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Pantel T, Neulen A, Mader MMD, Kurz E, Piffko A, Fassl V, Westphal M, Gempt J, Ringel F, Czorlich P. Impact of pre-hospital handling and initial time to cranial computed tomography on outcome in aneurysmal subarachnoid hemorrhage patients with out-of-hospital sudden cardiac arrest-a retrospective bi-centric study. Front Cardiovasc Med 2023; 10:1209939. [PMID: 37671140 PMCID: PMC10475531 DOI: 10.3389/fcvm.2023.1209939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/24/2023] [Indexed: 09/07/2023] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (SAH) presents occasionally with cardiac arrest (CA). The impact of pre-hospital and emergency room (ER) treatment on outcome remains unclear. Therefore, we investigated the impact of pre-hospital treatment, focusing on lay cardiopulmonary resuscitation (CPR), and ER handling on the outcome of SAH patients with out-of-hospital CA (OHCA). Methods In this bi-centric retrospective analysis, we reviewed SAH databases for OHCA and CPR from January 2011 to June 2021. Patients were analyzed for general clinical and epidemiological parameters. CPR data were obtained from ambulance reports and information on ER handling from the medical records. Data were correlated with patient survival at hospital discharge as a predefined outcome parameter. Results Of 1,120 patients with SAH, 45 (4.0%) were identified with OHCA and CPR, 38 of whom provided all required information and were included in this study. Time to resuscitation was significantly shorter with lay resuscitation (5.3 ± 5.2 min vs. 0.3 ± 1.2 min, p = 0.003). Nineteen patients were not initially scheduled for cranial computed tomography (CCT), resulting in a significantly longer time interval to first CCT (mean ± SD: 154 ± 217 min vs. 40 ± 23 min; p < 0.001). Overall survival to discharge was 31.6%. Pre-hospital lay CPR was not associated with higher survival (p = 0.632). However, we observed a shorter time to first CCT in surviving patients (p = 0.065). Conclusions OHCA in SAH patients is not uncommon. Besides high-quality CPR, time to diagnosis of SAH appears to play an important role. We therefore recommend considering CCT diagnostics as part of the diagnostic algorithm in patients with OHCA.
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Affiliation(s)
- Tobias Pantel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | - Elena Kurz
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Verena Fassl
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Reder SR, Lückerath S, Neulen A, Beiser KU, Grauhan NF, Othman AE, Brockmann MA, Brockmann C, Kronfeld A. DSA-Based 2D Perfusion Measurements in Delayed Cerebral Ischemia to Estimate the Clinical Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage: A Technical Feasibility Study. J Clin Med 2023; 12:4135. [PMID: 37373828 DOI: 10.3390/jcm12124135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/05/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: To predict clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH) and delayed cerebral ischemia (DCI) by assessment of the cerebral perfusion using a 2D perfusion angiography (2DPA) time-contrast agent (CA) concentration model. (2) Methods: Digital subtraction angiography (DSA) data sets of n = 26 subjects were acquired and post-processed focusing on changes in contrast density using a time-concentration model at three time points: (i) initial presentation with SAH (T0); (ii) vasospasm-associated acute clinical impairment (T1); and (iii) directly after endovascular treatment (T2) of SAH-associated large vessel vasospasm (LVV), which resulted in n = 78 data sets. Maximum slope (MS in SI/ms), time-to-peak (TTP in ms), and maximum amplitude of a CA bolus (dSI) were measured in brain parenchyma using regions of interest (ROIs). First, acquired parameters were standardized to the arterial input function (AIF) and then statistically analyzed as mean values. Additionally, data were clustered into two subsets consisting of patients with regredient or with stable/progredient symptoms (or Doppler signals) after endovascular treatment (n = 10 vs. n = 16). (3) Results: Perfusion parameters (MS, TTP, and dSI) differed significantly between T0 and T1 (p = 0.003 each). Significant changes between T1 and T2 were only detectable for MS (0.041 ± 0.016 vs. 0.059 ± 0.026; p = 0.011) in patients with regredient symptoms at T2 (0.04 ± 0.012 vs. 0.066 ± 0.031; p = 0.004). For dSI, there were significant differences between T0 and T2 (5095.8 ± 2541.9 vs. 3012.3 ± 968.3; p = 0.001), especially for those with stable symptoms at T2 (5685.4 ± 2967.2 vs. 3102.8 ± 1033.2; p = 0.02). Multiple linear regression analysis revealed that a) the difference in MS between T1 and T2 and b) patient's age (R = 0.6; R2 = 0.34; p = 0.009) strongly predict the modified Rankin Scale (mRS) at discharge. (4) Conclusions: 2DPA allows the direct measurement of treatment effects in SAH associated DCI and may be used to predict outcomes in these critically ill patients.
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Affiliation(s)
- Sebastian R Reder
- Department of Neuroradiology, University Medical Centre, Johannes Gutenberg University of Mainz, 55131 Mainz, Germany
| | - Steffen Lückerath
- Department of Neuroradiology, University Medical Centre, Johannes Gutenberg University of Mainz, 55131 Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Centre, Johannes Gutenberg University of Mainz, 55131 Mainz, Germany
| | - Katja U Beiser
- Department of Neuroradiology, University Medical Centre, Johannes Gutenberg University of Mainz, 55131 Mainz, Germany
| | - Nils F Grauhan
- Department of Neuroradiology, University Medical Centre, Johannes Gutenberg University of Mainz, 55131 Mainz, Germany
| | - Ahmed E Othman
- Department of Neuroradiology, University Medical Centre, Johannes Gutenberg University of Mainz, 55131 Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Centre, Johannes Gutenberg University of Mainz, 55131 Mainz, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Medical Centre, Johannes Gutenberg University of Mainz, 55131 Mainz, Germany
| | - Andrea Kronfeld
- Department of Neuroradiology, University Medical Centre, Johannes Gutenberg University of Mainz, 55131 Mainz, Germany
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3
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Krämer TJ, Pickart F, Pöttker B, Gölz C, Neulen A, Pantel T, Goetz H, Ritter K, Schäfer MKE, Thal SC. Early DNase-I therapy delays secondary brain damage after traumatic brain injury in adult mice. Sci Rep 2023; 13:4348. [PMID: 36928073 PMCID: PMC10018640 DOI: 10.1038/s41598-023-30421-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/22/2023] [Indexed: 03/18/2023] Open
Abstract
Traumatic brain injury (TBI) causes the release of danger-associated molecular patterns (DAMP) from damaged or dead cells, which contribute to secondary brain damage after TBI. Cell-free DNA (cfDNA) is a DAMP known to cause disruption of the blood-brain barrier (BBB), promote procoagulant processes, brain edema, and neuroinflammation. This study tested the hypothesis that administration of deoxyribonuclease-I (DNase-I) has a beneficial effect after TBI. Mice (n = 84) were subjected to controlled cortical impact (CCI) and posttraumatic intraperitoneal injections of low dose (LD) or high dose (HD) of DNase-I or vehicle solution at 30 min and 12 h after CCI. LD was most effective to reduce lesion volume (p = 0.003), brain water content (p < 0.0001) and to stabilize BBB integrity (p = 0.019) 1 day post-injury (dpi). At 6 h post injury LD-treated animals showed less cleavage of fibrin (p = 0.0014), and enhanced perfusion as assessed by micro-computer-tomography (p = 0.027). At 5 dpi the number of Iba1-positive cells (p = 0.037) were reduced, but the number of CD45-positive cells, motoric function and brain lesion volume was not different. Posttraumatic-treatment with DNase-I therefore stabilizes the BBB, reduces the formation of brain edema, immune response, and delays secondary brain damage. DNase-I might be a new approach to extend the treatment window after TBI.
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Affiliation(s)
- Tobias J Krämer
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany.
- Faculty of Health, University Witten/Herdecke, Witten, Germany.
| | - Florian Pickart
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Bruno Pöttker
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Christina Gölz
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Hermann Goetz
- Cell Biology Unit, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Katharina Ritter
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Michael K E Schäfer
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Focus Program Translational Neurosciences, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Research Center for Immunotherapy, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Center for Molecular Surgical Research, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Focus Program Translational Neurosciences, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Center for Molecular Surgical Research, University Medical Center of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Department of Anesthesiology, Helios University Hospital Wuppertal, University Witten/Herdecke, Heusnerstrasse 40, 42283, Wuppertal, Germany
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Meyer S, Hummel R, Neulen A, Hirnet T, Thal SC. Influence of traumatic brain injury on ipsilateral and contralateral cortical perfusion in mice. Neurosci Lett 2023; 795:137047. [PMID: 36603737 DOI: 10.1016/j.neulet.2023.137047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/28/2022] [Accepted: 01/01/2023] [Indexed: 01/04/2023]
Abstract
Traumatic brain injury (TBI) is one of the most important causes of death in young adults. After brain injury cortical perfusion is impaired by cortical spreading depression, cerebral microvasospasm or microvascular thrombosis and contributes to secondary expansion of lesion into surrounding healthy brain tissue. The present study was designed to determine the regional cortical perfusion pattern after experimental TBI induced by controlled cortical impact (CCI) in male C57/BL6N mice. We performed a longitudinal time series analysis by Laser speckle contrast imaging (LSCI). Measurements were carried out before, immediately and 24 h after trauma. Immediately after CCI cortical perfusion in the lesion core dropped to 10 % of before injury (baseline; %BL) and to 21-24 %BL in the cortical area surrounding the core. Interestingly, cortical perfusion was also significantly reduced in the contralateral non-injured hemisphere (41-58 %BL) matching the corresponding brain region of the injured hemisphere. 24 h after CCI perfusion of the contralateral hemisphere returned to baseline level in the area corresponding to the lesion core, whereas the lateral area of the parietal cortex was hyperperfused (125 %BL). The lesion core region itself remained severely hypoperfused (18 to 26 %BL) during the observation period. TBI causes a maldistribution of both ipsi- and contralateral cerebral perfusion immediately after trauma, which persist for at least 24 h. Higher perfusion levels in the lesion core 24 h after trauma were associated with increased tissue damage, which supports the role of reperfusion injury for secondary brain damage after TBI.
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Affiliation(s)
- Simon Meyer
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Regina Hummel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Tobias Hirnet
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany; Department of Anesthesiology, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Heusnerstraße 40, 42283 Wuppertal, Germany.
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Kurz S, Buggenhagen H, Wachter N, Penzkofer L, Dietz SO, König TT, Heinemann MK, Neulen A, Hanke LI, Huber T. [Testing of practical surgical teaching at a distance-Experiences with a hybrid OSCE in surgery]. Chirurgie (Heidelb) 2022; 93:976-982. [PMID: 35925137 PMCID: PMC9122243 DOI: 10.1007/s00104-022-01650-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The COVID-19 pandemic has changed medical teaching worldwide. Digital teaching and examinations are successful for cognitive learning objectives, whereas practical skills had to be carried out predominantly in person under strict hygiene standards. AIM This study presents the opportunities and challenges of using a presence objective structured clinical examination (OSCE) at a distance with digital support. METHOD Following surgical practical teaching an OSCE was conducted in presence, where students demonstrated practical skills in one room while the examiners were connected via videoconference from another room. Students were surveyed about the OSCE and sustained learning via a standardized online questionnaire after completion of the surgical teaching. Additionally, examiners were surveyed on their experiences. RESULTS In the online survey 40 students participated (25% of n = 157 students contacted) and 36 completed questionnaires were analyzed. Overall, the implementation of an OSCE even under pandemic conditions was perceived as very positive by the students (92% of students n = 33). In particular, the acquisition of practical skills was rated as very high. For 78% (n = 28) of the students, the acquisition of competencies through the practical examination was particularly sustainable. The vast majority of students and examiners felt safe regarding infection control because of the hygiene concept (92%, n = 33). Overall, 80 students achieved grade 1 (51%), 71 students grade 2 (45.2%) and 6 students grade 3 (3.8%) (grade 1 = very good, grade 6 = very bad). CONCLUSION Practical examinations are essential for checking practical learning objectives and can be implemented at a distance with a well-developed hygiene concept and digital support.
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Affiliation(s)
- S Kurz
- Rudolf Frey Lernklinik, Universitätsmedizin, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - H Buggenhagen
- Rudolf Frey Lernklinik, Universitätsmedizin, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - N Wachter
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin, Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - L Penzkofer
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin, Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - S O Dietz
- Zentrum für Orthopädie und Unfallchirurgie, Universitätsmedizin, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - T T König
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - M K Heinemann
- Klinik und Poliklinik für Herz- und Gefäßchirurgie, Universitätsmedizin, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - A Neulen
- Neurochirurgische Klinik und Poliklinik, Universitätsmedizin, Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - L I Hanke
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin, Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - T Huber
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin, Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
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Kramer A, Selbach M, Kerz T, Neulen A, Brockmann MA, Ringel F, Brockmann C. Continuous Intraarterial Nimodipine Infusion for the Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Retrospective, Single-Center Cohort Trial. Front Neurol 2022; 13:829938. [PMID: 35370871 PMCID: PMC8964957 DOI: 10.3389/fneur.2022.829938] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/04/2022] [Indexed: 11/14/2022] Open
Abstract
Background Delayed cerebral ischemia (DCI) occurs after aneurysmal subarachnoid hemorrhage (aSAH). Continuous intraarterial nimodipine infusion (CIAN) is a promising approach in patients with intracranial large vessel vasospasm (LVV). The objective of this retrospective single-center cohort study was to evaluate the outcome in aSAH-patients treated with CIAN. Methods CIAN was initiated and ended based on the clinical evaluation and transcranial Doppler (TCD), CT-angiography, CT-perfusion (PCT), and digital subtraction angiography (DSA). Nimodipine (0.5–2.0 mg/h) was administered continuously through microcatheters placed in the extracranial internal carotid and/or vertebral artery. Primary outcome measures were Glasgow Outcome Scale (GOS) at discharge and within 1 year after aSAH, and the occurrence of minor and major (<⅓ and >⅓ of LVV-affected territory) DCI-related infarctions in subsequent CT/MRI-scans. Secondary outcome measures were CIAN-associated complications. Results A total of 17 patients underwent CIAN. Median onset of CIAN was 9 (3–13) days after aSAH, median duration was 5 (1–13) days. A favorable outcome (GOS 4–5) was achieved in 9 patients (53%) at discharge and in 13 patients within 1 year (76%). One patient died of posthemorrhagic cerebral edema. Minor cerebral infarctions occurred in five and major infarctions in three patients. One patient developed cerebral edema possibly due to CIAN. Normalization of PCT-parameters within 2 days was observed in 9/17 patients. Six patients showed clinical response and thus did not require PCT imaging. Conclusion The favorable outcome in 76% of patients after 1 year is in line with previous studies. CIAN thus may be used to treat patients with severe therapy-refractory DCI.
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Affiliation(s)
- Andreas Kramer
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Moritz Selbach
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Thomas Kerz
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
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Hanke LI, Wachter N, Boedecker C, Penzkofer L, Koch M, Dietz SO, König TT, Heinemann MK, Neulen A, Kurz S, Lang H, Huber T. [Surgical Education of Medical Students in Times of COVID-19 - Necessary Adjustments are Chances for the Future]. Zentralbl Chir 2021; 146:586-596. [PMID: 34872114 DOI: 10.1055/a-1675-3955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Education of medical students in surgery not only consists of knowledge about diseases and their treatment but also of practical skills like i.e. suturing. In the clinical training of medical students, professional interaction and communication with patients is a key component. Due to the circumstances of distancing and reduced exposure to patients during the COVID-19 pandemic, clinical training of medical students has been challenging. To combat these restrictions, digital modern teaching concepts had to be implemented. MATERIAL AND METHODS Surgical education of medical students was reorganised during the summer semester 2020 and winter semester 2020/2021 and the necessary adjustments, as well as their evaluation by students, were analysed. Results were compared to the pre-COVID evaluations of the summer semester 2019. Furthermore a survey of all university surgical departments in Germany (n = 39) was conducted to compare the different approaches to handling this very new situation. RESULTS All participating centres were performing surgical education with medical students during the COVID-19 pandemic. Overall, digital teaching methods were well accepted by students and teachers, even though short-term changes were necessary during the second wave of the pandemic. Both students and teachers missed the direct mutual interaction as well as with patients (summer semester 2020 36%, winter semester 2020/2021 40%). Modern and digital teaching concepts were assessed positively (summer semester 2020 45%, winter semester 2020/2021 40%) and long term implementation was desired by students and teachers (winter semester 2020/2021 60%). CONCLUSION Training of practical surgical skills, as well as communication skills, can only be taught in presence. Digital learning concepts can support, but not replace, surgical courses held in presence, including contact to patients and manual training. Blended learning concepts facilitate a leap towards modern teaching concepts and increase the quality of classes spent in presence.
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Affiliation(s)
- Laura Isabel Hanke
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Nicolas Wachter
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Christian Boedecker
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Lea Penzkofer
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Martina Koch
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Sven-Oliver Dietz
- Zentrum für Orthopädie und Unfallchirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Tatjana Tamara König
- Klinik und Poliklinik für Kinderchirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Markus K Heinemann
- Klinik und Poliklinik für Herz- und Gefäßchirurgie, Universitätsmedizin Mainz, Mainz, Deutschland
| | - Axel Neulen
- Neuochirurgische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Sandra Kurz
- Rudolf Frey Lernklinik, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Hauke Lang
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
| | - Tobias Huber
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Deutschland
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8
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Neulen A, Molitor M, Kosterhon M, Pantel T, Karbach SH, Wenzel P, Gaul T, Ringel F, Thal SC. Analysis of Cerebral Vasospasm in a Murine Model of Subarachnoid Hemorrhage with High Frequency Transcranial Duplex Ultrasound. J Vis Exp 2021. [PMID: 34152320 DOI: 10.3791/62186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Cerebral vasospasm that occurs in the weeks after subarachnoid hemorrhage, a type of hemorrhagic stroke, contributes to delayed cerebral ischemia. A problem encountered in experimental studies using murine models of SAH is that methods for in vivo monitoring of cerebral vasospasm in mice are lacking. Here, we demonstrate the application of high frequency ultrasound to perform transcranial Duplex sonography examinations on mice. Using the method, the internal carotid arteries (ICA) could be identified. The blood flow velocities in the intracranial ICAs were accelerated significantly after induction of SAH, while blood flow velocities in the extracranial ICAs remained low, indicating cerebral vasospasm. In conclusion, the method demonstrated here allows functional, noninvasive in vivo monitoring of cerebral vasospasm in a murine SAH model.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz;
| | - Michael Molitor
- Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg-University of Mainz; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University of Mainz; German Center for Cardiovascular Research (DZHK) - Partner site Rhine-Main
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz
| | - Susanne H Karbach
- Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg-University of Mainz; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University of Mainz; German Center for Cardiovascular Research (DZHK) - Partner site Rhine-Main
| | - Philip Wenzel
- Center for Cardiology - Cardiology I, University Medical Center of the Johannes Gutenberg-University of Mainz; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University of Mainz; German Center for Cardiovascular Research (DZHK) - Partner site Rhine-Main
| | - Thomas Gaul
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University of Mainz
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University of Mainz
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9
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Neulen A, Pantel T, König J, Brockmann MA, Ringel F, Kantelhardt SR. Comparison of Unruptured Intracranial Aneurysm Treatment Score and PHASES Score in Subarachnoid Hemorrhage Patients With Multiple Intracranial Aneurysms. Front Neurol 2021; 12:616497. [PMID: 33897586 PMCID: PMC8059702 DOI: 10.3389/fneur.2021.616497] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/09/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Unruptured Intracranial Aneurysm (UIA) Treatment Score (UIATS) and PHASES score are used to inform treatment decision making for UIAs (treatment or observation). We assessed the ability of the scoring systems to discriminate between ruptured aneurysms and UIAs in a subarachnoid hemorrhage (SAH) cohort with multiple aneurysms. Methods: We retrospectively applied PHASES and UIATS scoring to the aneurysms of 40 consecutive patients with SAH and multiple intracranial aneurysms. Results: PHASES score discriminated better between ruptured aneurysms and UIAs than UIATS. PHASES scores and the difference between the UIATS subscores were higher for ruptured aneurysms compared with UIAs, which reached significance for the PHASES score. PHASES score estimated a low 5-year rupture risk in a larger proportion of the UIAs (≤0.7% in 62.3%, ≤1.7% in 98.4%) than of the ruptured aneurysms (≤0.7% in 22.5%, ≤1.7% in 82.5%). In the 40 ruptured aneurysms, UIATS provided recommendation for treatment in 11 (27.5%), conservative management in 14 (35.0%), and was inconclusive in 15 cases (37.5%). In the 61 UIAs, UIATS recommended treatment in 16 (26.2%), conservative management in 29 (47.5%), and was inconclusive in 16 (26.2%) cases. Conclusion: Similar to previous SAH cohorts, a significant proportion of the ruptured aneurysms exhibited a low-rupture risk. Nevertheless, PHASES score discriminated between ruptured aneurysms and UIAs in our cohort; the lower discriminatory power of UIATS was due to high weights of aneurysm-independent factors. We recommend careful integration of the scores for individual decision making. Large-scale prospective trials are required to establish score-based treatment strategies for UIAs.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Sven R Kantelhardt
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
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10
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Neulen A, Molitor M, Kosterhon M, Pantel T, Holzbach E, Rudi WS, Karbach SH, Wenzel P, Ringel F, Thal SC. Correlation of cardiac function and cerebral perfusion in a murine model of subarachnoid hemorrhage. Sci Rep 2021; 11:3317. [PMID: 33558609 PMCID: PMC7870815 DOI: 10.1038/s41598-021-82583-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/18/2021] [Indexed: 12/28/2022] Open
Abstract
Cerebral hypoperfusion is a key factor for determining the outcome after subarachnoid hemorrhage (SAH). A subset of SAH patients develop neurogenic stress cardiomyopathy (NSC), but it is unclear to what extent cerebral hypoperfusion is influenced by cardiac dysfunction after SAH. The aims of this study were to examine the association between cardiac function and cerebral perfusion in a murine model of SAH and to identify electrocardiographic and echocardiographic signs indicative of NSC. We quantified cortical perfusion by laser SPECKLE contrast imaging, and myocardial function by serial high-frequency ultrasound imaging, for up to 7 days after experimental SAH induction in mice by endovascular filament perforation. Cortical perfusion decreased significantly whereas cardiac output and left ventricular ejection fraction increased significantly shortly post-SAH. Transient pathological ECG and echocardiographic abnormalities, indicating NSC (right bundle branch block, reduced left ventricular contractility), were observed up to 3 h post-SAH in a subset of model animals. Cerebral perfusion improved over time after SAH and correlated significantly with left ventricular end-diastolic volume at 3, 24, and 72 h. The murine SAH model is appropriate to experimentally investigate NSC. We conclude that in addition to cerebrovascular dysfunction, cardiac dysfunction may significantly influence cerebral perfusion, with LVEDV presenting a potential parameter for risk stratification.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Michael Molitor
- Center for Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK)-Partner Site Rhine-Main, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Elisa Holzbach
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Wolf-Stephan Rudi
- Center for Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK)-Partner Site Rhine-Main, Mainz, Germany
| | - Susanne H Karbach
- Center for Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK)-Partner Site Rhine-Main, Mainz, Germany
| | - Philip Wenzel
- Center for Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK)-Partner Site Rhine-Main, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany. .,Center for Molecular Surgical Research (MFO), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
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11
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Neulen A, Kunzelmann S, Kosterhon M, Pantel T, Stein M, Berres M, Ringel F, Brockmann MA, Brockmann C, Kantelhardt SR. Automated Grading of Cerebral Vasospasm to Standardize Computed Tomography Angiography Examinations After Subarachnoid Hemorrhage. Front Neurol 2020; 11:13. [PMID: 32082241 PMCID: PMC7002561 DOI: 10.3389/fneur.2020.00013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/07/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Computed tomography angiography (CTA) is frequently used with computed tomography perfusion imaging (CTP) to evaluate whether endovascular vasospasm treatment is indicated for subarachnoid hemorrhage patients with delayed cerebral ischemia. However, objective parameters for CTA evaluation are lacking. In this study, we used an automated, investigator-independent, digital method to detect vasospasm, and we evaluated whether the method could predict the need for subsequent endovascular vasospasm treatment. Methods: We retrospectively reviewed the charts and analyzed imaging data for 40 consecutive patients with subarachnoid hemorrhages. The cerebrovascular trees were digitally reconstructed from CTA data, and vessel volume and the length of the arteries of the circle of Willis and their peripheral branches were determined. Receiver operating characteristic curve analysis based on a comparison with digital subtraction angiographies was used to determine volumetric thresholds that indicated severe vasospasm for each vessel segment. Results: The automated threshold-based volumetric evaluation of CTA data was able to detect severe vasospasm with high sensitivity and negative predictive value for predicting cerebral hypoperfusion on CTP, although the specificity and positive predictive value were low. Combining the automated detection of vasospasm on CTA and cerebral hypoperfusion on CTP was superior to CTP or CTA alone in predicting endovascular vasospasm treatment within 24 h after the examination. Conclusions: This digital volumetric analysis of the cerebrovascular tree allowed the objective, investigator-independent detection and quantification of vasospasms. This method could be used to standardize diagnostics and the selection of subarachnoid hemorrhage patients with delayed cerebral ischemia for endovascular diagnostics and possible interventions.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Svenja Kunzelmann
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Maximilian Stein
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Manfred Berres
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, Remagen, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Sven R Kantelhardt
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
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12
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Kosterhon M, Neufurth M, Neulen A, Schäfer L, Conrad J, Kantelhardt SR, Müller WEG, Ringel F. Multicolor 3D Printing of Complex Intracranial Tumors in Neurosurgery. J Vis Exp 2020. [PMID: 31984962 DOI: 10.3791/60471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Three-dimensional (3D) printing technologies offer the possibility of visualizing patient-specific pathologies in a physical model of correct dimensions. The model can be used for planning and simulating critical steps of a surgical approach. Therefore, it is important that anatomical structures such as blood vessels inside a tumor can be printed to be colored not only on their surface, but throughout their whole volume. During simulation this allows for the removal of certain parts (e.g., with a high-speed drill) and revealing internally located structures of a different color. Thus, diagnostic information from various imaging modalities (e.g., CT, MRI) can be combined in a single compact and tangible object. However, preparation and printing of such a fully colored anatomical model remains a difficult task. Therefore, a step-by-step guide is provided, demonstrating the fusion of different cross-sectional imaging data sets, segmentation of anatomical structures, and creation of a virtual model. In a second step the virtual model is printed with volumetrically colored anatomical structures using a plaster-based color 3D binder jetting technique. This method allows highly accurate reproduction of patient-specific anatomy as shown in a series of 3D-printed petrous apex chondrosarcomas. Furthermore, the models created can be cut and drilled, revealing internal structures that allow for simulation of surgical procedures.
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Affiliation(s)
- Michael Kosterhon
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University Mainz, Germany;
| | - Meik Neufurth
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Lea Schäfer
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Jens Conrad
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Sven R Kantelhardt
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Werner E G Müller
- Institute of Physiological Chemistry, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University Mainz, Germany
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13
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Neulen A, Stein M, Pantel T, Berres M, Brockmann C, Giese A, Kantelhardt SR. Image-Guided Transcranial Doppler Ultrasound for Monitoring Posthemorrhagic Vasospasms of Infratentorial Arteries: A Feasibility Study. World Neurosurg 2019; 134:284-291. [PMID: 31678314 DOI: 10.1016/j.wneu.2019.10.144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND A considerable number of patients with subarachnoid hemorrhage (SAH) develop vasospasms of the infratentorial arteries. Transcranial Doppler sonography (TCD) is used to screen for vasospasm. In this study, we used a technical modification that combines TCD with an image guidance device that the operator can use to navigate to the ultrasonic window and to predefined intracranial vascular targets. Our aim was to analyze the feasibility, spatial precision, and spatial reproducibility of serial image-guided TCD of infratentorial and-for comparison-supratentorial arteries in the clinical setting of monitoring for vasospasm after SAH. METHODS The study included 10 SAH patients, who each received 5 serial image-guided TCD examinations. Using computed tomography angiography data, trajectories to the infratentorial and supratentorial cerebral arteries were planned and loaded into an image guidance device tracking the Doppler probe. As a measure of spatial precision and spatial reproducibility, we analyzed the distances between the positions of preplanned vascular targets and optimal Doppler signals. RESULTS The mean distance between preplanned and optimal target points was 4.8 ± 2.1 mm (first exam), indicating high spatial precision. The spatial precision decreased with increasing depth of the vascular target. In all patients, image-guided TCD detected all predefined supratentorial and infratentorial vascular segments. There were no significant changes in spatial precision in serial exams, indicating high reproducibility. CONCLUSIONS Image-guided TCD is feasible for supratentorial and infratentorial arteries. It shows high spatial precision and reproducibility. This study provides a basis for future clinical studies on image-guided TCD for post-SAH vasospasm screening.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Maximilian Stein
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Manfred Berres
- Institute of Medical Biometry, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany; Department of Mathematics and Technology, University of Applied Sciences Koblenz, Remagen, Germany
| | - Carolin Brockmann
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Alf Giese
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany; Orthocentrum Hamburg, Hamburg, Germany
| | - Sven R Kantelhardt
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University of Mainz, Mainz, Germany.
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14
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Masomi-Bornwasser J, Winter P, Neulen A, Kantelhardt SR, König J, Kempski O, Ringel F, Keric N. Doppler sonography enhances rtPA-induced fibrinolysis in an in vitro clot model of spontaneous intracerebral hemorrhages. PLoS One 2019; 14:e0210810. [PMID: 30653589 PMCID: PMC6336417 DOI: 10.1371/journal.pone.0210810] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 01/02/2019] [Indexed: 01/25/2023] Open
Abstract
Background Transcranial Doppler (TCD) was shown to enhance intravascular fibrinolysis by rtPA in ischemic stroke. Studies revealed that catheter-based administration of rtPA induces lysis of intracerebral hemorrhages (ICH). However, it is unknown whether TCD would be suitable to enhance rtPA-induced fibrinolysis in patients with ICH. The aim of this study was to assess the potential of TCD to enhance rtPA-induced fibrinolysis in an in vitro clot system. Methods Reproducible human blood clots of 25 ml were incubated in a water bath at 37°C during treatments. They were weighed before and after 6 different treatments: (I) control (incubation only), (II) rtPA only, (III) one Doppler probe, (IV) two Doppler probes placed vis-à-vis, (V) one probe and rtPA and (VI) two probes and rtPA. To quantify lysis of the blood clots and attenuation of the Doppler through a temporal squama acoustic peak rarefaction pressure (APRP) was measured in the field of the probes. Temperature was assessed to evaluate possible side effects. Results Clot weight was reduced in all groups. The control group had the highest relative end weight of 70.2%±7.2% compared to all other groups (p<0,0001). Most efficient lysis was achieved using (VI) 2 probes and rtPA 36.3%±4.4% compared to (II, III, IV) (p<0.0001; p = 0.0002; p = 0.048). APRP was above lysis threshold (535.5±7.2 kPa) using 2 probes even through the temporal squama (731.6±32.5 kPa) (p = 0.0043). There was a maximal temperature elevation of 0.17±0.07°C using both probes. Conclusions TCD significantly enhances rtPA-induced lysis of blood clots, and the effect is amplified by using multiple probes. Our results indicate that bitemporal TCD insonation of hematomas could be a new and safe approach to enhance fibrinolysis of ICH´s treated with intralesional catheter and rtPA.
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Affiliation(s)
- Julia Masomi-Bornwasser
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- * E-mail:
| | - Philipp Winter
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Sven R. Kantelhardt
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Oliver Kempski
- Institute of Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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15
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Kerz T, von Loewenich FD, Roberts J, Neulen A, Ringel F. Cerebrospinal fluid penetration of very high-dose meropenem: a case report. Ann Clin Microbiol Antimicrob 2018; 17:47. [PMID: 30594199 PMCID: PMC6310956 DOI: 10.1186/s12941-018-0299-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 12/21/2018] [Indexed: 12/27/2022] Open
Abstract
Background Standard dosing of meropenem (2 g t.i.d.) produces CSF concentrations of only 1–2 mg/L which is inferior to the clinical breakpoint for most Gram-negative bacteria. There is therefore concern that dosing must be increased in order to achieve therapeutic CSF concentrations for bacteria with susceptibility close to clinical breakpoints. Yet, the effects of high-dose meropenem on CSF concentrations are not well described in literature. We therefore determined meropenem CSF-levels in a patient who was treated with 15 g/day of meropenem. Case presentation Our patient suffered from a brain trauma and an external ventricular drainage was implanted. Later, a carbapenemase-producing Acinetobacter baumannii (OXA-23, NDM-1) was isolated from blood cultures and CSF. The MIC for meropenem was > 32 mg/L (R), and we opted for a combination therapy of meropenem, colistin and fosfomycin. Meropenem was given at an unusual high-dose (15 g/day) with the aim of achieving high CSF concentrations. CSF concentrations peaked at 64 mg/L. Yet, the patient succumbed to an intracranial bleed into a preexisting cerebral contusion. Conclusions High-dose meropenem can achieve CSF levels largely superior to those achieved with commonly recommended dosing regimens. Though our patient succumbed to an intracranial bleed which could be regarded as a severe adverse event, we suggest that meropenem dosing can be increased when pathogens with increased MICs are found in the CSF. More in vivo data are however needed to determine the safety of high-dose meropenem.
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Affiliation(s)
- Thomas Kerz
- Department of Neurosurgery, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany.
| | | | - Jason Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center, Langenbeckstr. 1, 55131, Mainz, Germany
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16
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Luh C, Feiler S, Frauenknecht K, Meyer S, Lubomirov LT, Neulen A, Thal SC. The Contractile Apparatus Is Essential for the Integrity of the Blood-Brain Barrier After Experimental Subarachnoid Hemorrhage. Transl Stroke Res 2018; 10:534-545. [PMID: 30467816 PMCID: PMC6733822 DOI: 10.1007/s12975-018-0677-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 10/19/2018] [Accepted: 11/11/2018] [Indexed: 11/27/2022]
Abstract
Development of vasogenic brain edema is a key event contributing to mortality after subarachnoid hemorrhage (SAH). The precise underlying mechanisms at the neurovascular level that lead to disruption of the blood-brain barrier (BBB) are still unknown. Activation of myosin light chain kinases (MLCK) may result in change of endothelial cell shape and opening of the intercellular gap with subsequent vascular leakage. Male C57Bl6 mice were subjected to endovascular perforation. Brain water content was determined by wet-dry ratio and BBB integrity by Evans-Blue extravasation. The specific MLCK inhibitor ML-7 was administered to the mice to determine the role of the contractile apparatus of the neurovascular unit in determining brain water content, BBB integrity, neurofunctional outcome, brain damage, and survival at 7 days after SAH. Inhibition of MLCK significantly reduced BBB permeability (Evans Blue extravasation − 28%) and significantly decreased edema formation in comparison with controls (− 2%). MLCK-treated mice showed reduced intracranial pressure (− 53%), improved neurological outcome at 24 h and 48 h after SAH, and reduced 7-day mortality. Tight junction proteins claudin-5 and zonula occludens-1 levels were not influenced by ML-7 at 24 h after insult. The effect of ML-7 on pMLC was confirmed in brain endothelial cell culture (bEnd.3 cells) subjected to 4-h oxygen-glucose deprivation. The present study indicates that MLCK contributes to blood-brain barrier dysfunction after SAH by a mechanism that does not involve modulation of tight junction protein levels, but via activation of the contractile apparatus of the endothelial cell skeleton. This underlying mechanism may be a promising target for the treatment of SAH.
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Affiliation(s)
- Clara Luh
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Sergej Feiler
- Department of Neurosurgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Katrin Frauenknecht
- Institute of Neuropathology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon Meyer
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | | | - Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany. .,Center for Molecular Surgical Research (MFO), Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany.
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17
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Neulen A, Pantel T, Dieter A, Kosterhon M, Berres M, Thal SC, Brockmann MA, Kantelhardt SR. Volumetric analysis of intracranial vessels: a novel tool for evaluation of cerebral vasospasm. Int J Comput Assist Radiol Surg 2018; 14:157-167. [PMID: 30097958 DOI: 10.1007/s11548-018-1844-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 07/31/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Together with other diagnostic modalities, computed tomography angiography (CTA) is commonly used to indicate endovascular vasospasm treatment after subarachnoid hemorrhage (SAH), despite the fact that objective, user-independent parameters for evaluation of CTA are lacking. This exploratory study was designed to investigate whether quantification of vasospasm by automated volumetric analysis of the middle cerebral artery M1 segment from CTA data could be used as an objective parameter to indicate endovascular vasospasm treatment. METHODS We retrospectively identified SAH patients who underwent transcranial Doppler sonography (TCD), CTA, and CT perfusion (CTP), with or without subsequent endovascular treatment. We determined vessel volume/vessel length of the M1 segments from CTA data and used receiver operating characteristic curve analysis to determine the optimal threshold of vessel volume to predict vasospasm requiring endovascular treatment. In addition, blinded investigators independently analyzed TCD, CTA, and CTP data. RESULTS Of 45 CTA examinations with corresponding CTP and TCD examinations (24 SAH patients), nine indicated the need for endovascular vasospasm treatment during examination. In our patients, vessel volume < 5.8 µL/mm was moderately sensitive but fairly specific to detect vasospasm requiring endovascular treatment (sensitivity, 67%; specificity, 78%; negative predictive value (NPV), 89%; positive predictive value (PPV), 46%). For CTA, CTP, and TCD, we found NPVs of 96%, 92%, and 89%, PPVs of 40%, 35%, and 35%, sensitivities of 89%, 78%, and 67%, and specificities of 67%, 64%, and 69%, respectively. CONCLUSION Vessel volumes could provide a new objective parameter for the interpretation of CTA data and could thereby improve multimodal assessment of vasospasm in SAH patients.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Anna Dieter
- Department of Neuroradiology, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Manfred Berres
- Institute of Medical Biometry, Epidemiology and Informatics, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.,Department of Mathematics and Technology, University of Applied Sciences Koblenz, Joseph-Rovan-Allee 2, 53424, Remagen, Germany
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Sven R Kantelhardt
- Department of Neurosurgery, University Medical Center of Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
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Neulen A, Kosterhon M, Pantel T, Kirschner S, Goetz H, Brockmann MA, Kantelhardt SR, Thal SC. A Volumetric Method for Quantification of Cerebral Vasospasm in a Murine Model of Subarachnoid Hemorrhage. J Vis Exp 2018. [PMID: 30102288 PMCID: PMC6126573 DOI: 10.3791/57997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Subarachnoid hemorrhage (SAH) is a subtype of hemorrhagic stroke. Cerebral vasospasm that occurs in the aftermath of the bleeding is an important factor determining patient outcome and is therefore frequently taken as a study endpoint. However, in small animal studies on SAH, quantification of cerebral vasospasm is a major challenge. Here, an ex vivo method is presented that allows quantification of volumes of entire vessel segments, which can be used as an objective measure to quantify cerebral vasospasm. In a first step, endovascular casting of the cerebral vasculature is performed using a radiopaque casting agent. Then, cross-sectional imaging data are acquired by micro computed tomography. The final step involves 3-dimensional reconstruction of the virtual vascular tree, followed by an algorithm to calculate center lines and volumes of the selected vessel segments. The method resulted in a highly accurate virtual reconstruction of the cerebrovascular tree shown by a diameter-based comparison of anatomical samples with their virtual reconstructions. Compared with vessel diameters alone, the vessel volumes highlight the differences between vasospastic and non-vasospastic vessels shown in a series of SAH and sham-operated mice.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, Medical Center of the Johannes Gutenberg - University;
| | - Michael Kosterhon
- Department of Neurosurgery, Medical Center of the Johannes Gutenberg - University
| | - Tobias Pantel
- Department of Neurosurgery, Medical Center of the Johannes Gutenberg - University
| | - Stefanie Kirschner
- Department of Neuroradiology, Medical Center of the Johannes Gutenberg - University
| | - Hermann Goetz
- Platform for Biomaterial Research, Medical Center of the Johannes Gutenberg - University
| | - Marc A Brockmann
- Department of Neuroradiology, Medical Center of the Johannes Gutenberg - University
| | - Sven R Kantelhardt
- Department of Neurosurgery, Medical Center of the Johannes Gutenberg - University
| | - Serge C Thal
- Department of Anesthesiology, Medical Center of the Johannes Gutenberg - University;
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Neulen A, Meyer S, Kramer A, Pantel T, Kosterhon M, Kunzelmann S, Goetz H, Thal SC. Large Vessel Vasospasm Is Not Associated with Cerebral Cortical Hypoperfusion in a Murine Model of Subarachnoid Hemorrhage. Transl Stroke Res 2018; 10:10.1007/s12975-018-0647-6. [PMID: 30003500 PMCID: PMC6526146 DOI: 10.1007/s12975-018-0647-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/27/2018] [Accepted: 07/02/2018] [Indexed: 01/01/2023]
Abstract
Clinical studies on subarachnoid hemorrhage (SAH) have shown discrepancies between large vessel vasospasm, cerebral perfusion, and clinical outcome. We set out to analyze the contribution of large vessel vasospasm to impaired cerebral perfusion and neurological impairment in a murine model of SAH. SAH was induced in C57BL/6 mice by endovascular filament perforation. Vasospasm was analyzed with microcomputed tomography, cortical perfusion by laser SPECKLE contrast imaging, and functional impairment with a quantitative neuroscore. SAH animals developed large vessel vasospasm, as shown by significantly lower vessel volumes of a 2.5-mm segment of the left middle cerebral artery (MCA) (SAH 5.6 ± 0.6 nL, sham 8.3 ± 0.5 nL, p < 0.01). Induction of SAH significantly reduced cerebral perfusion of the corresponding left MCA territory compared to values before SAH, which only recovered partly (SAH vs. sham, 15 min 35.7 ± 3.1 vs. 101.4 ± 10.2%, p < 0.01; 3 h, 85.0 ± 8.6 vs. 121.9 ± 13.4, p < 0.05; 24 h, 75.3 ± 4.6 vs. 110.6 ± 11.4%, p < 0.01; 72 h, 81.8 ± 4.8 vs. 108.5 ± 14.5%, n.s.). MCA vessel volume did not correlate significantly with MCA perfusion after 72 h (r = 0.34, p = 0.25). Perfusion correlated moderately with neuroscore (24 h: r = - 0.58, p < 0.05; 72 h: r = - 0.44, p = 0.14). There was no significant correlation between vessel volume and neuroscore after 72 h (r = - 0.21, p = 0.50). In the murine SAH model, cerebral hypoperfusion occurs independently of large vessel vasospasm. Neurological outcome is associated with cortical hypoperfusion rather than large vessel vasospasm.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Simon Meyer
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Andreas Kramer
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Svenja Kunzelmann
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Hermann Goetz
- Platform for Biomaterial Research, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany.
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Neulen A, Pantel T, Kosterhon M, Kirschner S, Brockmann MA, Kantelhardt SR, Giese A, Thal SC. A segmentation-based volumetric approach to localize and quantify cerebral vasospasm based on tomographic imaging data. PLoS One 2017; 12:e0172010. [PMID: 28199398 PMCID: PMC5310853 DOI: 10.1371/journal.pone.0172010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 01/30/2017] [Indexed: 12/19/2022] Open
Abstract
Introduction Quantification of cerebral vasospasm after subarachnoid hemorrhage (SAH) is crucial in animal studies as well as clinical routine. We have developed a method for computer-based volumetric assessment of intracranial blood vessels from cross-sectional imaging data. Here we demonstrate the quantification of vasospasm from micro computed tomography (micro-CT) data in a rodent SAH model and the transferability of the volumetric approach to clinical data. Methods We obtained rodent data by performing an ex vivo micro-CT of murine brains after sham surgery or SAH by endovascular filament perforation on day 3 post hemorrhage. Clinical CT angiography (CTA) was performed for diagnostic reasons unrelated to this study. We digitally reconstructed and segmented intracranial vascular trees, followed by calculating volumes of defined vessel segments by standardized protocols using Amira® software. Results SAH animals demonstrated significantly smaller vessel diameters compared with sham (MCA: 134.4±26.9μm vs.165.0±18.7μm, p<0.05). We could highlight this difference by analyzing vessel volumes of a defined MCA-ICA segment (SAH: 0.044±0.017μl vs. sham: 0.07±0.006μl, p<0.001). Analysis of clinical CTA data allowed us to detect and volumetrically quantify vasospasm in a series of 5 SAH patients. Vessel diameters from digital reconstructions correlated well with those measured microscopically (rodent data, correlation coefficient 0.8, p<0.001), or angiographically (clinical data, 0.9, p<0.001). Conclusions Our methodological approach provides accurate anatomical reconstructions of intracranial vessels from cross-sectional imaging data. It allows volumetric assessment of entire vessel segments, hereby highlighting vasospasm-induced changes objectively in a murine SAH model. This method could also be a helpful tool for analysis of clinical CTA.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of Mainz, Mainz, Germany
- * E-mail: (AN); (SCT)
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of Mainz, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of Mainz, Mainz, Germany
| | - Stefanie Kirschner
- Department of Neuroradiology, University Medical Center of Mainz, Mainz, Germany
| | - Marc A. Brockmann
- Department of Neuroradiology, University Medical Center of Mainz, Mainz, Germany
| | - Sven R. Kantelhardt
- Department of Neurosurgery, University Medical Center of Mainz, Mainz, Germany
| | - Alf Giese
- Department of Neurosurgery, University Medical Center of Mainz, Mainz, Germany
| | - Serge C. Thal
- Department of Anesthesiology, University Medical Center of Mainz, Mainz, Germany
- * E-mail: (AN); (SCT)
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Neulen A, Prokesch E, Stein M, König J, Giese A. Image-guided transcranial Doppler sonography for monitoring of vasospasm after subarachnoid hemorrhage. Clin Neurol Neurosurg 2016; 145:14-8. [PMID: 27062685 DOI: 10.1016/j.clineuro.2016.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/13/2016] [Accepted: 03/16/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Transcranial Doppler ultrasound (TCD) is a standard method for bedside vasospasm monitoring after subarachnoid hemorrhage (SAH). Image guidance has previously been shown to reduce intra- and interobserver variability of this method. The aim of the present study was to compare image-guided and conventional TCD in vasospasm monitoring after SAH. PATIENTS AND METHODS 418 TCD exams of 24 consecutive SAH patients registered in a database were evaluated. Of these, 130 image-guided exams were identified which had been performed on the same day as conventional Doppler exams. These matched pairs were taken for statistical analysis. Data were tested statistically using the sign test applied at patient level to aggregated data. RESULTS The rate of complete exams (both M1, A1, P1 segments) was significantly higher in image-guided exams (92% vs. 74%, p<0.001), and the superiority of image-guided exams was significantly related to smaller sizes of the temporal bone window. There were more exams with Doppler sonographic vasospasm (mean flow velocity>120cm/s) in image-guided exams (38% vs. 33%) which, however, did not reach statistical significance. CONCLUSION Image-guidance leads to a standardization of serial TCD exams, which resulted in significantly more complete exams, most prominent in patients with poor temporal bone windows, and a higher detection rate of Doppler sonographic vasospasms. Image-guided TCD therefore has the capability to improve bedside vasospasm monitoring after SAH.
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Affiliation(s)
- A Neulen
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
| | - E Prokesch
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - M Stein
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - J König
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center, Johannes-Gutenberg-University of Mainz, Obere Zahlbacher Straße 69, 55131 Mainz, Germany
| | - A Giese
- Department of Neurosurgery, University Medical Center, Johannes-Gutenberg-University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
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Kantelhardt SR, Neulen A, Keric N, Gutenberg A, Conrad J, Giese A. Alternative radiation-free registration technique for image-guided pedicle screw placement in deformed cervico-thoracic segments. J Neurosurg Sci 2015; 61:464-472. [PMID: 26333386 DOI: 10.23736/s0390-5616.16.03311-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Image-guided pedicle screw placement in the cervico-thoracic region is a commonly applied technique. In some patients with deformed cervico-thoracic segments, conventional or 3D fluoroscopy based registration of image-guidance might be difficult or impossible because of the anatomic/pathological conditions. Landmark based registration has been used as an alternative, mostly using separate registration of each vertebra. We here investigated a routine for landmark based registration of rigid spinal segments as single objects, using cranial image-guidance software. METHODS Landmark based registration of image-guidance was performed using cranial navigation software. After surgical exposure of the spinous processes, lamina and facet joints and fixation of a reference marker array, up to 26 predefined landmarks were acquired using a pointer. All pedicle screws were implanted using image guidance alone. Following image-guided screw placement all patients underwent postoperative CT scanning. Screw positions as well as intraoperative and clinical parameters were retrospectively analyzed. RESULTS Thirteen patients received 73 pedicle screws at levels C6 to Th8. Registration of spinal segments, using the cranial image-guidance succeeded in all cases. Pedicle perforations were observed in 11.0%, severe perforations of >2 mm occurred in 5.4%. One patient developed a transient C8 syndrome and had to be revised for deviation of the C7 pedicle screw. No other pedicle screw-related complications were observed. CONCLUSIONS In selected patients suffering from pathologies of the cervico-thoracic region, which impair intraoperative fluoroscopy or 3D C-arm imaging, landmark based registration of image-guidance using cranial software is a feasible, radiation-saving and a safe alternative.
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Affiliation(s)
| | - Axel Neulen
- Department of Neurosurgery, University Medical Centre, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Centre, Mainz, Germany
| | | | - Jens Conrad
- Department of Neurosurgery, University Medical Centre, Mainz, Germany
| | - Alf Giese
- Department of Neurosurgery, University Medical Centre, Mainz, Germany
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Kantelhardt SR, Gutenberg A, Neulen A, Keric N, Renovanz M, Giese A. Video-Assisted Navigation for Adjustment of Image-Guidance Accuracy to Slight Brain Shift. Oper Neurosurg (Hagerstown) 2015; 11:504-511. [PMID: 29506163 DOI: 10.1227/neu.0000000000000921] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 07/14/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Information supplied by an image-guidance system can be superimposed on the operating microscope oculars or on a screen, generating augmented reality. Recently, the outline of a patient's head and skull, injected in the oculars of a standard operating microscope, has been used to check the registration accuracy of image guidance. OBJECTIVE To propose the use of the brain surface relief and superficial vessels for real-time intraoperative visualization and image-guidance accuracy and for intraoperative adjustment for brain shift. METHODS A commercially available image-guidance system and a standard operating microscope were used. Segmentation of the brain surface and cortical blood vessel relief was performed manually on preoperative computed tomography and magnetic resonance images. The overlay of segmented digital and real operating-microscope images was used to monitor image-guidance accuracy. Adjustment for brain shift was performed by manually matching digital images on real structures. RESULTS Experimental manipulation on a phantom proved that the brain surface relief could be used to restore accuracy if the primary registration shifted. Afterward, the technique was used to assist during surgery of 5 consecutive patients with 7 deep-seated brain tumors. The brain surface relief could be successfully used to monitor registration accuracy after craniotomy and during the whole procedure. If a certain degree of brain shift occurred after craniotomy, the accuracy could be restored in all cases, and corticotomies were correctly centered in all cases. CONCLUSION The proposed method was easy to perform and augmented image-guidance accuracy when operating on small deep-seated lesions.
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Affiliation(s)
- Sven R Kantelhardt
- Department of Neurosurgery, University Medical Centre, Johannes Gutenberg-University, Mainz, Germany
| | - Angelika Gutenberg
- Department of Neurosurgery, University Medical Centre, Johannes Gutenberg-University, Mainz, Germany
| | - Axel Neulen
- Department of Neurosurgery, University Medical Centre, Johannes Gutenberg-University, Mainz, Germany
| | - Naureen Keric
- Department of Neurosurgery, University Medical Centre, Johannes Gutenberg-University, Mainz, Germany
| | - Mirjam Renovanz
- Department of Neurosurgery, University Medical Centre, Johannes Gutenberg-University, Mainz, Germany
| | - Alf Giese
- Department of Neurosurgery, University Medical Centre, Johannes Gutenberg-University, Mainz, Germany
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Neulen A, Greke C, Prokesch E, König J, Wertheimer D, Giese A. Image guidance to improve reliability and data integrity of transcranial Doppler sonography. Clin Neurol Neurosurg 2013; 115:1382-8. [PMID: 23347687 DOI: 10.1016/j.clineuro.2012.12.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 12/07/2012] [Accepted: 12/30/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Principles and accuracy of image-guided transcranial Doppler (IG TCD) sonography have been published recently. However, it remains open whether combination of image guidance and TCD offers an additional clinical advantage. This study scores the accuracy of conventional TCD examinations and investigates the potential improvement of TCD data integrity and reliability regarding the additional use of IG. METHODS Conventional TCD was performed by a group of experienced investigators, who were blinded to images of a navigation system tracking the Doppler probe, whereas an independent observer documented the TCD findings, acquired by the investigators, due to saving spatial data of the TCD sample volume using IG for subsequent analysis. In a second set of experiments, image guidance was available to investigators without any previous TCD experience. RESULTS The analysis of 3D data of vessels (n=173) labeled by experienced investigators in conventional TCD, revealed a rate of 37% misinterpreted Doppler signals regarding the target vessel. Correctness of labeling was comparable between the different vascular segments. The rate of correct labeling was higher for right- (69%) than for left-sided vessels (57%). In comparison, by using IG, TCD investigators without any previous TCD experience achieved a significantly lower rate of 10% (n=39) mislabeled vessels. CONCLUSIONS Our data suggest, that misinterpretation of the vascular source of the Doppler signal is a common source of errors in conventional TCD. Visualization of the vascular anatomy by image guidance offers improved accuracy and reliability of TCD results and may positively influence the learning curve for inexperienced investigators.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg-University of Mainz, Langenbeckstrasse 1, 55101 Mainz, Germany
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Neulen A, Gutenberg A, Takács I, Wéber G, Wegmann J, Schulz-Schaeffer W, Giese A. Evaluation of efficacy and biocompatibility of a novel semisynthetic collagen matrix as a dural onlay graft in a large animal model. Acta Neurochir (Wien) 2011; 153:2241-50. [PMID: 21739175 PMCID: PMC3197932 DOI: 10.1007/s00701-011-1059-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 05/20/2011] [Indexed: 11/29/2022]
Abstract
Background Semisynthetic collagen matrices are promising duraplasty grafts with low risk of cerebrospinal fluid (CSF) fistulas, good tissue integration and minor foreign body reaction. The present study investigates the efficacy and biocompatibility of a novel semisynthetic bilayered collagen matrix (BCM, B. Braun Aesculap) as dural onlay graft for duraplasty. Methods Thirty-four pigs underwent osteoclastic trepanation, excision of the dura, and placement of a cortical defect, followed by duraplasty using BCM, Suturable DuraGen™ (Integra Neuroscience), or periosteum. CSF tightness and intraoperative handling of the grafts were evaluated. Pigs were sacrificed after 1 and 6 months for histological analysis. Findings BCM and DuraGen™ showed superior handling than periosteum with a trend for better adhesion to dura and CSF tightness for BCM. Periosteum, which was sutured unlike the synthetic grafts, had the highest intraoperative CSF tightness. Duraplasty time with periosteum was significantly higher (14.4 ± 2.7 min) compared with BCM (2.8 ± 0.8 min) or DuraGen™ (3.0 ± 0.5 min). Tissue integration by fibroblast infiltration was observed after 1 month for all devices. More adhesions between graft and cortex were observed with DuraGen™ compared with BCM and periosteum. No relevant adhesions between leptomeninges and BCM were observed and all devices showed comparable lymphocytic reaction of the brain. All devices were completely integrated after 6 months. BCM and DuraGen™ showed a trend for an enhanced lymphocytic reaction of the brain parenchyma compared with periosteum. Implant rejection was not observed. Conclusion Semisythetic collagen matrices are an attractive alternative in duraplasty due to their easy handling, lower surgical time, and high biocompatibility.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, Center of Neurological Medicine, University of Göttingen, Germany.
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Neulen A, Kantelhardt SR, Pilgram-Pastor SM, Metz I, Rohde V, Giese A. Microsurgical fenestration of perineural cysts to the thecal sac at the level of the distal dural sleeve. Acta Neurochir (Wien) 2011; 153:1427-34; discussion 1434. [PMID: 21562735 PMCID: PMC3111602 DOI: 10.1007/s00701-011-1043-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 04/26/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgery for symptomatic sacral perineural cysts remains an issue of discussion. Assuming micro-communications between the cyst and thecal sac resulting in a valve mechanism and trapping of CSF as a pathomechanism, microsurgical fenestration from the cyst to the thecal sac was performed to achieve free CSF communication. METHODS In 13 consecutive patients (10 female, 3 male), MRI revealed sacral perineural cysts and excluded other pathologies. Micro-communication between the thecal sac and the cysts was shown by delayed contrast filling of the cysts on postmyelographic CT. Surgical fenestration achieved free CSF communication between the thecal sac and cysts in all patients. The patient histories, follow-up examinations and self-assessment scales were analyzed. Symptoms at initial presentation included lumbosacral pain, pseudoradicular symptoms, genital pain and urinary dysfunction. Mean follow-up was 10.7 ± 6.6 months. FINDINGS Besides one CSF fistula, no surgical complications were observed. Five patients did not improve after surgery; in four of these cases multiple cysts were found, but small and promptly filling cysts remained untreated. Seven patients reported lasting benefit following surgery; three of these had single cysts, and all had cysts >1 cm. One patient initially benefited from cyst fenestration but experienced recurrent pain within 2 months postoperatively. Re-myelography revealed delayed contrast filling of the recurrent cyst; however, surgical revision did not lead to an improvement despite successful fenestration and collapse of the cyst revealed by postoperative imaging. CONCLUSIONS Microsurgical fenestration of sacral perineural cysts to the thecal sac is a surgical approach that has shown success in the treatment of lumbosacral pain, pseudoradicular symptoms, genital pain and urinary dysfunction associated with sacral perineural cysts. Our analysis, however, shows that mainly patients with singular large cysts benefit from this treatment.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, Center of Neurological Medicine, University of Göttingen, Göttingen, Germany.
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Pfitzer G, Lubomirov LT, Drinhaus H, Neulen A. cAMP mediated Ca2+‐desensitization of mouse tail arteries involves disinhibition of myosin light chain phosphatase (MLCP) in a PKA‐dependent and independent manner. FASEB J 2011. [DOI: 10.1096/fasebj.25.1_supplement.1026.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Eifinger F, Lubomirov L, Neulen A, Knolle S, Neiss W, Roth B, Pfitzer G. Wie wird die Kontraktion der glatten intestinalen Muskulatur bei murinen Neugeborenen reguliert? Experimentelle Daten aus dem Mausmodell. Z Geburtshilfe Neonatol 2008. [DOI: 10.1055/s-2008-1078992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Iorga B, Blaudeck N, Solzin J, Neulen A, Stehle I, Lopez Davila AJ, Pfitzer G, Stehle R. Lys184 deletion in troponin I impairs relaxation kinetics and induces hypercontractility in murine cardiac myofibrils. Cardiovasc Res 2007; 77:676-86. [PMID: 18096573 DOI: 10.1093/cvr/cvm113] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
AIMS To understand the functional consequences of the Lys184 deletion in murine cardiac troponin I (mcTnI(DeltaK184)), we have studied the primary effects of this mutation linked to familial hypertrophic cardiomyopathy (FHC) at the sarcomeric level. METHODS AND RESULTS Ca(2+) sensitivity and kinetics of force development and relaxation were investigated in cardiac myofibrils from transgenic mice expressing mcTnI(DeltaK184), as a model which co-segregates with FHC. Ca(2+)-dependent conformational changes (switch-on/off) of the fluorescence-labelled human troponin complex, containing either wild-type hcTnI or mutant hcTnI(DeltaK183), were investigated in myofibrils prepared from the guinea pig left ventricle. Ca(2+) sensitivity and maximum Ca(2+)-activated and passive forces were significantly enhanced and cooperativity was reduced in mutant myofibrils. At partial Ca(2+) activation, mutant but not wild-type myofibrils displayed spontaneous oscillatory contraction of sarcomeres. Both conformational switch-off rates of the incorporated troponin complex and the myofibrillar relaxation kinetics were slowed down by the mutation. Impaired relaxation kinetics and increased force at low [Ca(2+)] were reversed by 2,3-butanedione monoxime (BDM), which traps cross-bridges in non-force-generating states. CONCLUSION We conclude that these changes are not due to alterations of the intrinsic cross-bridge kinetics. The molecular mechanism of sarcomeric diastolic dysfunction in this FHC model is based on the impaired regulatory switch-off kinetics of cTnI, which induces incomplete inhibition of force-generating cross-bridges at low [Ca(2+)] and thereby slows down relaxation of sarcomeres. Ca(2+) sensitization and impairment of the relaxation of sarcomeres induced by this mutation may underlie the enhanced systolic function and diastolic dysfunction at the sarcomeric level.
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Affiliation(s)
- Bogdan Iorga
- Institute of Vegetative Physiology, University of Cologne, Robert-Koch-Strasse 39, Cologne, Germany.
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Neulen A, Blaudeck N, Zittrich S, Metzler D, Pfitzer G, Stehle R. Mn2+-dependent protein phosphatase 1 enhances protein kinase A-induced Ca2+ desensitisation in skinned murine myocardium. Cardiovasc Res 2007; 74:124-32. [PMID: 17321507 DOI: 10.1016/j.cardiores.2007.01.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Revised: 12/04/2006] [Accepted: 01/23/2007] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Phosphorylation of proteins in cardiac myofilaments is a major determinant in the regulation of the Ca(2+) sensitivity of contraction. Whereas most reports have focused on effects of phosphorylation, little is known about reverse effects of dephosphorylation in skinned myocardium. Here we studied the effect of the Mn(2+)-dependent catalytic subunit of protein phosphatase 1 (PP1c-alpha) on the Ca(2+) regulation of contraction. In particular, we tested the hypothesis that phosphorylation persists after the skinning procedure and thereby attenuates protein kinase A (PKA)-induced Ca(2+) desensitisation. METHODS Effects of Mn(2+) and Mn(2+)-PP1c on the Ca(2+) sensitivity of contraction (pCa(50)) were investigated in triton-skinned cardiac fibres from mice and compared with those of PKA treatment. Phosphorylation of proteins was monitored by autoradiography. RESULTS PKA treatment significantly decreased the pCa(50) by 0.04 pCa units. In contrast, treatment with PP1c or Mn(2+)-containing PP1c buffer significantly increased the pCa(50) by 0.26 units or 0.09 units, respectively. These Ca(2+) sensitisations were completely reversed by subsequent PKA treatment. Replacement of the endogenous cardiac troponin I (cTnI) in fibres with the phospho-mimicking mutant human cTnI(S22/23D) abolished the PP1c-induced Ca(2+) sensitisation. PP1c removed (32)P which had been incorporated into cTnI and cardiac myosin binding protein C by PKA treatment. PKA incorporated twofold more (32)P into cTnI in fibres pre-treated with PP1c. CONCLUSIONS Mn(2+)-dependent PP1c increases the Ca(2+) sensitivity of contraction of skinned cardiac fibres. This can be ascribed to dephosphorylation of PKA-dependent phosphorylation sites. Hence PKA-dependent phosphorylation of sarcomeric proteins persists to a functionally relevant degree after the skinning procedure.
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Affiliation(s)
- Axel Neulen
- Institute of Vegetative Physiology, University of Cologne, Robert-Koch-Strasse 39, D-50931 Köln, Germany.
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