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Mader MMD, Napole A, Wu D, Atkins M, Scavetti A, Shibuya Y, Foltz A, Hahn O, Yoo Y, Danziger R, Tan C, Wyss-Coray T, Steinman L, Wernig M. Myeloid cell replacement is neuroprotective in chronic experimental autoimmune encephalomyelitis. Nat Neurosci 2024; 27:901-912. [PMID: 38514857 DOI: 10.1038/s41593-024-01609-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/22/2024] [Indexed: 03/23/2024]
Abstract
Multiple sclerosis (MS) is an autoimmune disease characterized by demyelination of the central nervous system (CNS). Autologous hematopoietic cell transplantation (HCT) shows promising benefits for relapsing-remitting MS in open-label clinical studies, but the cellular mechanisms underlying its therapeutic effects remain unclear. Using single-nucleus RNA sequencing, we identify a reactive myeloid cell state in chronic experimental autoimmune encephalitis (EAE) associated with neuroprotection and immune suppression. HCT in EAE mice results in an increase of the neuroprotective myeloid state, improvement of neurological deficits, reduced number of demyelinated lesions, decreased number of effector T cells and amelioration of reactive astrogliosis. Enhancing myeloid cell incorporation after a modified HCT further improved these neuroprotective effects. These data suggest that myeloid cell manipulation or replacement may be an effective therapeutic strategy for chronic inflammatory conditions of the CNS.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Alan Napole
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Danwei Wu
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Neurology and Neurosciences, Division of Neuroimmunology and Multiple Sclerosis Center, Stanford University of Medicine, Stanford, CA, USA
| | - Micaiah Atkins
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Alexa Scavetti
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yohei Shibuya
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Aulden Foltz
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Oliver Hahn
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Yongjin Yoo
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ron Danziger
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Christina Tan
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Tony Wyss-Coray
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Lawrence Steinman
- Department of Neurology and Neurosciences, Division of Neuroimmunology and Multiple Sclerosis Center, Stanford University of Medicine, Stanford, CA, USA
| | - Marius Wernig
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.
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Schweingruber N, Bremer J, Wiehe A, Mader MMD, Mayer C, Woo MS, Kluge S, Grensemann J, Quandt F, Gempt J, Fischer M, Thomalla G, Gerloff C, Sauvigny J, Czorlich P. Early prediction of ventricular peritoneal shunt dependency in aneurysmal subarachnoid haemorrhage patients by recurrent neural network-based machine learning using routine intensive care unit data. J Clin Monit Comput 2024:10.1007/s10877-024-01151-4. [PMID: 38512361 DOI: 10.1007/s10877-024-01151-4] [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: 11/26/2023] [Accepted: 03/08/2024] [Indexed: 03/23/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) can lead to complications such as acute hydrocephalic congestion. Treatment of this acute condition often includes establishing an external ventricular drainage (EVD). However, chronic hydrocephalus develops in some patients, who then require placement of a permanent ventriculoperitoneal (VP) shunt. The aim of this study was to employ recurrent neural network (RNN)-based machine learning techniques to identify patients who require VP shunt placement at an early stage. This retrospective single-centre study included all patients who were diagnosed with aSAH and treated in the intensive care unit (ICU) between November 2010 and May 2020 (n = 602). More than 120 parameters were analysed, including routine neurocritical care data, vital signs and blood gas analyses. Various machine learning techniques, including RNNs and gradient boosting machines, were evaluated for their ability to predict VP shunt dependency. VP-shunt dependency could be predicted using an RNN after just one day of ICU stay, with an AUC-ROC of 0.77 (CI: 0.75-0.79). The accuracy of the prediction improved after four days of observation (Day 4: AUC-ROC 0.81, CI: 0.79-0.84). At that point, the accuracy of the prediction was 76% (CI: 75.98-83.09%), with a sensitivity of 85% (CI: 83-88%) and a specificity of 74% (CI: 71-78%). RNN-based machine learning has the potential to predict VP shunt dependency on Day 4 after ictus in aSAH patients using routine data collected in the ICU. The use of machine learning may allow early identification of patients with specific therapeutic needs and accelerate the execution of required procedures.
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Affiliation(s)
- Nils Schweingruber
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Jan Bremer
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Anton Wiehe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
- Department of Informatics, University of Hamburg, 22527, Hamburg, Germany
| | - Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Christina Mayer
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), Center for Molecular Neurobiology Hamburg (ZMNH), University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Marcel Seungsu Woo
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), Center for Molecular Neurobiology Hamburg (ZMNH), University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Fanny Quandt
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Jennifer Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Sauvigny J, Mader MMD, Freundlieb N, Gempt J, Westphal M, Zöllner C, Mende A, Czorlich P. Patient perception and satisfaction in awake burr hole trepanation under local anesthesia for evacuation of chronic subdural hematoma. Clin Neurol Neurosurg 2024; 236:108085. [PMID: 38134758 DOI: 10.1016/j.clineuro.2023.108085] [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: 11/13/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023]
Abstract
Evacuation of chronic subdural hematoma (CSDH) will be one of the most common neurosurgical procedures in the future in the increasingly aging societies. Performing cranial surgery on awake patients may place a psychological burden on them. Aim of this study was to evaluate the psychological distress of patients during awake CSDH relief. Patients with awake evacuation of CSDH via burr hole trepanation were included in our monocentric prospective study. Patient perception and satisfaction were measured using standardized surveys 3-5 days and 6 months after surgery. Among other questionnaires, the Hospital Anxiety and Depression and the Impact of Event Scale, were used to quantify patients' stress. A total of 50 patients (mean age 72.9 years (range 51 - 92)) were included. During surgery, 28 patients reported pain (mean 4.1 (SD 3.3)). Postoperatively, 26 patients experienced pain (mean 2.7 (SD 2.6)). Patients' satisfaction with intraoperative communication was reported with a mean of 8.3 (SD 2.1). There was a significant negative correlation between intraoperatively perceived pain and satisfaction with intraoperative communication (p = 0.023). Good intraoperative communication during evacuation of CSDH in awake patients is associated with positive patient perception and correlates with pain reduction.
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Affiliation(s)
- Jennifer Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | - Nils Freundlieb
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Mende
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Yoo Y, Neumayer G, Shibuya Y, Mader MMD, Wernig M. A cell therapy approach to restore microglial Trem2 function in a mouse model of Alzheimer's disease. Cell Stem Cell 2023; 30:1392. [PMID: 37802040 DOI: 10.1016/j.stem.2023.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
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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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Yoo Y, Neumayer G, Shibuya Y, Mader MMD, Wernig M. A cell therapy approach to restore microglial Trem2 function in a mouse model of Alzheimer's disease. Cell Stem Cell 2023; 30:1043-1053.e6. [PMID: 37541210 DOI: 10.1016/j.stem.2023.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/10/2023] [Accepted: 07/11/2023] [Indexed: 08/06/2023]
Abstract
Alzheimer's disease (AD) remains one of the grand challenges facing human society. Much controversy exists around the complex and multifaceted pathogenesis of this prevalent disease. Given strong human genetic evidence, there is little doubt, however, that microglia play an important role in preventing degeneration of neurons. For example, loss of function of the microglial gene Trem2 renders microglia dysfunctional and causes an early-onset neurodegenerative syndrome, and Trem2 variants are among the strongest genetic risk factors for AD. Thus, restoring microglial function represents a rational therapeutic approach. Here, we show that systemic hematopoietic cell transplantation followed by enhancement of microglia replacement restores microglial function in a Trem2 mutant mouse model of AD.
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Affiliation(s)
- Yongjin Yoo
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Gernot Neumayer
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Yohei Shibuya
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Marius Marc-Daniel Mader
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Marius Wernig
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Mader MMD, Napole A, Wu D, Shibuya Y, Scavetti A, Foltz A, Atkins M, Hahn O, Yoo Y, Danziger R, Tan C, Wyss-Coray T, Steinman L, Wernig M. Augmentation of a neuroprotective myeloid state by hematopoietic cell transplantation. bioRxiv 2023:2023.03.10.532123. [PMID: 36945385 PMCID: PMC10028976 DOI: 10.1101/2023.03.10.532123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Multiple sclerosis (MS) is an autoimmune disease associated with inflammatory demyelination in the central nervous system (CNS). Autologous hematopoietic cell transplantation (HCT) is under investigation as a promising therapy for treatment-refractory MS. Here we identify a reactive myeloid state in chronic experimental autoimmune encephalitis (EAE) mice and MS patients that is surprisingly associated with neuroprotection and immune suppression. HCT in EAE mice leads to an enhancement of this myeloid state, as well as clinical improvement, reduction of demyelinated lesions, suppression of cytotoxic T cells, and amelioration of reactive astrogliosis reflected in reduced expression of EAE-associated gene signatures in oligodendrocytes and astrocytes. Further enhancement of myeloid cell incorporation into the CNS following a modified HCT protocol results in an even more consistent therapeutic effect corroborated by additional amplification of HCT-induced transcriptional changes, underlining myeloid-derived beneficial effects in the chronic phase of EAE. Replacement or manipulation of CNS myeloid cells thus represents an intriguing therapeutic direction for inflammatory demyelinating disease.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Institute for Stem Cell Biology and Regenerative Medicine and
Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305,
USA
- Department of Pathology, Stanford University School of Medicine,
Stanford, CA 94305, USA
| | - Alan Napole
- Institute for Stem Cell Biology and Regenerative Medicine and
Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305,
USA
- Department of Pathology, Stanford University School of Medicine,
Stanford, CA 94305, USA
| | - Danwei Wu
- Institute for Stem Cell Biology and Regenerative Medicine and
Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305,
USA
- Department of Pathology, Stanford University School of Medicine,
Stanford, CA 94305, USA
- Department of Neurology and Neurosciences, Division of
Neuroimmunology and Multiple Sclerosis Center, Stanford University of Medicine, Stanford, CA
94305, USA
| | - Yohei Shibuya
- Institute for Stem Cell Biology and Regenerative Medicine and
Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305,
USA
- Department of Pathology, Stanford University School of Medicine,
Stanford, CA 94305, USA
| | - Alexa Scavetti
- Institute for Stem Cell Biology and Regenerative Medicine and
Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305,
USA
- Department of Pathology, Stanford University School of Medicine,
Stanford, CA 94305, USA
| | - Aulden Foltz
- Department of Neurology and Neurological Sciences, Stanford
University School of Medicine, Stanford, CA 94305, USA
- Veterans Administration Palo Alto Healthcare System, Palo Alto,
CA 94304, USA
| | - Micaiah Atkins
- Department of Neurology and Neurological Sciences, Stanford
University School of Medicine, Stanford, CA 94305, USA
- Veterans Administration Palo Alto Healthcare System, Palo Alto,
CA 94304, USA
| | - Oliver Hahn
- Department of Neurology and Neurological Sciences, Stanford
University School of Medicine, Stanford, CA 94305, USA
- Veterans Administration Palo Alto Healthcare System, Palo Alto,
CA 94304, USA
| | - Yongjin Yoo
- Institute for Stem Cell Biology and Regenerative Medicine and
Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305,
USA
- Department of Pathology, Stanford University School of Medicine,
Stanford, CA 94305, USA
| | - Ron Danziger
- Institute for Stem Cell Biology and Regenerative Medicine and
Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305,
USA
- Department of Pathology, Stanford University School of Medicine,
Stanford, CA 94305, USA
| | - Christina Tan
- Institute for Stem Cell Biology and Regenerative Medicine and
Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305,
USA
- Department of Pathology, Stanford University School of Medicine,
Stanford, CA 94305, USA
| | - Tony Wyss-Coray
- Department of Neurology and Neurological Sciences, Stanford
University School of Medicine, Stanford, CA 94305, USA
- Veterans Administration Palo Alto Healthcare System, Palo Alto,
CA 94304, USA
| | - Lawrence Steinman
- Department of Neurology and Neurosciences, Division of
Neuroimmunology and Multiple Sclerosis Center, Stanford University of Medicine, Stanford, CA
94305, USA
| | - Marius Wernig
- Institute for Stem Cell Biology and Regenerative Medicine and
Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305,
USA
- Department of Pathology, Stanford University School of Medicine,
Stanford, CA 94305, USA
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Piffko A, Ricklefs FL, Schweingruber N, Sauvigny T, Mader MMD, Mohme M, Dührsen L, Westphal M, Regelsberger J, Schmidt NO, Czorlich P. Corticosteroid-Dependent Leukocytosis Masks the Predictive Potential of White Blood Cells for Delayed Cerebral Ischemia and Ventriculoperitoneal Shunt Dependency in Aneurysmatic Subarachnoid Hemorrhage. J Clin Med 2023; 12:jcm12031006. [PMID: 36769654 PMCID: PMC9917511 DOI: 10.3390/jcm12031006] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/21/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
A multitude of pathological and inflammatory processes determine the clinical course after aneurysmal subarachnoid hemorrhage (aSAH). However, our understanding of predictive factors and therapeutic consequences is limited. We evaluated the predictive value of clinically relevant factors readily available in the ICU setting, such as white blood cell (WBC) count and CRP, for two of the leading comorbidities, delayed cerebral ischemia (DCI) and ventriculoperitoneal (VP) shunt dependency in aSAH patients with and without corticosteroid treatment. We conducted a retrospective analysis of 484 aSAH patients admitted to our institution over an eight-year period. Relevant clinical factors affecting the risk of DCI and VP shunt dependency were identified and included in a multivariate logistic regression model. Overall, 233/484 (48.1%) patients were treated with corticosteroids. Intriguingly, predictive factors associated with the occurrence of DCI differed significantly depending on the corticosteroid treatment status (dexamethasone group: Hunt and Hess grade (p = 0.002), endovascular treatment (p = 0.016); no-dexamethasone group: acute hydrocephalus (p = 0.018), peripheral leukocyte count 7 days post SAH (WBC at day 7) (p = 0.009)). Similar disparities were found for VP shunt dependency (dexamethasone group: acute hydrocephalus (p = 0.002); no-dexamethasone group: WBC d7 (p = 0.036), CRP peak within 72 h (p = 0.015)). Our study shows that corticosteroid-induced leukocytosis negates the predictive prognostic potential of systemic inflammatory markers for DCI and VP shunt dependency, which has previously been neglected and should be accounted for in future studies.
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Affiliation(s)
- Andras Piffko
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL 60637, USA
- Ludwig Center for Metastasis Research, University of Chicago, Chicago, IL 60637, USA
| | - Franz L. Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Nils Schweingruber
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Malte Mohme
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Jan Regelsberger
- Department of Neurosurgery, Diako Hospital Flensburg, 24939 Flensburg, Germany
| | - Nils Ole Schmidt
- Department of Neurosurgery, Regensburg University Hospital, 93053 Regensburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
- Correspondence: ; Tel.: +49-40-7410-50753
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Mader MMD, Lefering R, Westphal M, Maegele M, Czorlich P. Extracorporeal membrane oxygenation in traumatic brain injury - A retrospective, multicenter cohort study. Injury 2023; 54:1271-1277. [PMID: 36621363 DOI: 10.1016/j.injury.2023.01.002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 12/14/2022] [Accepted: 01/01/2023] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Patients with traumatic brain injury (TBI) regularly require intensive care with prolonged invasive ventilation. Consequently, these patients are at increased risk of pulmonary failure, potentially requiring extracorporeal membrane oxygenation (ECMO). The aim of this work was to provide an overview of ECMO treatment in TBI patients based upon data captured into the TraumaRegister DGU® (TR-DGU). METHODS A retrospective multi-center cohort analysis of patients registered in the TR-DGU was conducted. Adult patients with relevant TBI (AISHead ≥3) who had been treated in German, Austrian, or Swiss level I or II trauma centers using ECMO therapy between 2015 and 2019 were included. A multivariable logistic regression analysis was used to identify risk factors for the need for ECMO treatment. RESULTS 12,247 patients fulfilled the inclusion criteria. The overall rate of ECMO treatment was 1.1% (134 patients). Patients on ECMO had an overall hospital mortality rate of 38% (51/134 patients) while 13% (1523/12,113 patients) of TBI patients without ECMO therapy died. Male gender (p = 0.014), AISChest 3+ (p<0.001), higher Injury Severity Score (p<0.001) and packed red blood cell (pRBC) transfusion (p<0.001) were associated with ECMO treatment. CONCLUSION ECMO therapy is a potentially lifesaving modality for the treatment of moderate-to-severe TBI when combined with severe chest trauma and pulmonary failure. The in-hospital mortality is increased in this high-risk population, but the majority of patients is surviving.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Federal Republic of Germany; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Federal Republic of Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Federal Republic of Germany
| | - Marc Maegele
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Federal Republic of Germany; Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Federal Republic of Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Federal Republic of Germany.
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Grensemann J, Mader MMD, Westphal M, Kluge S, Czorlich P. Hyperoxia is Dose-Dependently Associated with an Increase of Unfavorable Outcomes in Ventilated Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study. Neurocrit Care 2022; 37:523-530. [PMID: 35672497 PMCID: PMC9519732 DOI: 10.1007/s12028-022-01534-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/05/2022] [Indexed: 11/05/2022]
Abstract
Background Adequate oxygenation in patients with aneurysmal subarachnoid hemorrhage (SAH) is imperative. However, hyperoxia increases formation of reactive oxygen species and may be associated with a dose-dependent toxicity. We postulated a threshold for arterial partial pressure of oxygen (paO2) above which toxicity effects precipitate and sought to study the effects on 30-day mortality, favorable outcome at discharge and at 3 months, and delayed cerebral ischemia. Methods In this retrospective single-center cohort study, patients with SAH and mechanical ventilation > 72 h were included. Oxygen integrals were calculated above the following thresholds: 80, 100, 120, and 150 mm Hg and time-weighted mean paO2. All calculations were done from admission to end of day 1, day 3, and day 14. We conducted multivariable logistic regression analyses adjusted for age, sex, duration of ventilation, and Hunt and Hess grade. Time-weighted mean paO2 was categorized by quartiles. Favorable outcome was defined as Glasgow Outcome Scale scores of 4 and 5. Results From November 2010 to February 2021, 282 of 549 patients fulfilled the inclusion criteria. Odds ratios for 30-day mortality increased dose dependently and were as follows: 1.07 (95% confidence interval [CI] 1.03–1.11; p = 0.001) for each 1 mm Hg per day above 80 mm Hg; 1.16 (95% CI 1.07–1.27), above 100 mm Hg; 1.36 (95% CI 1.15–1.61), above 120 mm Hg; and 1.59 (95% CI 1.22–2.08), above 150 mm Hg (all p < 0.001) at day 14. For favorable outcome at 3 months, odds ratios were 0.96 (95% CI 0.92–0.99) for each 1 mm Hg per day above 80 mm Hg; 0.90 (95% CI 0.84–0.98), above 100 mm Hg; 0.83 (95% CI 0.72–0.97), above 120 mm Hg; and 0.77 (95% CI 0.61–0.97), above 150 mm Hg (all p < 0.05). For time-weighted mean paO2, lowest 30-day mortality and highest favorable outcome at 3 months were found in the second quartile (78–85 mm Hg). Thirty-day mortality increased above 93 mm Hg (fourth quartile), with an odds ratio of 3.4 (95% CI 1.4–8.4, p = 0.007). Odds ratios for favorable outcome at 3 months were 0.28 (95% CI 0.12–0.69), 0.27 (95% CI 0.11–0.67), and 0.24 (95% CI 0.10–0.59) for the first, third, and fourth quartiles, respectively (all p < 0.01). No significant association was found at day 1 and day 3, for favorable outcome at discharge, or for delayed cerebral ischemia. Conclusions Integrals above the defined paO2 thresholds were dose-dependently associated with an increase in mortality in ventilated patients with SAH. When we considered time-weighted mean paO2, unfavorable outcomes and 30-day mortality were more frequent both below and above a certain range. Unfavorable outcomes increased in paO2 ranges usually defined as normoxia. This emphasizes the necessity to further characterize oxygenation thresholds in ventilated patients with SAH in prospective clinical studies. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01534-y.
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11
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Shibuya Y, Kumar KK, Mader MMD, Yoo Y, Ayala LA, Zhou M, Mohr MA, Neumayer G, Kumar I, Yamamoto R, Marcoux P, Liou B, Bennett FC, Nakauchi H, Sun Y, Chen X, Heppner FL, Wyss-Coray T, Südhof TC, Wernig M. Treatment of a genetic brain disease by CNS-wide microglia replacement. Sci Transl Med 2022; 14:eabl9945. [PMID: 35294256 PMCID: PMC9618306 DOI: 10.1126/scitranslmed.abl9945] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Hematopoietic cell transplantation after myeloablative conditioning has been used to treat various genetic metabolic syndromes but is largely ineffective in diseases affecting the brain presumably due to poor and variable myeloid cell incorporation into the central nervous system. Here, we developed and characterized a near-complete and homogeneous replacement of microglia with bone marrow cells in mice without the need for genetic manipulation of donor or host. The high chimerism resulted from a competitive advantage of scarce donor cells during microglia repopulation rather than enhanced recruitment from the periphery. Hematopoietic stem cells, but not immediate myeloid or monocyte progenitor cells, contained full microglia replacement potency equivalent to whole bone marrow. To explore its therapeutic potential, we applied microglia replacement to a mouse model for Prosaposin deficiency, which is characterized by a progressive neurodegeneration phenotype. We found a reduction of cerebellar neurodegeneration and gliosis in treated brains, improvement of motor and balance impairment, and life span extension even with treatment started in young adulthood. This proof-of-concept study suggests that efficient microglia replacement may have therapeutic efficacy for a variety of neurological diseases.
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Affiliation(s)
- Yohei Shibuya
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Kevin K Kumar
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA,These authors contributed equally
| | - Marius Marc-Daniel Mader
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,These authors contributed equally
| | - Yongjin Yoo
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,These authors contributed equally
| | - Luis Angel Ayala
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Mu Zhou
- Department of Molecular and Cellular Physiology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | | | - Gernot Neumayer
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Ishan Kumar
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Ryo Yamamoto
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Paul Marcoux
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Benjamin Liou
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - F Chris Bennett
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hiromitsu Nakauchi
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA,Division of Stem Cell Therapy, Distinguished Professor Unit, The Institute of Medical Science, The University of Tokyo, Tokyo 108-8639, Japan
| | - Ying Sun
- Division of Human Genetics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Xiaoke Chen
- Department of Biology, Stanford University, Stanford, CA 94305, USA
| | - Frank L. Heppner
- Department of Neuropathology, Cluster of Excellence, NeuroCure, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany,Department of Neuropathology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany,Cluster of Excellence, NeuroCure, Charitéplatz 1, 10117 Berlin, Germany,Berlin Institute of Health (BIH), 10117 Berlin, Germany,German Center for Neurodegenerative Diseases (DZNE) Berlin, 10117 Berlin, Germany
| | - Tony Wyss-Coray
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA,Veterans Administration Palo Alto Healthcare System, Palo Alto, CA 94304, USA
| | - Thomas C. Südhof
- Department of Molecular and Cellular Physiology, Stanford University School of Medicine, Stanford, CA 94305, USA,Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Marius Wernig
- Institute for Stem Cell Biology and Regenerative Medicine and Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA,Lead Contact,Correspondence:
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12
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Mader MMD, Deuter D, Sauvigny T, Borchert P, Faizy TD, Bester M, Westphal M, Rosengarth K, Schmidt NO, Sedlacik J, Dührsen L. Diffusion tensor imaging changes in patients with glioma-associated seizures. J Neurooncol 2022; 160:311-320. [PMID: 36344852 PMCID: PMC9722813 DOI: 10.1007/s11060-022-04139-9] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 09/19/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Structural white matter changes associated with certain epilepsy subtypes have been demonstrated using diffusion tensor imaging (DTI). This observational study aims to identify potential water diffusion abnormalities in glioma patients with associated seizures. METHODS Two cohorts from two centers were analyzed independently: (A) Prospectively recruited patients diagnosed with glioma who received preoperative DTI to measure mean diffusivity (MD) and fractional anisotropy (FA) in regions-of-interest (ROIs) including the marginal tumor zone (TU), adjacent peritumoral white matter as well as distant ipsilateral and contralateral white matter and cortex. Data were compared between patients with and without seizures and tested for statistical significance. (B) A retrospective cohort using an alternative technical approach sampling ROIs in contrast enhancement, necrosis, non-enhancing tumor, marginal non-enhancing tumor zone, peritumoral tissue, edema and non-tumorous tissue. RESULTS (A) The prospective study cohort consisted of 23 patients with 12 (52.2%) presenting with a history of seizures. There were no significant seizure-associated differences in MD or FA for non-tumor white matter or cortical areas. MD-TU was significantly lower in patients with seizures (p = 0.005). (B) In the retrospective cohort consisting of 46 patients with a seizure incidence of 50.0%, significantly decreased normalized values of MD were observed for non-enhancing tumor regions of non-glioblastoma multiforme (GBM) cases in patients with seizures (p = 0.022). CONCLUSION DTI analyses in glioma patients demonstrated seizure-associated diffusion restrictions in certain tumor-related areas. No other structural abnormalities in adjacent or distant white matter or cortical regions were detected.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany ,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, 265 Campus Drive, Stanford, CA 94305 USA
| | - Daniel Deuter
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Patrick Borchert
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Tobias D. Faizy
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany ,Department of Neuroimaging and Neurointervention, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305 USA
| | - Maxim Bester
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Katharina Rosengarth
- Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Nils O. Schmidt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany ,Department of Neurosurgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Jan Sedlacik
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany ,Centre for the Developing Brain and Biomedical Engineering Department, School of Biomedical Engineering & Imaging Sciences, King’s College London, London, UK
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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13
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Abstract
Nitric oxide is an important mediator of vascular autoregulation and is involved in pathophysiological changes after acute neurological disorders. Nitric oxide is generated by nitric oxide synthases from the amino acid L-arginine. L-arginine can also serve as a substrate for arginases or lead to the generation of dimethylarginines, asymmetric dimethylarginine, and symmetric dimethylarginine, by methylation. Asymmetric dimethylarginine is an endogenous inhibitor of nitric oxide synthase and can lead to endothelial dysfunction. This review discusses the role of L-arginine metabolism in patients suffering from acute and critical neurological disorders often requiring neuro-intensive care treatment. Conditions addressed in this review include intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, and traumatic brain injury. Recent therapeutic advances in the field are described including current randomized controlled trials for traumatic brain injuries and hemorrhagic stroke.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Faizy TD, Kabiri R, Christensen S, Mlynash M, Kuraitis G, Mader MMD, Albers GW, Lansberg MG, Fiehler J, Wintermark M, Marks MP, Heit JJ. Association of Venous Outflow Profiles and Successful Vessel Reperfusion After Thrombectomy. Neurology 2021; 96:e2903-e2911. [PMID: 33952649 PMCID: PMC8253568 DOI: 10.1212/wnl.0000000000012106] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 03/17/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Robust arterial collaterals are associated with successful reperfusion after thrombectomy treatment of acute ischemic stroke due to large vessel occlusion (AIS-LVO). Excellent venous outflow (VO) reflects excellent tissue perfusion and collateral status in patients with AIS-LVO. The goal of this study was to determine whether favorable VO profiles assessed on pretreatment CT angiography (CTA) images correlate with successful vessel reperfusion after thrombectomy in patients with AIS-LVO. METHODS This was a multicenter retrospective cohort study of consecutive patients with AIS-LVO treated by thrombectomy. Baseline CTA was used to assess collateral status (Tan scale) and VO using the Cortical Vein Opacification Score (COVES). Favorable VO was defined as COVES ≥3. Primary outcome was excellent vessel reperfusion status (modified Thrombolysis in Cerebral Infarction 2c/3). Secondary outcome was good functional outcome defined as a score of 0 to 2 on the modified Rankin Scale after 90 days. RESULTS Five hundred sixty-five patients met the inclusion criteria. Multivariable logistic regression analysis showed that favorable VO (odds ratio [OR] 2.10 [95% confidence interval (CI) 1.39-3.16]; p < 0.001) was associated with excellent vessel reperfusion during thrombectomy, regardless of good CTA collateral status (OR 0.87 [95% CI 0.58-1.34]; p = 0.48). A favorable VO profile (OR 8.9 [95%CI 5.3-14.9]; p < 0.001) and excellent vessel reperfusion status (OR 2.7 [95%CI 1.7-4.4]; p < 0.001) were independently associated with good functional outcome adjusted for age, sex, glucose, tissue plasminogen activator administration, good CTA collateral status, and presentation NIH Stroke Scale score. CONCLUSION A favorable VO profile is associated with reperfusion success and good functional outcomes in patients with AIS-LVO treated by endovascular thrombectomy. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that a favorable VO profile is associated with reperfusion success and good functional outcomes in patients with AIS-LVO treated by endovascular thrombectomy.
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Affiliation(s)
- Tobias Djamsched Faizy
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reza Kabiri
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Soren Christensen
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Mlynash
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriella Kuraitis
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marius Marc-Daniel Mader
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gregory W Albers
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maarten G Lansberg
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Max Wintermark
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael P Marks
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- From the Department of Neuroimaging and Neurointerventions (T.D.F., R.K., G.K., M.W., M.P.M., J.J.H.) and Stanford Stroke Center (S.C., M.M., G.W.A., M.G.L.), Stanford University, CA; and Departments of Neurosurgery (M.M.-D.M.) and Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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15
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Mader MMD, Rotermund R, Lefering R, Westphal M, Maegele M, Czorlich P. The faster the better? Time to first CT scan after admission in moderate-to-severe traumatic brain injury and its association with mortality. Neurosurg Rev 2020; 44:2697-2706. [PMID: 33340052 PMCID: PMC8490239 DOI: 10.1007/s10143-020-01456-3] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
Fast acquisition of a first computed tomography (CT) scan after traumatic brain injury (TBI) is recommended. This study is aimed at investigating whether the length of the period preceding initial CT scan influences mortality in patients with leading TBI. A retrospective cohort analysis of patients registered in the TraumaRegister DGU® was conducted including adult patients with TBI, defined as Abbreviated Injury ScaleHead ≥ 3 and GCS ≤ 13 who had been treated in level 1 or 2 trauma centers from 2007-2016. Patients were grouped according to time intervals either from trauma or from admission to CT. A total of 6904 patients met the inclusion criteria. Mean time period from trauma to hospital admission was 68.8 min. From admission to first CT, a mean of 19.0 min elapsed. Trauma severity was higher in groups with a longer duration from trauma to CT as represented by a mean (± standard deviation) Injury Severity Score (ISS) of 19.8 ± 9.0, 20.7 ± 9.3, and 21.4 ± 7.5 and similar distribution of mortality of 24.9%, 29.9%, and 36.3% in the ≤ 60-min, 61-120-min, and ≥ 121-min groups, respectively. An adjusted multivariable logistic regression model showed a significant influence of the level of the trauma center (p = 0.037) but not for interval from admission to CT (p = 0.528). TBI patients with a longer time span from trauma to first CT were more severely injured and demonstrated a worse prognosis, but received a CT scan faster when duration from admission is observed. The duration until the CT scan was obtained showed no significant impact on the mortality.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Roman Rotermund
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Rolf Lefering
- Institute of Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marc Maegele
- Institute of Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany.,Department for Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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16
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Mader MMD, Lefering R, Westphal M, Maegele M, Czorlich P. Traumatic brain injury with concomitant injury to the spleen: characteristics and mortality of a high-risk trauma cohort from the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2020; 48:4451-4459. [PMID: 33206232 DOI: 10.1007/s00068-020-01544-5] [Citation(s) in RCA: 2] [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] [Received: 08/18/2020] [Accepted: 10/31/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Based on the hypothesis that systemic inflammation contributes to secondary injury after initial traumatic brain injury (TBI), this study aims to describe the effect of splenectomy on mortality in trauma patients with TBI and splenic injury. METHODS A retrospective cohort analysis of patients prospectively registered into the TraumaRegister DGU® (TR-DGU) with TBI (AISHead ≥ 3) combined with injury to the spleen (AISSpleen ≥ 1) was conducted. Multivariable logistic regression modeling was performed to adjust for confounding factors and to assess the independent effect of splenectomy on in-hospital mortality. RESULTS The cohort consisted of 1114 patients out of which 328 (29.4%) had undergone early splenectomy. Patients with splenectomy demonstrated a higher Injury Severity Score (median: 34 vs. 44, p < 0.001) and lower Glasgow Coma Scale (median: 9 vs. 7, p = 0.014) upon admission. Splenectomized patients were more frequently hypotensive upon admission (19.8% vs. 38.0%, p < 0.001) and in need for blood transfusion (30.3% vs. 61.0%, p < 0.001). The mortality was 20.7% in the splenectomy group and 10.3% in the remaining cohort. After adjustment for confounding factors, early splenectomy was not found to exert a significant effect on in-hospital mortality (OR 1.29 (0.67-2.50), p = 0.45). CONCLUSION Trauma patients with TBI and spleen injury undergoing splenectomy demonstrate a more severe injury pattern, more compromised hemodynamic status and higher in-hospital mortality than patients without splenectomy. Adjustment for confounding factors reveals that the splenectomy procedure itself is not independently associated with survival.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany. .,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, 265 Campus Drive, Stanford, CA, 94305, USA.
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marc Maegele
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, 51109, Cologne, Germany.,Department of Trauma and Orthopaedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Center, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Mader MMD, Czorlich P, König C, Fuhrmann V, Kluge S, Westphal M, Grensemann J. Intrathecal penetration of meropenem and vancomycin administered by continuous infusion in patients suffering from ventriculitis-a retrospective analysis. Acta Neurochir (Wien) 2018; 160:2099-2105. [PMID: 30242495 DOI: 10.1007/s00701-018-3680-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 08/07/2018] [Accepted: 09/12/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Vancomycin and meropenem are frequently used as empiric treatment for ventriculitis. Penetration into the cerebrospinal fluid (CSF) depends on various factors with a high inter-individual variability. Because attaining and maintaining adequate concentrations of meropenem and vancomycin in the CSF is crucial for their bactericidal effect, we introduced a routine therapeutic drug monitoring (TDM) from CSF and serum for both antibiotics. We studied the antibiotic penetration into the CSF. METHODS Patient data including serum and CSF concentrations for meropenem and vancomycin were collected in a retrospective fashion. Antibiotic CSF penetration ratio was calculated for each patient. Antibiotics were administered by continuous infusion aiming for serum target concentrations of 20-30 mg/L for vancomycin and 16-32 mg/L for meropenem. RESULTS Twenty-two patients with 36 CSF/serum pairs for meropenem and 43 pairs for vancomycin were studied. No patient suffered from renal or liver insufficiency. Mean vancomycin serum concentration was 22 ± 8 mg/L and the mean CSF concentration 4.5 ± 2.6 mg/L. CSF penetration was 20 ± 11% (coefficient of determination (R2) 0.02). For meropenem, the mean serum concentration was 30.7 ± 14.9 mg/L, mean CSF concentration 5.5 ± 5.2 mg/L, and a penetration of 18 ± 12%, R2 = 0.42. CONCLUSION Penetration of meropenem and vancomycin into the CSF is low while showing a high interindividual variability. Various patients in our study cohort were at risk for insufficient target attainment in CSF. Continuous administration of antibiotics under routine TDM appears to be a feasible and reasonable approach for optimization of intrathecal drug levels in patients suffering from ventriculitis. TDM might guide individual dosing adaptation and efforts to predict the CSF penetration of meropenem and vancomycin in cases of ventriculitis.
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Affiliation(s)
- Marius Marc-Daniel Mader
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christina König
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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