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Lin V, Tian C, Wahlster S, Castillo-Pinto C, Mainali S, Johnson NJ. Temperature Control in Acute Brain Injury: An Update. Semin Neurol 2024. [PMID: 38593854 DOI: 10.1055/s-0044-1785647] [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: 04/11/2024]
Abstract
Temperature control in severe acute brain injury (SABI) is a key component of acute management. This manuscript delves into the complex role of temperature management in SABI, encompassing conditions like traumatic brain injury (TBI), acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (aSAH), and hypoxemic/ischemic brain injury following cardiac arrest. Fever is a common complication in SABI and is linked to worse neurological outcomes due to increased inflammatory responses and intracranial pressure (ICP). Temperature management, particularly hypothermic temperature control (HTC), appears to mitigate these adverse effects primarily by reducing cerebral metabolic demand and dampening inflammatory pathways. However, the effectiveness of HTC varies across different SABI conditions. In the context of post-cardiac arrest, the impact of HTC on neurological outcomes has shown inconsistent results. In cases of TBI, HTC seems promising for reducing ICP, but its influence on long-term outcomes remains uncertain. For AIS, clinical trials have yet to conclusively demonstrate the benefits of HTC, despite encouraging preclinical evidence. This variability in efficacy is also observed in ICH, aSAH, bacterial meningitis, and status epilepticus. In pediatric and neonatal populations, while HTC shows significant benefits in hypoxic-ischemic encephalopathy, its effectiveness in other brain injuries is mixed. Although the theoretical basis for employing temperature control, especially HTC, is strong, the clinical outcomes differ among various SABI subtypes. The current consensus indicates that fever prevention is beneficial across the board, but the application and effectiveness of HTC are more nuanced, underscoring the need for further research to establish optimal temperature management strategies. Here we provide an overview of the clinical evidence surrounding the use of temperature control in various types of SABI.
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Affiliation(s)
- Victor Lin
- Department of Neurology, University of Washington, Seattle, Washington
| | - Cindy Tian
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, Washington
- Department of Neurosurgery, University of Washington, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Uppal P, Smith J, Castillo-Pinto C, Wells EM, Jayakar A, Harrar D. Glial Fibrillary Acidic Protein (GFAP) Astrocytopathy: An Emerging Cause of Meningoencephalomyelitis in Children and Adolescents. J Child Neurol 2023; 38:659-664. [PMID: 37981797 DOI: 10.1177/08830738231214301] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Introduction: We describe 5 children with GFAP astrocytopathy with the goal of further characterizing this rare form of meningoencephalomyelitis. Methods: Retrospective chart review of patients diagnosed with GFAP astrocytopathy between 2019 and 2021. Results: Patients were 8-17 years old, and all were male. Fever, headache, and vomiting were common presenting symptoms, and weakness, tremor, and ataxia were common initial examination findings. Initial magnetic resonance imaging (MRI) showed spinal cord abnormalities in 2 patients and leptomeningeal enhancement in 1. Most patients had cerebral spinal fluid pleocytosis, and all screened negative for malignancy. Three patients progressed to coma, and all were treated with immunosuppressant therapy. By discharge, all patients had improved over their clinical nadir, although none had returned to baseline. Discussion: GFAP astrocytopathy is a recently recognized cause of meningoencephalomyelitis in children. Here, we expand our understanding of this entity with the goal of aiding those treating children with GFAP astrocytopathy.
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Affiliation(s)
- Prayerna Uppal
- The School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Jacklyn Smith
- Department of Neurology, Nicklaus Children's Hospital, Miami, FL, USA
| | | | - Elizabeth M Wells
- Division of Neurology, Children's National Hospital, Washington, DC, USA
| | - Anuj Jayakar
- Department of Neurology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Dana Harrar
- Division of Neurology, Children's National Hospital, Washington, DC, USA
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Castillo-Pinto C, Lamotte G, Mehta A, Sonti R, Di Maria G, Ruiz D, Kumar PN, Stemer AB, Denny MC. Healthcare Worker With Large Vessel Acute Ischemic Stroke Likely Related to Mild SARS-CoV-2 Infection. Neurohospitalist 2022; 12:48-56. [PMID: 34950386 PMCID: PMC8689530 DOI: 10.1177/1941874420966845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
We report the case of a healthcare worker who presented with a large vessel acute ischemic stroke in setting of a mild SARS-CoV-2 infection and provide a review of the emerging literature on COVID-related stroke. A 43-year-old female presented with right-sided hemiparesis, aphasia and dysarthria. She had a nonproductive of cough for 1 week without fever, fatigue or dyspnea. A CT Head, CT angiography and CT perfusion imaging revealed a M1 segment occlusion of the left middle cerebral artery requiring transfer from a primary to a comprehensive stroke center. A nasopharyngeal swab confirmed SARS-CoV-2 infection prior to arrival at the accepting center. During the thrombectomy a 3 cm thrombus was removed. Thrombus was also evident in the 8 French short sheath during closure device placement so a hypercoagulable state was suspected. Stroke work-up revealed a glycosylated hemoglobin of 8.7%, elevation of inflammatory markers and an indeterminate level of lupus anticoagulant IgM. On discharge home, she had near complete neurological recovery. This case highlights suspected mechanisms of hypercoagulability in SARS-CoV-2 infection and the importance of optimizing stroke care systems during the COVID-19 pandemic.
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Affiliation(s)
- Carlos Castillo-Pinto
- Department of Pediatric Neurology, Children’s National Medical Center, Washington, DC, USA
- Georgetown University Medical Center, Washington, DC, USA
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Guillaume Lamotte
- Georgetown University Medical Center, Washington, DC, USA
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Amit Mehta
- Georgetown University Medical Center, Washington, DC, USA
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Rajiv Sonti
- Georgetown University Medical Center, Washington, DC, USA
- MedStar Georgetown University Hospital, Division of Pulmonary, Department of Medicine, Critical Care and Sleep Medicine, Washington, DC, USA
| | - Gianluca Di Maria
- Georgetown University Medical Center, Washington, DC, USA
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Daniel Ruiz
- Georgetown University Medical Center, Washington, DC, USA
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Princy N. Kumar
- Georgetown University Medical Center, Washington, DC, USA
- Division of Infectious Diseases, Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Andrew B. Stemer
- Georgetown University Medical Center, Washington, DC, USA
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - M. Carter Denny
- Georgetown University Medical Center, Washington, DC, USA
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
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Castillo-Pinto C, Sen K, Gropman A. Neuromonitoring in Rare Disorders of Metabolism. Yale J Biol Med 2021; 94:645-655. [PMID: 34970103 PMCID: PMC8686771] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Inborn errors of metabolism (IEM) are a unique class of genetic diseases due to mutations in genes involved in key metabolic pathways. The combined incidence of IEM has been estimated to be as high as 1:1000. Urea Cycle disorders (UCD), one class of IEM, can present with cerebral edema and represent a possible target to explore the utility of different neuromonitoring techniques during an hyperammonemic crisis. The last two decades have brought advances in the early identification and comprehensive management of UCD, including further understanding of neuroimaging patterns associated with neurocognitive function. Nonetheless, very important questions remain about the potential acute neurotoxic effects of hyperammonemia to better understand how to treat and prevent secondary brain injury. In this review, we describe existing neuromonitoring techniques that have been used in rare metabolic disorders to assess and allow amelioration of ongoing brain injury. Directions of future research should be focused on identifying new diagnostic approaches in the management of metabolic crises to optimize care and reduce long term morbidity and mortality in patients with IEM.
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Affiliation(s)
| | - Kuntal Sen
- Neurogenetics and Neurodevelopmental Pediatrics, Children's National, Washington DC, USA
| | - Andrea Gropman
- Neurogenetics and Neurodevelopmental Pediatrics, Children's National, Washington DC, USA
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Abstract
Patients with severe obesity tend to have higher rates of morbidities which can complicate and even lengthen their hospital admission course. Hospitals which do not have the resources to efficiently manage bariatric patients due to equipment weight-restrictions should be proactive in their care and knowledgeable about their options to avoid long delays in treatment. Amid this obesity epidemic, the neurologist plays a role in the inpatient management of patients with severe obesity and could serve as a channel to improve the quality of care and reduce the length of stay. We present a case of a patient with severe obesity who presented with visual loss secondary to idiopathic intracranial hypertension. The patient’s treatment was delayed several weeks from the time of admission until his weight decreased enough to safely undergo CT imaging in the operating room, developing complications throughout the course of his stay. This paper highlights the identified barriers of care and potential solutions to ensure improvement in the quality of care of patients with severe obesity, in order to reduce preventable complications.
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Affiliation(s)
- Navin Prasad
- Georgetown University School of Medicine, Washington, DC, USA
| | - Carlos Castillo-Pinto
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amy Li Safadi
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Benjamin Osborne
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
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Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Gailloud P, Pearl MS. Endovascular therapy for acute stroke in children: age and size technical limitations. J Neurointerv Surg 2021; 13:794-798. [PMID: 33832970 DOI: 10.1136/neurintsurg-2021-017311] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 01/18/2023]
Abstract
Endovascular therapies for acute childhood stroke remain controversial and little evidence exists to determine the minimum age and size cut-off for thrombectomy in children. Despite this, an increasing number of reports suggest feasibility of thrombectomy in at least some children by experienced operators. When compared with adults, technical modifications may be necessary in children owing to differences in vessel sizes, tolerance of blood loss, safety of contrast and radiation exposure, and differing stroke etiologies. We review critical considerations for neurologists and neurointerventionalists when treating pediatric stroke with endovascular therapies. We discuss technical factors that may limit feasibility of endovascular therapy, including size of the femoral and cervicocerebral arteries, which contributes to vasospasm risk. The risk of femoral vasospasm can be assessed by comparing catheter outer diameter with estimated femoral artery size, which can be estimated based on the child's height. We review evidence supporting specific strategies to mitigate cervicocerebral arterial injury, including technique (stent retrieval vs direct aspiration) and device size selection. The importance of and strategies for minimizing blood loss, radiation exposure, and contrast administration are reviewed. Attention to these technical limitations is critical to delivering the safest possible care when thrombectomy is being considered for children with acute stroke.
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Affiliation(s)
- Lisa R Sun
- Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dana Harrar
- Neurology, Children's National Hospital, Washington, District of Columbia, USA
| | - Gerald Drocton
- Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Philippe Gailloud
- Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Monica S Pearl
- Radiology, Children's National Hospital, Washington, District of Columbia, USA.,Radiology and Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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Sun LR, Harrar D, Drocton G, Castillo-Pinto C, Felling R, Carpenter JL, Wernovsky G, McDougall CG, Gailloud P, Pearl MS. Mechanical Thrombectomy for Acute Ischemic Stroke: Considerations in Children. Stroke 2020; 51:3174-3181. [PMID: 32912096 DOI: 10.1161/strokeaha.120.029698] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of mechanical thrombectomy for the treatment of acute childhood arterial ischemic stroke with large vessel occlusion is increasing, with mounting evidence for its feasibility and safety. Despite this emerging evidence, clear guidelines for patient selection, thrombectomy technique, and postprocedure care do not exist for the pediatric population. Due to unique features of stroke in children, neurologists and interventionalists must consider differences in patient size, anatomy, collateral vessels, imaging parameters, and expected outcomes that may impact appropriate patient selection and timing criteria. In addition, different causes of stroke and comorbidities in children must be considered and may alter the safety and efficacy of thrombectomy. To optimize the success of endovascular intervention in children, a multidisciplinary team should take into account these nuanced considerations when determining patient eligibility, developing a procedural approach, and formulating a postprocedure neurological monitoring and therapeutic plan.
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Affiliation(s)
- Lisa R Sun
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD. (L.R.S., R.F.)
| | - Dana Harrar
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Gerald Drocton
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.)
| | - Carlos Castillo-Pinto
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Ryan Felling
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD. (L.R.S., R.F.)
| | - Jessica L Carpenter
- Department of Neurology, Children's National Hospital, Washington, DC. (D.H., C.C.P., J.L.C.)
| | - Gil Wernovsky
- Divisions of Cardiac Critical Care and Pediatric Cardiology, Children's National Hospital, Washington, DC. (G.W.)
| | - Cameron G McDougall
- Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, MD. (C.G.M.)
| | - Philippe Gailloud
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.)
| | - Monica S Pearl
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD. (G.D., P.G., M.S.P.).,Department of Radiology, Children's National Hospital, Washington, DC. (M.S.P.)
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Alfaro-Bittner K, Castillo-Pinto C, Clerc MG, González-Cortés G, Jara-Schulz G, Rojas RG. Front propagation steered by a high-wavenumber modulation: Theory and experiments. Chaos 2020; 30:053138. [PMID: 32491917 DOI: 10.1063/5.0003519] [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] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 05/04/2020] [Indexed: 06/11/2023]
Abstract
Homogeneously driven dynamical systems exhibit multistability. Depending on the initial conditions, fronts present a rich dynamical behavior between equilibria. Qualitatively, this phenomenology is persistent under spatially modulated forcing. However, the understanding of equilibria and front dynamics organization is not fully established. Here, we investigate these phenomena in the high-wavenumber limit. Based on a model that describes the reorientation transition of a liquid crystal light valve with spatially modulated optical forcing and the homogenization method, equilibria and fronts as a function of forcing parameters are studied. The forcing induces patterns coexisting with the uniform state in regions where the system without forcing is monostable. The front dynamics is characterized theoretically and numerically. Experimental results verify these phenomena and the law describing bistability, showing quite good agreement.
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Affiliation(s)
- K Alfaro-Bittner
- Departamento de Física, Universidad Técnica Federico Santa María, Av. España 1680, Casilla 110V, Valparaíso, Chile
| | - C Castillo-Pinto
- Departamento de Física and Millennium Institute for Research in Optics, FCFM, Universidad de Chile, Casilla 487-3, Santiago, Chile
| | - M G Clerc
- Departamento de Física and Millennium Institute for Research in Optics, FCFM, Universidad de Chile, Casilla 487-3, Santiago, Chile
| | - G González-Cortés
- Departamento de Física and Millennium Institute for Research in Optics, FCFM, Universidad de Chile, Casilla 487-3, Santiago, Chile
| | - G Jara-Schulz
- Departamento de Física and Millennium Institute for Research in Optics, FCFM, Universidad de Chile, Casilla 487-3, Santiago, Chile
| | - R G Rojas
- Instituto de Física, Pontificia Universidad Católica de Valparaíso, Casilla 4059, Valparaíso, Chile
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Andrade-Silva I, Bortolozzo U, Castillo-Pinto C, Clerc MG, González-Cortés G, Residori S, Wilson M. Dissipative structures induced by photoisomerization in a dye-doped nematic liquid crystal layer. Philos Trans A Math Phys Eng Sci 2018; 376:rsta.2017.0382. [PMID: 30420545 PMCID: PMC6232603 DOI: 10.1098/rsta.2017.0382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/13/2018] [Indexed: 06/09/2023]
Abstract
Order-disorder phase transitions driven by temperature or light in soft matter materials exhibit complex dissipative structures. Here, we investigate the spatio-temporal phenomena induced by light in a dye-doped nematic liquid crystal layer. Experimentally, for planar anchoring of the nematic layer and high enough input power, photoisomerization processes induce a nematic-isotropic phase transition mediated by interface propagation between the two phases. In the case of a twisted nematic layer and for intermediate input power, the light induces a spatially modulated phase, which exhibits stripe patterns. The pattern originates as an instability mediated by interface propagation between the modulated and the homogeneous nematic states. Theoretically, the phase transition, emergence of stripe patterns and front dynamics are described on the basis of a proposed model for the dopant concentration coupled with the nematic order parameter. Numerical simulations show quite a fair agreement with the experimental observations.This article is part of the theme issue 'Dissipative structures in matter out of equilibrium: from chemistry, photonics and biology (part 2)'.
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Affiliation(s)
- I Andrade-Silva
- Department of Physics, Facultad de Ciencias Físicas y Matemáticas, Millennium Institute for Research in Optics, Universidad de Chile, Casilla 487-3, Santiago, Chile
| | - U Bortolozzo
- UMR7010, CNRS, Université de Nice-Sophia Antipolis, Institut de Physique de Nice, 1361 Route des Lucioles, 06560 Valbonne, France
| | - C Castillo-Pinto
- Department of Physics, Facultad de Ciencias Físicas y Matemáticas, Millennium Institute for Research in Optics, Universidad de Chile, Casilla 487-3, Santiago, Chile
| | - M G Clerc
- Department of Physics, Facultad de Ciencias Físicas y Matemáticas, Millennium Institute for Research in Optics, Universidad de Chile, Casilla 487-3, Santiago, Chile
| | - G González-Cortés
- Department of Physics, Facultad de Ciencias Físicas y Matemáticas, Millennium Institute for Research in Optics, Universidad de Chile, Casilla 487-3, Santiago, Chile
| | - S Residori
- UMR7010, CNRS, Université de Nice-Sophia Antipolis, Institut de Physique de Nice, 1361 Route des Lucioles, 06560 Valbonne, France
| | - M Wilson
- CONACYT - CICESE, Carretera Ensenada-Tijuana 3918, Zona Playitas, C.P. 22860 Ensenada, Mexico
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