. AJNR Am J Neuroradiol 2017; 38:462-468. [PMID: 28082263 DOI: 10.3174/ajnr.a5034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/03/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE CT angiography and perfusion imaging is an important prognostic tool in the management of patients with aneurysmal subarachnoid hemorrhage. The purpose of this study was to perform a cost-effectiveness analysis of advanced imaging in patients with SAH, incorporating the risks of radiation exposure from CT angiography and CT perfusion imaging. MATERIALS AND METHODS The risks of radiation-induced brain cancer and cataracts were incorporated into our established decision model comparing the cost-effectiveness of CT angiography and CT perfusion imaging and transcranial Doppler sonography in SAH. Cancer risk was calculated by using National Cancer Institute methodology. The remaining input probabilities were based on literature data and a cohort at our institution. Outcomes were expected quality-adjusted life years gained, costs, and incremental cost-effectiveness ratios. One-way, 2-way, and probabilistic sensitivity analyses were performed. RESULTS CT angiography and CT perfusion imaging were the dominant strategies, resulting in both better health outcomes and lower costs, even when incorporating brain cancer and cataract risks. Our results remained robust in 2-way sensitivity analyses varying the prolonged latency period up to 30 years, with either brain cancer risk up to 50 times higher than the upper 95% CI limit or the probability of cataracts from 0 to 1. Results were consistent for scenarios that considered either symptomatic or asymptomatic patients with SAH. Probabilistic sensitivity analysis confirmed our findings over a broad range of selected input parameters. CONCLUSIONS While risks of radiation exposure represent an important consideration, CT angiography and CT perfusion imaging remained the preferred imaging compared with transcranial Doppler sonography in both asymptomatic and symptomatic patients with SAH, with improved health outcomes and lower health care costs, even when modeling a significantly higher risk and shorter latency period for both cataract and brain cancer than that currently known.
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Affiliation(s)
- J Ivanidze
- From the Departments of Radiology (J.I., R.A.C., O.N.K., K.K., P.C.S.)
| | - R A Charalel
- From the Departments of Radiology (J.I., R.A.C., O.N.K., K.K., P.C.S.)
| | - I Shuryak
- Department of Radiology (I.S., D.B.), NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - D Brenner
- Department of Radiology (I.S., D.B.), NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - A Pandya
- Department of Health Policy and Management (A.P.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - O N Kallas
- From the Departments of Radiology (J.I., R.A.C., O.N.K., K.K., P.C.S.)
| | - K Kesavabhotla
- From the Departments of Radiology (J.I., R.A.C., O.N.K., K.K., P.C.S.)
| | | | - M S Simon
- Internal Medicine and Public Health (M.S.S.), Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
- Department of Radiology (M.S.S., P.C.S.), Northwell Health, Manhasset, New York
| | - P C Sanelli
- From the Departments of Radiology (J.I., R.A.C., O.N.K., K.K., P.C.S.)
- Department of Radiology (M.S.S., P.C.S.), Northwell Health, Manhasset, New York
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24
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Ji B, Zhou F, Han L, Yang J, Fan H, Li S, Li J, Zhang X, Wang X, Chen X, Xu Y. Sodium Tanshinone IIA Sulfonate Enhances Effectiveness Rt-PA Treatment in Acute Ischemic Stroke Patients Associated with Ameliorating Blood-Brain Barrier Damage. Transl Stroke Res 2017; 8:334-340. [PMID: 28243834 PMCID: PMC5493726 DOI: 10.1007/s12975-017-0526-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 12/11/2022]
Abstract
Treatment with sodium tanshinone IIA sulfonate (STS) may ameliorate blood-brain barrier (BBB) damage in acute ischemic stroke patients receiving recombinant tissue plasminogen activator (rt-PA) thrombolysis and improve stroke patients’ outcome. This randomized, single-center, placebo-controlled clinical trial investigated the potential effects and underlying mechanisms of STS. Forty-two acute ischemic stroke patients receiving intravenous rt-PA thrombolysis were randomized to intravenous administration either with STS (60 mg/day) (n = 21) or with equivalent volume of saline as a placebo (n = 21) after randomization for 10 days. Clinical outcomes, computer tomography perfusion (CTP) imaging with permeability-surface area product (PS) maps and serum levels of BBB damage biomarkers, were compared between the two groups. The percentage of patients with excellent functional outcome indicated by a 90-day mRS ≤1 was significantly higher in the STS group than in the placebo group (p = 0.028). For patients with CTP imaging (n = 30), PS in the ipsilateral lesion (p = 0.034) and relative PS (p = 0.013) were significantly lower in the STS group than that in placebo. STS-treated patients also had lower levels of matrix metalloproteinase (MMP)-9 (p = 0.036) and claudin-5 (p = 0.026), but higher levels of tissue inhibitor of metalloproteinase (TIMP)-1 (p = 0.040) than those in the placebo group. Post-stroke STS treatment could improve neurologic functional outcomes for acute ischemic stroke patients following rt-PA treatment by reducing BBB leakage and damage, which might be mechanistically associated with MMP-9 inhibition.
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Affiliation(s)
- Biying Ji
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Fei Zhou
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Lijuan Han
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Jun Yang
- GE Healthcare, Shanghai, People's Republic of China
| | - Haijian Fan
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Shanshan Li
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Jingwei Li
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Xin Zhang
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China
| | - Xiaoying Wang
- Departments of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Xiangyan Chen
- Departments of Medicine and Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
| | - Yun Xu
- Department of Neurology and Radiology, Drum Tower Hospital, Medical School and The State Key Laboratory of Pharmaceutical Biotechnology and Jiangsu Key Laboratory for Molecular Medicine of Nanjing University, Nanjing, People's Republic of China.
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25
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Ivanidze J, Kallas ON, Gupta A, Weidman E, Baradaran H, Mir D, Giambrone A, Segal AZ, Claassen J, Sanelli PC. Application of Blood-Brain Barrier Permeability Imaging in Global Cerebral Edema. AJNR Am J Neuroradiol 2016; 37:1599-603. [PMID: 27127002 DOI: 10.3174/ajnr.a4784] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 02/22/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Blood-brain barrier permeability is not routinely evaluated in the clinical setting. Global cerebral edema occurs after SAH and is associated with BBB disruption. Detection of global cerebral edema using current imaging techniques is challenging. Our purpose was to apply blood-brain barrier permeability imaging in patients with global cerebral edema by using extended CT perfusion. MATERIALS AND METHODS Patients with SAH underwent CTP in the early phase after aneurysmal rupture (days 0-3) and were classified as having global cerebral edema or nonglobal cerebral edema using established noncontrast CT criteria. CTP data were postprocessed into blood-brain barrier permeability quantitative maps of PS (permeability surface-area product), K(trans) (volume transfer constant from blood plasma to extravascular extracellular space), Kep (washout rate constant of the contrast agent from extravascular extracellular space to intravascular space), VE (extravascular extracellular space volume per unit of tissue volume), VP (plasmatic volume per unit of tissue volume), and F (plasma flow) by using Olea Sphere software. Mean values were compared using t tests. RESULTS Twenty-two patients were included in the analysis. Kep (1.32 versus 1.52, P < .0001), K(trans) (0.15 versus 0.19, P < .0001), VP (0.51 versus 0.57, P = .0007), and F (1176 versus 1329, P = .0001) were decreased in global cerebral edema compared with nonglobal cerebral edema while VE (0.81 versus 0.39, P < .0001) was increased. CONCLUSIONS Extended CTP was used to evaluate blood-brain barrier permeability in patients with SAH with and without global cerebral edema. Kep is an important indicator of altered blood-brain barrier permeability in patients with decreased blood flow, as Kep is flow-independent. Further study of blood-brain barrier permeability is needed to improve diagnosis and monitoring of global cerebral edema.
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Affiliation(s)
- J Ivanidze
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - O N Kallas
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - A Gupta
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - E Weidman
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - H Baradaran
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - D Mir
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
| | - A Giambrone
- Healthcare Policy and Research (A.Giambrone)
| | - A Z Segal
- Neurology (A.Z.S.), Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
| | - J Claassen
- Department of Neurology (J.C.), New York-Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | - P C Sanelli
- From the Departments of Radiology (J.I., O.N.K., A.Gupta, E.W., H.B., D.M., P.C.S.)
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26
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Hammer C, Daou B, Chalouhi N, Starke RM, Ya'qoub L, Mouchtouris N, Koduri S, Tjoumakaris S, Rosenwasser RH, Jabbour P. Decreased CSF output as a clinical indicator of cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2016; 144:101-4. [PMID: 27037865 DOI: 10.1016/j.clineuro.2016.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 02/22/2016] [Accepted: 03/27/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Vasospasm is a significant cause of morbidity and mortality among those with aneurysmal subarachnoid hemorrhage (aSAH). Treating increased intracranial pressure by drainage of cerebral spinal fluid through an external ventriculostomy is routine practice. The objective of this study is to evaluate the trends of CSF output in patients who experience vasospasm. METHODS Electronic medical charts were reviewed to identify two groups of patients with aSAH, 75 consecutive patients who developed vasospasm and 75 matched patients who did not develop vasospasm. CSF output was recorded within 3 days before and 3 days after the occurrence of vasospasm. CSF output was recorded for the same days after SAH in matched patients with no vasospasm. RESULTS Total CSF output was lower in patients with vasospasm as compared to patients without vasospasm matched for the same day (p<0.001). In patients with vasospasm, CSF output recordings were significantly higher prior to the occurrence of vasospasm (438ml/day) than the period following vasospasm (325.7ml/day), with a consistent decrease in CSF drainage from day 3 before vasospasm to day 3 after vasospasm (p=0.012). Decreasing CSF output was significantly associated with the occurrence of vasospasm (p=0.017). Youden indices demonstrated that daily CSF drainage <160ml was significantly associated with the occurrence of vasospasm. The sensitivity of this test was 64.79% and the specificity was 55.38%. CONCLUSIONS In addition to clinical exam findings, observation of a CSF output decline to less than 160ml/day may be used as additional support for the diagnosis of vasospasm.
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Affiliation(s)
- Christine Hammer
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Badih Daou
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Robert M Starke
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Lina Ya'qoub
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Sravanthi Koduri
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
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