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Kalyani P, Lippa SM, Werner JK, Amyot F, Moore CB, Kenney K, Diaz-Arrastia R. Phosphodiesterase-5 (PDE-5) Inhibitors as Therapy for Cerebrovascular Dysfunction in Chronic Traumatic Brain Injury. Neurotherapeutics 2023; 20:1629-1640. [PMID: 37697134 PMCID: PMC10684467 DOI: 10.1007/s13311-023-01430-z] [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] [Accepted: 08/22/2023] [Indexed: 09/13/2023] Open
Abstract
Multiple phase III randomized controlled trials (RCTs) for pharmacologic interventions in traumatic brain injury (TBI) have failed despite promising results in experimental models. The heterogeneity of TBI, in terms of pathomechanisms and impacted brain structures, likely contributes to these failures. Biomarkers have been recommended to identify patients with relevant pathology (predictive biomarkers) and confirm target engagement and monitor therapy response (pharmacodynamic biomarkers). Our group focuses on traumatic cerebrovascular injury as an understudied endophenotype of TBI and is validating a predictive and pharmacodynamic imaging biomarker (cerebrovascular reactivity; CVR) in moderate-severe TBI. We aim to extend these studies to milder forms of TBI to determine the optimal dose of sildenafil for maximal improvement in CVR. We will conduct a phase II dose-finding study involving 160 chronic TBI patients (mostly mild) using three doses of sildenafil, a phosphodiesterase-5 (PDE-5) inhibitor. The study measures baseline CVR and evaluates the effect of escalating sildenafil doses on CVR improvement. A 4-week trial of thrice daily sildenafil will assess safety, tolerability, and clinical efficacy. This dual-site 4-year study, funded by the Department of Defense and registered in ClinicalTrials.gov (NCT05782244), plans to launch in June 2023. Biomarker-informed RCTs are essential for developing effective TBI interventions, relying on an understanding of underlying pathomechanisms. Traumatic microvascular injury (TMVI) is an attractive mechanism which can be targeted by vaso-active drugs such as PDE-5 inhibitors. CVR is a potential predictive and pharmacodynamic biomarker for targeted interventions aimed at TMVI. (Trial registration: NCT05782244, ClinicalTrials.gov ).
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Affiliation(s)
- Priyanka Kalyani
- Department of Neurology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
| | - Sara M Lippa
- Walter Reed National Military Medical Center, The National Intrepid Center of Excellence, Palmer Rd S, Bethesda, MD, 20814, USA
- Department of Neuroscience, Uniformed Services University Health Sciences, 4301, Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - J Kent Werner
- Walter Reed National Military Medical Center, The National Intrepid Center of Excellence, Palmer Rd S, Bethesda, MD, 20814, USA
- Department of Neuroscience, Uniformed Services University Health Sciences, 4301, Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - Franck Amyot
- Walter Reed National Military Medical Center, The National Intrepid Center of Excellence, Palmer Rd S, Bethesda, MD, 20814, USA
| | - Carol B Moore
- Department of Neuroscience, Uniformed Services University Health Sciences, 4301, Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - Kimbra Kenney
- Department of Neuroscience, Uniformed Services University Health Sciences, 4301, Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
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Chiu SC, Hsu ST, Huang CW, Shen WC, Peng SL. Phase Contrast Magnetic Resonance Imaging in the Rat Common Carotid Artery. J Vis Exp 2018. [PMID: 30247472 DOI: 10.3791/57304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Phase contrast magnetic resonance imaging (PC-MRI) is a noninvasive approach that can quantify flow-related parameters such as blood flow. Previous studies have shown that abnormal blood flow may be associated with systemic vascular risk. Thus, PC-MRI can facilitate the translation of data obtained from animal models of cardiovascular diseases to pertinent clinical investigations. In this report, we describe the procedure for measuring blood flow in the common carotid artery (CCA) of rats using cine-gated PC-MRI and discuss relevant analysis methods. This procedure can be performed in a live, anesthetized animal and does not require euthanasia after the procedure. The proposed scanning parameters yield repeatable measurements for blood flow, indicating excellent reproducibility of the results. The PC-MRI procedure described in this article can be used for pharmacological testing, pathophysiological assessment, and cerebral hemodynamics evaluation.
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Affiliation(s)
- Shao-Chieh Chiu
- Center for Advanced Molecular Imaging and Translation, Chang Gung Memorial Hospital
| | - Shih-Ting Hsu
- Center for Advanced Molecular Imaging and Translation, Chang Gung Memorial Hospital
| | - Chiun-Wei Huang
- Center for Advanced Molecular Imaging and Translation, Chang Gung Memorial Hospital
| | - Wu-Chung Shen
- Department of Biomedical Imaging and Radiological Science, China Medical University
| | - Shin-Lei Peng
- Department of Biomedical Imaging and Radiological Science, China Medical University;
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Shum GL, Cinnamond S, Hough AD, Craven R, Whittingham W. Test-Retest Reliability of Measuring the Vertebral Arterial Blood Flow Velocity in People With Cervicogenic Dizziness. J Manipulative Physiol Ther 2017; 40:255-262. [PMID: 28390708 DOI: 10.1016/j.jmpt.2017.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 10/19/2016] [Accepted: 10/19/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the within-session and between-sessions reliability of measuring the vertebral artery blood flow velocities in people with cervicogenic dizziness using Doppler ultrasound at both upper and lower cervical levels. METHODS Outcome measures were taken on 2 occasions 3 weeks apart with no active treatment provided in between the assessments on 12 participants. Pulsed-wave Doppler ultrasound was used to quantify time-averaged mean velocities through the vertebral artery at upper cervical (C0-1) and lower cervical vertebrae (C5-6). The clinical outcome measures were also recorded in people with cervicogenic dizziness. The intraclass correlation coefficient (ICC) was used to determine the within-session and between-session repeatability. Paired t test was used to determine the differences in the time-averaged mean velocities of blood flow at the same site of the vertebral artery and the clinical outcome measures in 2 sessions 3 weeks apart. RESULTS In people with cervicogenic dizziness, there was no significant change in both clinical outcome measures and the time-averaged mean velocities when the patients were measured 3 weeks apart (P > .05). This study identified good within-session (ICC: 0.903-0.967) and between-session (ICC: 0.922-0.984) repeatability in measuring the vertical blood flow velocities in patients with cervicogenic dizziness when the clinical outcome measures were unchanged. CONCLUSIONS This study supports the use of Doppler ultrasound to identify changes in mean vertebral arterial blood flow velocities before and after intervention in people with cervicogenic dizziness in future studies.
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Affiliation(s)
- Gary L Shum
- Faculty of Sport & Health Sciences, Plymouth Marjon University, Plymouth, United Kingdom.
| | - Sally Cinnamond
- Faculty of Sport & Health Sciences, Plymouth Marjon University, Plymouth, United Kingdom
| | - Alan D Hough
- Faculty of Sport & Health Sciences, Plymouth Marjon University, Plymouth, United Kingdom
| | - Richard Craven
- Vascular Assessment Unit, Derriford Hospital, Plymouth, United Kingdom
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Shakeri A, Nemati M, Shakeri M, Goldust M. Color Doppler Sonography in Healthy Old Persons, Vertebral Arteries. JOURNAL OF MEDICAL SCIENCES 2012. [DOI: 10.3923/jms.2012.292.297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mukherjee KK, Singh SK, Khosla VK, Mohindra S, Salunke P. Safety and efficacy of sildenafil citrate in reversal of cerebral vasospasm: A feasibility study. Surg Neurol Int 2012; 3:3. [PMID: 22347673 PMCID: PMC3280003 DOI: 10.4103/2152-7806.92164] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 12/13/2011] [Indexed: 12/28/2022] Open
Abstract
Objective: Cerebral vasospasm is the commonest cause for mortality and morbidity in patients following clipping of a ruptured aneurysm. Selective phosphodiesterase (PDE) inhibitor like sildenafil acts as a vasodilator. The objective of this study was to evaluate the safety and feasibility of oral sildenafil citrate in patients with symptomatic refractory vasospasm. Methods: A total of 832 patients with aneurysmal subarachnoid bleed were operated in 4 years. Two hundred and seventy-three patients had vasospasm. Of these, 72 patients had refractory cerebral vasospasm. Vasospasm was defined as refractory when institution of “HHH” failed to reverse the transcranial Doppler (TCD) values even after 24 hours. Computed tomography (CT) scan showed no infarct, hematoma, or hydrocephalus, and the serum electrolytes were within normal limits. They received 100–150 mg of sildenafil every 4 hours. Response was evaluated by 2-hourly TCD. Results: Eight patients had sustained (TCD values normal for >48 hours) and four had temporary relief in vasospasm, as suggested. Four patients developed complications significant enough to terminate the therapy. Conclusions: Sildenafil citrate may be effective in patients with refractory symptomatic vasospasm. It calls upon the pharmacologists and scientists to discover newer supraselective PDE inhibitors, specific to PDE receptors in brain vessels.
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