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Kollmar R, Biesel J. Contrast-Induced Encephalopathy. Dtsch Arztebl Int 2024; 121:24. [PMID: 38386943 PMCID: PMC10916767 DOI: 10.3238/arztebl.m2023.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Affiliation(s)
- Rainer Kollmar
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt GmbH,
| | - Julia Biesel
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt GmbH,
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2
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Bardutzky J, Kollmar R, Al-Rawi F, Lambeck J, Fazel M, Taschner C, Niesen WD. COmbination of Targeted temperature management and Thrombectomy after acute Ischemic Stroke (COTTIS): a pilot study. Stroke Vasc Neurol 2023:svn-2023-002420. [PMID: 37612052 DOI: 10.1136/svn-2023-002420] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/05/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND To evaluate the feasibility and safety of a fast initiation of cooling to a target temperature of 35°C by means of transnasal cooling in patients with anterior circulation large vessel occlusion (LVO) undergoing endovascular thrombectomy (EVT). METHODS Patients with an LVO onset of <24 hour who had an indication for EVT were included in the study. Transnasal cooling (RhinoChill) was initiated immediately after the patient was intubated for EVT and continued until an oesophageal target temperature of 35°C was reached. Hypothermia was maintained with surface cooling for 6-hour postrecanalisation, followed by active rewarming (+0.2°C/hour). The primary outcome was defined as the time required to reach 35°C, while secondary outcomes comprised clinical, radiological and safety parameters. RESULTS Twenty-two patients (median age, 77 years) were included in the study (14 received additional thrombolysis, 4 additional stenting of the proximal internal carotid artery). The median time intervals were 309 min for last-seen-normal-to-groin, 58 min for door-to-cooling-initiation, 65 min for door-to-groin and 123 min for door-to-recanalisation. The target temperature of 35°C was reached within 30 min (range 13-78 min), corresponding to a cooling rate of 2.6 °C/hour. On recanalisation, 86% of the patients had a body temperature of ≤35°C. The median National Institutes of Health Stroke Scale at admission was 15 and improved to 2 by day 7, and 68% of patients had a good outcome (modified Rankin Scale 0-2) at 3 months. Postprocedure complications included asymptomatic bradycardia (32%), pneumonia (18%) and asymptomatic haemorrhagic transformation (18%). CONCLUSION The combined application of hypothermia and thrombectomy was found to be feasible in sedated and ventilated patents. Adverse events were comparable to those previously described for EVT in the absence of hypothermia. The effect of this procedure will next be evaluated in the randomised COmbination of Targeted temperature management and Thrombectomy after acute Ischemic Stroke-2 trial.
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Affiliation(s)
- Jürgen Bardutzky
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rainer Kollmar
- Neurology and Neurointensive Care, Darmstadt Hospital, Darmstadt, Germany
| | - Forat Al-Rawi
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Christian Taschner
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Kollmar R, De Georgia M. Milestones in the history of neurocritical care. Neurol Res Pract 2023; 5:43. [PMID: 37559106 PMCID: PMC10413505 DOI: 10.1186/s42466-023-00271-7] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023] Open
Abstract
Over the last century, significant milestones have been achieved in managing critical illness and diagnosing and treating neurological diseases. Building upon these milestones, the field of neurocritical care emerged in the 1980 and 1990 s at the convergence of critical care medicine and acute neurological treatment. This comprehensive review presents a historical account of key developments in neurocritical care in both the United States and Europe, with a special emphasis on German contributions. The scope of the review encompasses: the foundations of neurocritical care, including post-operative units in the 1920s and 30s, respiratory support during the poliomyelitis epidemics in the 40 and 50 s, cardiac and hemodynamic care in the 60 and 70 s, and stroke units in the 80 and 90 s; key innovations including cerebral angiography, computed tomography, and intracranial pressure and multi-modal monitoring; and advances in stroke, traumatic brain injury, cardiac arrest, neuromuscular disorders, meningitis and encephalitis. These advances have revolutionized the management of neurological emergencies, emphasizing interdisciplinary teamwork, evidence-based protocols, and personalized approaches to care.
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Affiliation(s)
- Rainer Kollmar
- Department of Neurology and Neurointensive Care, Darmstadt Academic Hospital, Darmstadt, Germany.
| | - Michael De Georgia
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Wang R, Moeller S, Akhundova A, Marthol H, Kollmar R, Köhrmann M, Hilz MJ. Rapid recovery of poststroke cardiac autonomic dysfunction: Causes to be considered. Eur J Neurol 2023. [PMID: 37159491 DOI: 10.1111/ene.15853] [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: 01/27/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND AND PURPOSE Acute stroke frequently causes cardiovascular-autonomic dysfunction (CAD). Studies of CAD recovery are inconclusive, whereas poststroke arrhythmias may wane within 72 h. We evaluated whether poststroke CAD recovers within 72 h upon stroke onset in association with neurological improvement or increased use of cardiovascular medication. METHODS In 50 ischemic stroke patients (68 ± 13 years old) who-prior to hospital-admission-had no known diseases nor took medication affecting autonomic modulation, we assessed National Institutes of Health Stroke Scale (NIHSS) scores, RR intervals (RRIs), systolic and diastolic blood pressure (BP), respiration rate, parameters reflecting total autonomic modulation (RRI SD, RRI total powers), sympathetic modulation (RRI low-frequency powers, systolic BP low-frequency powers), and parasympathetic modulation (square root of mean squared differences of successive RRIs [RMSSD], RRI high-frequency powers), and baroreflex sensitivity within 24 h (Assessment 1) and 72 h after stroke onset (Assessment 2) and compared data to those of 31 healthy controls (64 ± 10 years). We correlated delta NIHSS values (Assessment 1 - Assessment 2) with delta values of autonomic parameters (Spearman rank correlation tests; significance: p < 0.05). RESULTS At Assessment 1, patients were not yet on vasoactive medication and had higher systolic BP, respiration rate, and heart rate, that is, lower RRIs, but lower RRI SD, RRI coefficient of variance, RRI low-frequency powers, RRI high-frequency powers, RRI total powers, RMSSDs, and baroreflex sensitivity. At Assessment 2, patients were on antihypertensives, had higher RRI SD, RRI coefficient of variance, RRI low-frequency powers, RRI high-frequency powers, RRI total powers, RMSSDs, and baroreflex sensitivity but lower systolic blood pressure and NIHSS values than at Assessment 1; values no longer differed between patients and controls except for lower RRIs and higher respiration rate in patients. Delta NIHSS scores correlated inversely with delta values of RRI SD, RRI coefficient of variance, RMSSDs, RRI low-frequency powers, RRI high-frequency powers, RRI total powers, and baroreflex sensitivity. CONCLUSIONS In our patients, CAD recovery was almost complete within 72 h after stroke onset and correlated with neurological improvement. Most likely, early initiation of cardiovascular medication and probably attenuating stress supported rapid CAD recovery.
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Affiliation(s)
- Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian Moeller
- Faculty of Health/School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Aynur Akhundova
- Department of Neurology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Harald Marthol
- Department of Psychiatry, Addiction, Psychotherapy, and Psychosomatics, Klinikum am Europakanal, Erlangen, Germany
| | - Rainer Kollmar
- Department of Neurology, General Hospital Darmstadt, Darmstadt, Germany
| | - Martin Köhrmann
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Bösel J, Kollmar R. [Neurointensive care unites neuro-disciplines : Severe nonvascular brain function disorders and syndromes]. Nervenarzt 2023; 94:73-74. [PMID: 36735014 PMCID: PMC9897151 DOI: 10.1007/s00115-022-01429-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Julian Bösel
- Deutsche Gesellschaft für NeuroIntensiv- und Notfallmedizin (DGNI), Geschäftsstelle Jena, Jena, Deutschland.
- , Goethestr. 74, 34119, Kassel, Deutschland.
| | - Rainer Kollmar
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt GmbH, Grafenstr. 9, 64283, Darmstadt, Deutschland.
- Sektion Neuromedizin, Deutsche Interdisziplinäre Vereinigung für Intensivmedzin (DIVI), Geschäftsstelle Berlin, Berlin, Deutschland.
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Baker TS, Kellner CP, Colbourne F, Rincon F, Kollmar R, Badjatia N, Dangayach N, Mocco J, Selim MH, Lyden P, Polderman K, Mayer S. Consensus recommendations on therapeutic hypothermia after minimally invasive intracerebral hemorrhage evacuation from the hypothermia for intracerebral hemorrhage (HICH) working group. Front Neurol 2022; 13:859894. [PMID: 36062017 PMCID: PMC9428129 DOI: 10.3389/fneur.2022.859894] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Therapeutic hypothermia (TH), or targeted temperature management (TTM), is a classic treatment option for reducing inflammation and potentially other destructive processes across a wide range of pathologies, and has been successfully used in numerous disease states. The ability for TH to improve neurological outcomes seems promising for inflammatory injuries but has yet to demonstrate clinical benefit in the intracerebral hemorrhage (ICH) patient population. Minimally invasive ICH evacuation also presents a promising option for ICH treatment with strong preclinical data but has yet to demonstrate functional improvement in large randomized trials. The biochemical mechanisms of action of ICH evacuation and TH appear to be synergistic, and thus combining hematoma evacuation with cooling therapy could provide synergistic benefits. The purpose of this working group was to develop consensus recommendations on optimal clinical trial design and outcomes for the use of therapeutic hypothermia in ICH in conjunction with minimally invasive ICH evacuation. Methods An international panel of experts on the intersection of critical-care TH and ICH was convened to analyze available evidence and form a consensus on critical elements of a focal cooling protocol and clinical trial design. Three focused sessions and three full-group meetings were held virtually from December 2020 to February 2021. Each meeting focused on a specific subtopic, allowing for guided, open discussion. Results These recommendations detail key elements of a clinical cooling protocol and an outline for the roll-out of clinical trials to test and validate the use of TH in conjunction with hematoma evacuation as well as late-stage protocols to improve the cooling approach. The combined use of systemic normothermia and localized moderate (33.5°C) hypothermia was identified as the most promising treatment strategy. Conclusions These recommendations provide a general outline for the use of TH after minimally invasive ICH evacuation. More research is needed to further refine the use and combination of these promising treatment paradigms for this patient population.
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Affiliation(s)
- Turner S. Baker
- Icahn School of Medicine at Mount Sinai, Sinai BioDesign, New York, NY, United States
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Turner S. Baker
| | - Christopher P. Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Fred Rincon
- Department of Neurology, Thomas Jefferson University Hospital, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Neha Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - J. Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Magdy H. Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, United States
| | - Patrick Lyden
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, CA, United States
| | - Kees Polderman
- United Memorial Medical Center, Houston, TX, United States
| | - Stephan Mayer
- Westchester Medical Center Health Network, Valhalla, NY, United States
- Department of Neurology, New York Medical College, Valhalla, NY, United States
- Department of Neurosurgery, New York Medical College, Valhalla, NY, United States
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Wang R, Köhrmann M, Kollmar R, Koehn J, Schwab S, Kallmünzer B, Hilz MJ. Posterior circulation ischemic stroke not involving the brainstem is associated with cardiovascular autonomic dysfunction. Eur J Neurol 2022; 29:2690-2700. [PMID: 35638371 DOI: 10.1111/ene.15427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 05/03/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke may induce cardiovascular autonomic dysfunction. Yet, most previous studies included patients with anterior circulation ischemic stroke or brainstem stroke. It remains unclear whether posterior circulation ischemic stroke (PCIS) without brainstem involvement also compromises cardiovascular autonomic modulation (CAM). Therefore, we aimed to assess CAM in PCIS patients with and without brainstem involvement. METHODS In four subgroups of 61 PCIS-patients (14 occipital lobe, 16 thalamic, 12 cerebellar, and 19 brainstem strokes) and 30 healthy controls, we recorded RR-intervals (RRI), systolic, diastolic blood pressures (BPsys, BPdia), and respiration at supine rest during the first week after stroke-onset. We calculated parameters reflecting total CAM [RRI-standard-deviation (RRI-SD), RRI-total-powers], predominantly sympathetic CAM [RRI-low-frequency-powers (RRI-LF-powers) and BPsys-LF-powers] and parasympathetic CAM [Root-Mean-Square-of-Successive-RRI-Differences (RMSSD), RRI-high-frequency-powers (RRI-HF-powers)], sympathetic-parasympathetic balance (RRI-LF/HF-ratios), and baroreflex-sensitivity (BRS). Values were compared between the four PCIS-groups and controls using one-way ANOVA Kruskal-Wallis-tests, with post-hoc analyses. Significance was assumed for P<0.05. RESULTS In each PCIS-subgroup, values of RRI, RRI-SD, RMSSD, RRI-HF-powers, and BRS were significantly lower, while BPsys-LF-powers were higher than in the controls. Only in patients with occipital lobe stroke, RRI-LF/HF-ratios were significantly higher than in controls. Otherwise, autonomic parameters did not differ between the four PCIS-subgroups. CONCLUSIONS During the first week after stroke-onset, our PCIS patients with occipital lobe, thalamic, cerebellar, or brainstem strokes all had reduced cardiovagal modulation, compromised baroreflex, and increased peripheral sympathetic modulation. The RRI-LF/HF-ratios suggest that sympathetic predominance is slightly more prominent after occipital lobe stroke. PCIS may trigger cardiovascular autonomic dysfunction even without brainstem involvement.
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Affiliation(s)
- Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Rainer Kollmar
- Department of Neurology, General Hospital Darmstadt, Darmstadt, Germany
| | - Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Alonso A, Kollmar R, Dimitriadis K. Das ist neu in der Neurointensiv- und Notfallmedizin: die wichtigsten Studien des Jahres im Rück- und Überblick. Nervenarzt 2022; 93:1228-1234. [PMID: 35380221 PMCID: PMC8981881 DOI: 10.1007/s00115-022-01285-3] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/24/2022]
Abstract
Die vorliegende Übersichtsarbeit fasst wichtige klinische Studien der neurologischen Notfall- und Intensivmedizin zwischen 2020 und 2021 zusammen zu den Themen: rekanalisierende Therapie beim ischämischen Schlaganfall, Anwendbarkeit und Auswirkung eines zerebralen Sauerstoffgewebemonitorings bei Subarachnoidalblutung, Wirksamkeit induzierter Hypothermie bei Patienten mit „cardiac arrest“ (CA), Wertigkeit früher kranialer Bildgebung nach CA, Relevanz eines schnellen Managements und medikamentöser Therapie beim Status epilepticus sowie Inzidenz von Critical-illness-Polyneuropathie-Myopathie bei intensivpflichtigen COVID-Patienten.
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Affiliation(s)
- Angelika Alonso
- Department of Neurology, Mannheim Center for Translational Neurosciences, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany.
- Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany.
| | - Konstantin Dimitriadis
- Department of Neurology, University Hospital LMU Munich, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), Ludwig-Maximilians-Universität (LMU), Munich, Germany
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Alonso A, Kollmar R, Dimitriadis K. [Erratum to: New aspects in neurointensive and emergency medicine: the most important studies in a review and overview]. Nervenarzt 2022; 93:1235. [PMID: 35748893 PMCID: PMC9828820 DOI: 10.1007/s00115-022-01345-8] [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] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Angelika Alonso
- grid.7700.00000 0001 2190 4373Department of Neurology, Mannheim Center for Translational Neurosciences, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Deutschland
| | - Rainer Kollmar
- grid.5330.50000 0001 2107 3311Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Deutschland ,Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Deutschland
| | - Konstantin Dimitriadis
- grid.411095.80000 0004 0477 2585Department of Neurology, University Hospital LMU Munich, München, Deutschland ,grid.5252.00000 0004 1936 973XInstitute for Stroke and Dementia Research (ISD), Ludwig-Maximilians-Universität (LMU), München, Deutschland
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Affiliation(s)
- Lisa Mäder
- From the Department of Neurology and Neurointensive Care Medicine, Klinikum Darmstadt, Darmstadt
| | - Rainer Kollmar
- From the Department of Neurology and Neurointensive Care Medicine, Klinikum Darmstadt, Darmstadt
| | - Hanns-Martin Lorenz
- Division of Rheumatology, Department of Medicine V, Universitätsklinikum Heidelberg, Heidelberg, Germany
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Koehn J, Wang R, de Rojas Leal C, Kallmünzer B, Winder K, Köhrmann M, Kollmar R, Schwab S, Hilz MJ. Correction to: Neck cooling induces blood pressure increase and peripheral vasoconstriction in healthy persons. Neurol Sci 2021; 42:3517. [PMID: 34224027 PMCID: PMC8342398 DOI: 10.1007/s10072-021-05355-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A Correction to this paper has been published: https://doi.org/10.1007/s10072-021-05355-3
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Affiliation(s)
- Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Carmen de Rojas Leal
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Klemens Winder
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Rainer Kollmar
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.,Department of Neurology, General Hospital Darmstadt, Grafenstr. 9, 64283, Darmstadt, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany. .,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Lee H, Hedtmann G, Schwab S, Kollmar R. Effects of a 4-Step Standard Operating Procedure for the Treatment of Fever in Patients With Acute Stroke. Front Neurol 2021; 12:614266. [PMID: 33746874 PMCID: PMC7970170 DOI: 10.3389/fneur.2021.614266] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Fever in the acute phase of stroke leads to an unfavorable clinical outcome and increased mortality. However, no specific form of effective fever treatment has been established, so far. We analyzed the effectiveness of our in-house standard operating procedure (SOP) of fever treatment. Methods: This SOP was analyzed for a period of 33 weeks. Patients with cerebral ischemia (ischemic stroke, transient ischemic attack) or cerebral hemorrhage (intracerebral, subarachnoid) and body temperature elevation of ≥ 37.5°C within the first 6 days after admission were eligible for inclusion in the analysis. The results of SOP group, who's data have been collected prospectively were then compared with a historical control group that had been treated conventionally 1 year earlier in the same period. The data of control group have been collected in retrospect. The primary endpoint was the total duration of the fever for the first 6 days after admission to the stroke unit. Results: A total of 130 patients (mean age of 78 ± 12) received 370 antipyretic interventions. Sequential application of paracetamol (n = 245), metamizole (n = 53) and calf compress (n = 15) led to significant reduction in body temperature. In patients who did not respond to these applications, normothermia could be achieved after infusion of the cooled saline solution. Normothermia could be achieved within 120 min in more than 90% of the cases treated by the SOP. The SOP reduced the fever duration in the 6 days significantly, from 12.2 ± 2.7 h [95% confidence interval (CI) for mean] in the control group to 3.9 ± 1.0 h (95% CI) in the SOP group (p < 0.001). The SOP was rated to be reasonable and effective. Conclusion: Our in-house SOP is cost-efficient and effective for fever treatment in stroke patients, that can be implemented by local health care professionals.
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Affiliation(s)
- Hanna Lee
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany.,Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany
| | - Günter Hedtmann
- Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany.,Department of Neurology and Neurological Intensive Care, Darmstadt Academic Teaching Hospital, Darmstadt, Germany
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Myftiu A, Hedtmann G, Kollmar R. [Uncomplicated thrombolysis treatment with rt-PA via an intraosseous access after acute ischemic stroke]. Nervenarzt 2020; 91:534-536. [PMID: 32347326 DOI: 10.1007/s00115-020-00914-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Anisa Myftiu
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt GmbH, Grafenstraße 9, 64283, Darmstadt, Deutschland.
| | - Günter Hedtmann
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt GmbH, Grafenstraße 9, 64283, Darmstadt, Deutschland
| | - Rainer Kollmar
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt GmbH, Grafenstraße 9, 64283, Darmstadt, Deutschland
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Koehn J, Wang R, de Rojas Leal C, Kallmünzer B, Winder K, Köhrmann M, Kollmar R, Schwab S, Hilz MJ. Neck cooling induces blood pressure increase and peripheral vasoconstriction in healthy persons. Neurol Sci 2020; 41:2521-2529. [PMID: 32219592 PMCID: PMC8197712 DOI: 10.1007/s10072-020-04349-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 01/06/2020] [Accepted: 03/16/2020] [Indexed: 12/18/2022]
Abstract
Introduction Noninvasive temperature modulation by localized neck cooling might be desirable in the prehospital phase of acute hypoxic brain injuries. While combined head and neck cooling induces significant discomfort, peripheral vasoconstriction, and blood pressure increase, localized neck cooling more selectively targets blood vessels that supply the brain, spares thermal receptors of the face and skull, and might therefore cause less discomfort cardiovascular side effects compared to head- and neck cooling. The purpose of this study is to assess the effects of noninvasive selective neck cooling on cardiovascular parameters and cerebral blood flow velocity (CBFV). Methods Eleven healthy persons (6 women, mean age 42 ± 11 years) underwent 90 min of localized dorsal and frontal neck cooling (EMCOOLS Brain.Pad™) without sedation. Before and after cooling onset, and after every 10 min of cooling, we determined rectal, tympanic, and neck skin temperatures. Before and after cooling onset, after 60- and 90-min cooling, we monitored RR intervals (RRI), systolic, diastolic blood pressures (BPsys, BPdia), laser Doppler skin blood flow (SBF) at the index finger pulp, and CBFV at the proximal middle cerebral artery (MCA). We compared values before and during cooling by analysis of variance for repeated measurements with post hoc analysis (significance: p < 0.05). Results Neck skin temperature dropped significantly by 9.2 ± 4.5 °C (minimum after 40 min), while tympanic temperature decreased by only 0.8 ± 0.4 °C (minimum after 50 min), and rectal temperature by only 0.2 ± 0.3 °C (minimum after 60 min of cooling). Index finger SBF decreased (by 83.4 ± 126.0 PU), BPsys and BPdia increased (by 11.2 ± 13.1 mmHg and 8.0 ± 10.1 mmHg), and heart rate slowed significantly while MCA-CBFV remained unchanged during cooling. Conclusions While localized neck cooling prominently lowered neck skin temperature, it had little effect on tympanic temperature but significantly increased BP which may have detrimental effects in patients with acute brain injuries.
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Affiliation(s)
- Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Carmen de Rojas Leal
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Klemens Winder
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Rainer Kollmar
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.,Department of Neurology, General Hospital Darmstadt, Grafenstr. 9, 64283, Darmstadt, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Max J Hilz
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany. .,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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15
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Neugebauer H, Schneider H, Bösel J, Hobohm C, Poli S, Kollmar R, Sobesky J, Wolf S, Bauer M, Tittel S, Beyersmann J, Woitzik J, Heuschmann PU, Jüttler E. Outcomes of Hypothermia in Addition to Decompressive Hemicraniectomy in Treatment of Malignant Middle Cerebral Artery Stroke: A Randomized Clinical Trial. JAMA Neurol 2020; 76:571-579. [PMID: 30657812 DOI: 10.1001/jamaneurol.2018.4822] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Moderate hypothermia in addition to early decompressive hemicraniectomy has been suggested to further reduce mortality and improve functional outcome in patients with malignant middle cerebral artery (MCA) stroke. Objective To investigate whether moderate hypothermia vs standard treatment after early hemicraniectomy reduces mortality at day 14 in patients with malignant MCA stroke. Design, Setting, and Participants This randomized clinical trial recruited patients from August 2011 through September 2015 at 6 German university hospitals with dedicated neurointensive care units. Of the patients treated with hemicraniectomy and assessed for eligibility, patients were randomly assigned to either standard care or moderate hypothermia. Data analysis was completed from December 2016 to June 2018. Interventions Moderate hypothermia (temperature, 33.0 ± 1.0°C) was maintained for at least 72 hours immediately after hemicraniectomy. Main Outcomes and Measures The primary outcome was mortality rate at day 14 compared with the Fisher exact test and expressed as odds ratio (ORs) with 95% CIs. Rates of patients with serious adverse events were estimated for the period of the first 14 days after hemicraniectomy and 12 months of follow-up. Secondary outcome measures included functional outcome at 12 months. Results Of the 50 study participants, 24 were assigned to standard care and 26 to moderate hypothermia. Twenty-eight were male (56%); the mean (SD) patient age was 51.3 (6.6) years. Recruitment was suspended for safety concerns: 12 of 26 patients (46%) in the hypothermia group and 7 of 24 patients (29%) receiving standard care had at least 1 serious adverse event within 14 days (OR, 2.05 [95% CI, 0.56-8.00]; P = .26); after 12 months, rates of serious adverse events were 80% (n = 20 of 25) in the hypothermia group and 43% (n = 10 of 23) in the standard care group (hazard ratio, 2.54 [95% CI, 1.29-5.00]; P = .005). The mortality rate at day 14 was 19% (5 of 26 patients) in the hypothermia group and 13% (3 of 24 patients) in the group receiving standard care (OR, 1.65 [95% CI, 0.28-12.01]; P = .70). There was no significant difference regarding functional outcome after 12 months of follow-up. Interpretation In patients with malignant MCA stroke, moderate hypothermia early after hemicraniectomy did not improve mortality and functional outcome compared with standard care, but may cause serious harm in this specific setting. Trial Registration http://www.drks.de, identifier DRKS00000623.
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Affiliation(s)
- Hermann Neugebauer
- Department of Neurology, RKU-University and Rehabilitation Hospitals Ulm, University of Ulm, Ulm, Germany
| | - Hauke Schneider
- Department of Neurology, University Hospital, Technische Universität Dresden, Dresden, Germany.,Department of Neurology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Julian Bösel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany.,Department of Neurology, Klinikum Kassel, Kassel, Germany
| | - Carsten Hobohm
- Department of Neurology, University of Leipzig, Leipzig, Germany.,Klinikum Saalekreis, Merseburg, Germany
| | - Sven Poli
- Department of Neurology, University of Tübingen, Tübingen, Germany
| | - Rainer Kollmar
- Department of Neurology, University of Erlangen, Erlangen, Germany.,Department of Neurology and Neurointensive Care, Klinikum Darmstadt, Darmstadt, Germany
| | - Jan Sobesky
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Johanna-Etienne-Krankenhaus Neuss, Neuss, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Miriam Bauer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sascha Tittel
- Institute of Statistics, University of Ulm, Ulm, Germany
| | - Jan Beyersmann
- Institute of Statistics, University of Ulm, Ulm, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter U Heuschmann
- Institute for Clinical Epidemiology and Biometry, Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany.,Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
| | - Eric Jüttler
- Department of Neurology, RKU-University and Rehabilitation Hospitals Ulm, University of Ulm, Ulm, Germany.,Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany
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16
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Cheng B, Boutitie F, Nickel A, Wouters A, Cho TH, Ebinger M, Endres M, Fiebach JB, Fiehler J, Galinovic I, Puig J, Thijs V, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Simonsen CZ, Gerloff C, Thomalla G, Golsari A, Alegiani A, Beck C, Choe CU, Voget D, Hoppe J, Schröder J, Rozanski M, Nave AH, Wollboldt C, van Sloten I, Göhler J, Herm J, Jungehülsing J, Lückl J, Kröber JM, Schurig J, Koehler L, Schlemm L, Knops M, Roennefarth M, Ipsen N, Harmel P, Bathe-Peters R, Fleischmann R, Ganeshan R, Geran R, Hellwig S, Schmidt S, Tütüncü S, Krause T, Gramse V, Röther J, Michels P, Michalski D, Pelz J, Schulz A, Hobohm C, Weise C, Weise G, Orthgieß J, Pomrehn K, Wegscheider M, Mueller AK, Hennerici M, Griebe M, Alonso A, Filipov A, Marzina A, Anders B, Bähr C, Hoyer C, Schwarzbach C, Weber C, Hornberger E, Pledl HW, Klockziem M, Stuermlinger M, Wittayer M, Wolf M, Meyer N, Eisele P, Steinert S, Sauer T, Held V, Ringleb P, Nagel S, Veltkamp R, Schwarting S, Schwarz A, Gumbinger C, Hametner C, Amiri H, Purrucker J, Ciatipis M, Menn O, Mundiyanapurath S, Schieber S, Kessler T, Reiff T, Panitz V, Singer O, Foerch C, Lauer A, Männer A, Seiler A, Guerzoglu D, Schäfer JH, Filipski K, Lorenz M, Kurka N, Zeiner P, Pfeilschifter W, Dziewas R, Minnerup J, Albiker C, Ritter M, Seidel M, Dittrich R, Kallmünzer B, Bobinger T, Madzar D, Stark D, Sembill J, Macha K, Winder K, Breuer L, Koehrmann M, Spruegel M, Gerner S, Kraft P, Mackenrodt D, Kleinschnitz C, Elhfnawy A, Heinen F, Gunreben I, Poli S, Ziemann U, Gaenslen A, Schlak D, Haertig F, Russo F, Richter H, Ebner M, Ribitsch M, Wolf M, Weimar C, Zegarac V, Chen HC, Althaus K, Neugebauer H, Jüttler E, Meier J, Stösser S, Puetz V, Bodechtel U, Ostergaard L, Møller A, Damgaard D, Dupont KH, Poulsen M, Hjort N, de Morales NR, von Weitzel P, Harbo T, Marstrand J, Hansen A, Christensen H, Aegidius K, Jeppesen L, Meden P, Rosenbaum S, Iversen H, Hansen J, Michelsen L, Truelsen T, Modrau B, Vestergaard K, Oppel L, Sygehus A, Aalborg S, Swinnen B, Smets I, Demeestere J, Dobbels L, Brouns R, De Smedt A, DeKeyser J, Yperzeele L, Van Hooff RJ, Peeters A, Dusart A, Etexberria A, Hanseeuw B, London F, Leempoel J, Hohenbichler K, Younan N, Maqueda V, Laloux P, De Coene B, De Maeseneire C, Turine G, Vandermeeren Y, De Klippel N, Willems C, de Hollander I, Soors P, Hermans S, Hemelsoet D, Desfontaines P, Vanacker P, Rutgers M, Druart C, Peeters D, Bruneel B, Vancaester E, Vanhee F, Meersman G, Bourgeois P, Vanderdonckt P, Benoit A, Derex L, Mechthouff L, Berhoune N, Ritzenthaler T, Amarenco P, Hobeanu C, Gancedo EM, Calvet D, Ladoux A, Machet A, Lamy C, Mellerio C, Oppenheim C, Rodriguez-Regent C, Bodiguel E, Turc G, Birchenall J, Legrand L, Morin L, Edjali-Goujon M, Naggara O, Raphaelle S, Godon-Hardy S, Domigo V, Guiraud V, Samson Y, Leger A, Rosso C, Baronnet-Chauvet F, Crozier S, Deltour S, Yger M, Sibon I, Renou P, Sagnier S, Zuber M, Tamazyan R, Rodier G, Morel N, Felix S, Vadot W, Wolff V, Aniculaesei A, Yalo B, Bindila D, Quenardelle V, Blanc-Lasserre K, Landrault E, Breynaert L, Cakmak S, Peysson S, Viguier A, Lebely C, Raposo N, Vallet AE, Vallet P, Brugirard S, Cheripelli B, Kalladka D, Moreton F, Dani K, Tawil SE, Ramachandran S, Huang X, Warburton E, Evans N, Perry R, Patel B, Cloud G, Pereira A, Moynihan B, Lovelock C, Choy L, Khan U, Roffe C, Tyrell P, Smith C, Dixit A, Louw S, Broughton D, Shetty A, Appleton J, Sprigg N, Acosta BR, van Eendenburg C, Leal JS, Mar Castellanos Rodrigo MD, Izaga MT, Guillamon OB, Arenillas J, Calleja A, Cortijo E, Mulero P, de la Ossa NP, Garrido A, Martinez A, Esperón CG, Guerrero C, Carrera D, Vilas D, Lopez-cancio E, Palomeras E, Lucente G, Gomis M, Isern I, Becerra JL, Vicente JH, Sánchez J, Dorado L, Grau L, Ispierto L, Prats L, Almendrote M, Hernández M, Jimenez M, Sánchez ML, Torne MM, Presas S, Ustrell X, Pellisé A, Navalpotro I, Luna A, Schonewille W, Nederkoorn P, Majoie C, van den Berg L, van den Berg S, Zonneveld T, Remmers M, Fazekas F, Pichler A, Fandler S, Gattringer T, Mutzenbach J, Weber J, Höfner E, Kohlfürst H, Weinstich K, Kellert L, Bayer-Karpinska A, Opherk C, Wollenweber F, Klein M, Neumann- Haefelin T, Pierskalla A, Harloff A, Bardutzky J, Buggle F, von Schrader J, Kollmar R, Schill J, Löbbe AM, Moulin T, Bouamra B, Bonnet L, Touzé E, Bonnet AL, Touze E, Cogez J, Li L, Guettier S, Kar A, Sivagnanaratham A, Geraghty O, Bojaryn U, Nallasivan A, Gonzales MB, Rodríguez-Yáñez M, Tembl J, Gorriz D, Oberndorfer S, Prohaska E. Quantitative Signal Intensity in Fluid-Attenuated Inversion Recovery and Treatment Effect in the WAKE-UP Trial. Stroke 2020; 51:209-215. [DOI: 10.1161/strokeaha.119.027390] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Relative signal intensity of acute ischemic stroke lesions in fluid-attenuated inversion recovery (fluid-attenuated inversion recovery relative signal intensity [FLAIR-rSI]) magnetic resonance imaging is associated with time elapsed since stroke onset with higher intensities signifying longer time intervals. In the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke Trial), intravenous alteplase was effective in patients with unknown onset stroke selected by visual assessment of diffusion weighted imaging fluid-attenuated inversion recovery mismatch, that is, in those with no marked fluid-attenuated inversion recovery hyperintensity in the region of the acute diffusion weighted imaging lesion. In this post hoc analysis, we investigated whether quantitatively measured FLAIR-rSI modifies treatment effect of intravenous alteplase.
Methods—
FLAIR-rSI of stroke lesions was measured relative to signal intensity in a mirrored region in the contralesional hemisphere. The relationship between FLAIR-rSI and treatment effect on functional outcome assessed by the modified Rankin Scale (mRS) after 90 days was analyzed by binary logistic regression using different end points, that is, favorable outcome defined as mRS score of 0 to 1, independent outcome defined as mRS score of 0 to 2, ordinal analysis of mRS scores (shift analysis). All models were adjusted for National Institutes of Health Stroke Scale at symptom onset and stroke lesion volume.
Results—
FLAIR-rSI was successfully quantified in stroke lesions in 433 patients (86% of 503 patients included in WAKE-UP). Mean FLAIR-rSI was 1.06 (SD, 0.09). Interaction of FLAIR-rSI and treatment effect was not significant for mRS score of 0 to 1 (
P
=0.169) and shift analysis (
P
=0.086) but reached significance for mRS score of 0 to 2 (
P
=0.004). We observed a smooth continuing trend of decreasing treatment effects in relation to clinical end points with increasing FLAIR-rSI.
Conclusions—
In patients in whom no marked parenchymal fluid-attenuated inversion recovery hyperintensity was detected by visual judgement in the WAKE-UP trial, higher FLAIR-rSI of diffusion weighted imaging lesions was associated with decreased treatment effects of intravenous thrombolysis. This parallels the known association of treatment effect and elapsing time of stroke onset.
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Affiliation(s)
- Bastian Cheng
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Florent Boutitie
- Service de Biostatistique, Hospices Civils de Lyon, France (F.B.)
- Université Lyon 1, Villeurbanne, France (F.B.)
- CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France (F.B.)
| | - Alina Nickel
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Anke Wouters
- Department of Neurology, University Hospitals Leuven, Belgium (A.W., R.L.)
- Department of Neurosciences, Experimental Neurology, KU Leuven–University of Leuven, Belgium (A.W., R.L.)
- VIB, Center for Brain and Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Leuven, Belgium (A.W., R.L.)
| | - Tae-Hee Cho
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, France (T.-H.C., N.N.)
- Hospices Civils de Lyon, France (T.-H.C., N.N.)
| | - Martin Ebinger
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
- Neurologie der Rehaklinik Medical Park Humboldtmühle, Berlin, Germany (M. Ebinger)
| | - Matthias Endres
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
- Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany (M. Endres)
| | - Jochen B. Fiebach
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Ivana Galinovic
- Centrum für Schlaganfallforschung Berlin, Charité–Universitätsmedizin Berlin, Campus Mitte, Germany (M. Ebinger, M. Endres, J.B.F., I.G.)
| | - Josep Puig
- Department of Radiology, Institut de Diagnostic per la Image, Hospital Dr Josep Trueta, Institut d’Investigació Biomèdica de Girona, Parc Hospitalari Martí i Julià de Salt, Girona, Spain (J.P., S.P.)
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia (V.T.)
- Austin Health, Department of Neurology, VIC, Australia (V.T.)
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Belgium (A.W., R.L.)
- Department of Neurosciences, Experimental Neurology, KU Leuven–University of Leuven, Belgium (A.W., R.L.)
- VIB, Center for Brain and Disease Research, Laboratory of Neurobiology, Campus Gasthuisberg, Leuven, Belgium (A.W., R.L.)
| | - Keith W. Muir
- Institute of Neuroscience and Psychology, University of Glasgow, United Kingdom (K.W.M.)
| | - Norbert Nighoghossian
- Department of Stroke Medicine, Université Claude Bernard Lyon 1, CREATIS CNRS UMR 5220-INSERM U1206, INSA-Lyon, France (T.-H.C., N.N.)
- Hospices Civils de Lyon, France (T.-H.C., N.N.)
| | - Salvador Pedraza
- Department of Radiology, Institut de Diagnostic per la Image, Hospital Dr Josep Trueta, Institut d’Investigació Biomèdica de Girona, Parc Hospitalari Martí i Julià de Salt, Girona, Spain (J.P., S.P.)
| | - Claus Z. Simonsen
- Department of Neurology, Aarhus University Hospital, Denmark (C.Z.S.)
| | - Christian Gerloff
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- From the Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum (B.C., A.N., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
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Mooney S, Kollmar R, Gurevich R, Tromblee J, Banerjee A, Sundaram K, Silverman JB, Stewart M. An oxygen-rich atmosphere or systemic fluoxetine extend the time to respiratory arrest in a rat model of obstructive apnea. Neurobiol Dis 2019; 134:104682. [PMID: 31759134 DOI: 10.1016/j.nbd.2019.104682] [Citation(s) in RCA: 4] [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: 09/14/2019] [Revised: 10/23/2019] [Accepted: 11/19/2019] [Indexed: 12/19/2022] Open
Abstract
Audiogenic seizure-prone mice can be protected from seizure-associated death by exposure to an oxygen atmosphere or treatment with selective serotonergic reuptake inhibitors (SSRIs). We have shown previously in a rat model that epileptic seizure activity can spread through brainstem areas to cause sufficient laryngospasm for obstructive apnea and that the period of seizure-associated obstructive apnea can last long enough for respiratory arrest to occur. We hypothesized that both the oxygen-rich atmosphere and SSRIs function by prolonging the time to respiratory arrest, thus ensuring that seizure activity stops before the point of respiratory arrest to allow recovery of respiratory function. To test this hypothesis, we evaluated each preventative treatment in a rat model of controlled airway occlusion where the times to respiratory arrest can be measured. Adult male Sprague Dawley rats (median age = 66 days) were studied in the absence of any seizure activity. By directly studying responses to controlled airway occlusion, rather than airway occlusion secondary to seizure activity, we could isolate the effects of manipulations that might prolong respiratory arrest from the effects of those manipulations on seizure intensity. All group sizes were ≥ 8 animals per group. We found that both oxygen exposure and fluoxetine significantly increased the time to respiratory arrest by up to 65% (p < .0001 for 5 min oxygen exposure; p = .031 for 25 mg/kg fluoxetine tested 60 min after injection) and, given that neither treatment has been shown to significantly alter seizure duration, these increases can account for the protection of either manipulation against death in sudden death models. Importantly, we found that 30 s of exposure to oxygen produced nearly the same protection as 5 min exposure suggesting that oxygen exposure could start after a seizure starts (p = .0012 for 30 s oxygen exposure). Experiments with 50% oxygen/50% air mixtures indicate that the oxygen concentration needs to be above about 60% to ensure that times to respiratory arrest will always be longer than a period of seizure-induced airway occlusion. Selective serotonin reuptake inhibitors, while instructive with regard to mechanism, require impractical dosing and may carry additional risk in the form of greater challenges for resuscitation. We conclude that oxygen exposure or SSRI treatment prevent seizure associated death by sufficiently prolonging the time to respiratory arrest so that respiratory function can recover after the seizure abates and eliminates the stimulus for seizure-induced apnea.
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Affiliation(s)
- S Mooney
- Department of Physiology and Pharmacology, SUNY Health Sciences University, Brooklyn, NY, United States of America
| | - R Kollmar
- Department of Cell Biology, SUNY Health Sciences University, Brooklyn, NY, United States of America; Department of Otolaryngology, SUNY Health Sciences University, Brooklyn, NY, United States of America
| | - R Gurevich
- Department of Physiology and Pharmacology, SUNY Health Sciences University, Brooklyn, NY, United States of America
| | - J Tromblee
- Department of Physiology and Pharmacology, SUNY Health Sciences University, Brooklyn, NY, United States of America
| | - A Banerjee
- Department of Physiology and Pharmacology, SUNY Health Sciences University, Brooklyn, NY, United States of America
| | - K Sundaram
- Department of Otolaryngology, SUNY Health Sciences University, Brooklyn, NY, United States of America
| | - J B Silverman
- Department of Otolaryngology, Long Island Jewish Medical Center, New Hyde Park, NY, United States of America
| | - M Stewart
- Department of Physiology and Pharmacology, SUNY Health Sciences University, Brooklyn, NY, United States of America; Department of Neurology, SUNY Health Sciences University, Brooklyn, NY, United States of America.
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18
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Neugebauer H, Schneider H, Kollmar R. Letter by Neugebauer et al. regarding article "Hypothermia after decompressive hemicraniectomy in treatment of malignant middle cerebral artery stroke: comment on the randomized clinical trial". Crit Care 2019; 23:315. [PMID: 31530280 PMCID: PMC6749710 DOI: 10.1186/s13054-019-2600-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/05/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
- Hermann Neugebauer
- Department of Neurology, University of Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
| | - Hauke Schneider
- Department of Neurology, University Hospital Augsburg, Augsburg, Germany
| | - Rainer Kollmar
- Department of Neurology and Neurointensive Care, Klinikum Darmstadt, Darmstadt, Germany
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19
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Bornstein NM, Saver JL, Diener HC, Gorelick PB, Shuaib A, Solberg Y, Devlin T, Leung T, Molina CA, Skoloudik D, Fiksa J, Krieger D, Andersen G, Berrouschot J, Hobohm C, Schneider D, Griewing B, Endres M, Hausler KG, Kimmig H, Ringleb P, Weimar C, Schilling M, Kohrmann M, Hetzel A, Kaps M, Cheung R, Sobolewski P, Nyke W, Czlonkowska A, Stepien A, Waldemar B, Słowik A, Zbigniewem S, Lubiński I, Portela P, Segure T, Marti-Fabregas J, Alonso M, Nunez A, Miguel MB, Campello A, Arenillas J, Marshall N, Chiu D, Shownkeen H, Rymer M, Sen S, Roubec M, Kuliha M, Lakomý C, Tyl D, Kemlink D, Doležal O, Rekova P, Krejčí V, Christensen A, Belhage B, Maschmann C, Kruse Larsen C, Pott F, Christensen H, Marstrand J, Nielsen JK, Meden P, Prytz S, Rosenbaum S, Hedemann Sorensen JC, Stenhoj Meier K, Schmift Ettrup K, Dupont Hougaard K, Von Wietzel P, Stoll A, Schwetlick H, Pradel H, Hemprich A, Schulz A, Frerich B, Hobohm C, Weise C, Michalski D, Schaller F, Schiefke F, Helmrich J, Pelz J, Schnieder M, Schneider M, Matzen P, Langos R, Müller-Duerwald S, Lukhaup S, Bauer U, Kloppig W, Hiermann E, Mucha G, Soda H, Weinhardt R, Mucha T, Ziegler V, Abbushi A, Hotter B, Winter B, Anthofer B, Noack C, Laubisch D, Heldge Schneider G, Jan Jungehulsing G, Mueller H, Dreier J, Fiebach J, Flechsenhar J, Villringer K, Ebinger M, Rozanski M, Vajkoczy P, Klingebiel R, Steinicke R, Pittl S, Hoffmann S, Maul S, Krause T, Liman T, Plath T, Nowe T, Schmidt W, Fritzsch C, Haas C, Will HG, Haußmann-Betz K, Bayat M, Pordzik T, Hug A, Staff CJ, Lichy C, Eggers G, Kloss M, Bendszus M, Herrmann O, Seeberger R, Schwarting S, Rhode S, Rizos T, Hacke W, Frank B, Bozkurt B, Holle D, Mueller D, Koch D, Shanib H, Sudendey J, Brenck J, Busch K, Gartzen K, Gasser T, Hagenacker T, Buerke B, Prigge G, Minnerup J, Albers J, Wermker K, Schwindt W, Kallmünzer RB, Hauer E, Breuer L, Schellinger P, Kollmar R, Sauer R, Schwab S, Struffert T, Funfack A, Stechmann A, Schlaeger A, Laeppchen C, Schuchardt F, Klingler JH, Reis J, Lambeck J, Friedrich M, Laible M, Wellermeyer P, Beck S, Rutsch S, Niesen WD, Tanislav C, Schaaf H, Kerkmann H, Schirotzek I, Allendörfer J, Wolff S, Yuk-Lun Lau A, Yin Yan Chan A, Siu D, Wong EHC, Chu Wong GK, Leung H, Wong LK, Zhu XL, Yan Soo YO, Ting Tse AC, Kit Leung GK, Leung KM, Ngai Hung K, Wai Mei Kwan M, Man Yu Tse M, Tse P, Hon Chan P, Lee R, Shek Kwan Chang R, Yin Yu Pang S, Fong Kwong Hon S, Cheng TS, Lui WM, Wo Mak WW, Sobota A, Wiater B, Loch B, Wolak G, Łabudzka I, Dabal J, Grzesik M, Sledzinska M, Hatalska-Żerebiec R, Szczuchniak W, Gójska A, Nałęcz D, Gasecki D, Kozera G, Dylewicz Ł, Niekra M, Kwarciany M, Chomik P, Skowron P, Kobayashi A, Chabik G, Makowicz G, Bembenek J, Jędrzejewska J, Karlinski M, Czepiel W, Brodacki B, Staszewski J, Kosek J, Jadczak M, Durka-Kęsy M, Kaluzny K, Ziomek M, Fudala M, Sosnowski Z, Ferens A, Szczygieł E, Banaszkiewicz K, Ziomek M, Wnuk M, Szczepańska-Szerej A, Jach E, Maslanko GE, Wojczal J, Luchowski P, Kowalczyk A, Jakubiak J, Kopcewicz J, Gajda M, Wichlinska-Lubinska M, Rodriguez D, Santamarin E, Pagola J, Lorente Guerrero J, Ribo M, Rubiera M, Maisterra O, Pinero S, Catalina Iglesias V, Plans G, Quesada H, Aparicio Caballero MA, Portela PC, De Diego AB, Garay DS, García Rodriguez MR, Martin OA, Braña SC, Garcia J, Hernandez FM, Catala I, Marti-Vilalta JL, Delgado Mederos R, de Quintana SC, Martinez-Ramirez S, Valcarcel Gonzalez J, Masjuan Vallejo J, Diamantopoulus J, Del Alamo M, Poveda PD, Pastor AG, Carballal CF, Diaz F, Garcia Leal R, Juretschke R, Echabe EA, Sanchez JC, Yanez MR, Garcia RS, Muino RL, Rivas SA, Lopez Gonzalez DM, Cuadrado E, Giralt E, Villalba G, Roquer J, Angel O, Jimenez M, Cedeño RR, Salinas R, Lejarreta S, Silva Y, Fraile A, Calleja A, Cepeda Landínez GA, Tellez N, Garcia Bermejo P, Santos PJ, Herranz RF, Hunt P, Browning D, Violette M, Hoddeson R, Rose J, Zhang J, Mazumdar A, Echiverri H, Chow J, Lovick D, Coleman M, Akhtar N, Sugg R, Zanation A, Germanwala A, Senior B, Huang D, Aucutt-Walter N, Kasner S, LeRoux P, von Kummer R, Palesch Y. Sphenopalatine Ganglion Stimulation to Augment Cerebral Blood Flow. Stroke 2019; 50:2108-2117. [DOI: 10.1161/strokeaha.118.024582] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Many patients with acute ischemic stroke are not eligible for thrombolysis or mechanical reperfusion therapies due to contraindications, inaccessible vascular occlusions, late presentation, or large infarct core. Sphenopalatine ganglion (SPG) stimulation to enhance collateral flow and stabilize the blood-brain barrier offers an alternative, potentially more widely deliverable, therapy.
Methods—
In a randomized, sham-controlled, double-masked trial at 41 centers in 7 countries, patients with anterior circulation ischemic stroke not treated with reperfusion therapies within 24 hours of onset were randomly allocated to active SPG stimulation or sham control. The primary efficacy outcome was improvement beyond expectations on the modified Rankin Scale of global disability at 90 days (sliding dichotomy), assessed in the modified intention-to-treat population. The initial planned sample size was 660 patients, but the trial was stopped early when technical improvements in device placement occurred, so that analysis of accumulated experience could be conducted to inform a successor trial.
Results—
Among 303 enrolled patients, 253 received at least one active SPG or sham stimulation, constituting the modified intention-to-treat population (153 SPG stimulation and 100 sham control). Age was median 73 years (interquartile range, 64–79), 52.6% were female, deficit severity on the National Institutes of Health Stroke Scale was median 11 (interquartile range, 9–15), and time from last known well median 18.6 hours (interquartile range, 14.5–22.5). For the primary outcome, improved 3-month disability beyond expectations, rates in the SPG versus sham treatment groups were 49.7% versus 40.0%; odds ratio, 1.48 (95% CI, 0.89–2.47);
P
=0.13. A significant treatment interaction with stroke location (cortical versus noncortical) was noted,
P
=0.04. In the 87 patients with confirmed cortical involvement, rates of improvement beyond expectations were 50.0% versus 27.0%; odds ratio, 2.70 (95% CI, 1.08–6.73);
P
=0.03. Similar response patterns were observed for all prespecified secondary efficacy outcomes. No differences in mortality or serious adverse event safety end points were observed.
Conclusions—
SPG stimulation within 24 hours of onset is safe in acute ischemic stroke. SPG stimulation was not shown to statistically significantly improve 3-month disability above expectations, though favorable outcomes were nominally higher with SPG stimulation. Beneficial effects may distinctively be conferred in patients with confirmed cortical involvement. The results of this study need to be confirmed in a larger pivotal study.
Clinical Trial Registration—
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03767192.
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Affiliation(s)
- Natan M. Bornstein
- From the Brain Division, Shaarei Zedek Medical Center, Jerusalem and Tel Aviv Sourasky Medical School, Tel Aviv University (N.M.B.)
| | - Jeffrey L. Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA, Los Angeles CA (J.L.S.)
| | | | - Philip B. Gorelick
- Davee Department of Neurology, Northwestern University, Chicago, IL (P.B.G.)
| | - Ashfaq Shuaib
- Department of Medicine (Neurology), University of Alberta, Edmonton (A.S.)
| | | | - Thomas Devlin
- Department of Neurology, University of Tennessee College of Medicine, Chattanooga (T.D.)
| | - Thomas Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong (T.L.)
| | - Carlos A. Molina
- and Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Barcelona (C.A.M.)
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20
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Bien CI, Nehls F, Kollmar R, Weis M, Steinke W, Woermann F, Dalmau J, Bien CG. Identification of adenylate kinase 5 antibodies during routine diagnostics in a tissue-based assay: Three new cases and a review of the literature. J Neuroimmunol 2019; 334:576975. [PMID: 31177032 DOI: 10.1016/j.jneuroim.2019.576975] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 04/17/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 01/03/2023]
Abstract
Antibodies against adenylate kinase 5 (AK5) have been described in patients with non-paraneoplastic limbic encephalitis, mainly in men around 70 years of age. Routine testing with specific cell-based assays is not yet available. Three patients with episodic anterograde memory problems and depression had extensive limbic lesions and developed severe atrophy, mainly of the medial temporal lobes. The antibodies were identified in serum and CSF based on the typical staining pattern of AK5 antibodies on a tissue-based assay (here, unfixed mouse brain). Subsequently, they were confirmed by a research laboratory through a cell-based assay.
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Affiliation(s)
| | - Ferdinand Nehls
- Katholisches Krankenhaus Hagen, Department of Neurology, Hagen, Germany
| | - Rainer Kollmar
- Klinikum Darmstadt, Department of Neurology and Neurological Intensive Care, Darmstadt, Germany
| | - Maria Weis
- Klinikum Darmstadt, Department of Neurology and Neurological Intensive Care, Darmstadt, Germany
| | - Wolfgang Steinke
- Marien-Hospital Düsseldorf, Department of Neurology, Düsseldorf, Germany
| | - Friedrich Woermann
- Epilepsy Center Bethel, Krankenhaus Mara, Bielefeld, Germany; Society of Epilepsy Research, Bielefeld, Germany
| | - Josep Dalmau
- Neurology Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barelona, Spain; ICREA (Catalan Institution for Research and Advanced Studies), Barcelona, Spain; Department of Neurology, University of Pennsylvania, Philadelphia, USA
| | - Christian G Bien
- Laboratory Krone, Bad Salzuflen, Germany; Epilepsy Center Bethel, Krankenhaus Mara, Bielefeld, Germany.
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21
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Tejada de Rink MM, Naumann U, Kollmar R, Schwab S, Dietel B, Harada H, Tauchi M. A Single Injection of N-Oleoyldopamine, an Endogenous Agonist for Transient Receptor Potential Vanilloid-1, Induced Brain Hypothermia, but No Neuroprotective Effects in Experimentally Induced Cerebral Ischemia in Rats. Ther Hypothermia Temp Manag 2019; 10:91-101. [PMID: 31084468 DOI: 10.1089/ther.2018.0036] [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] [Indexed: 10/26/2022] Open
Abstract
Targeted temperature management, or therapeutic hypothermia, is a potent neuroprotective approach after ischemic brain injury. Hypothermia should be induced as soon as possible after the onset of acute stroke to assure better outcomes. Accordingly, drugs with a fast-acting hypothermic effect sustainable through the period of emergency transportation to hospital would have clinical advantages. Activation of the transient receptor potential vanilloid-1 (TRPV1) can induce hypothermia. Our immunohistochemical investigations confirmed that TRPV1 was distributed to perivascular and periventricular regions of the rat brain, where TRPV1 can be easily detected by TRPV1 agonists. An endogenous TRPV1 selective agonist, N-oleoyldopamine (OLDA), and a synthetic antagonist, AMG 9810, were injected intraperitoneally into healthy adult male Wister rats, and brain and core temperatures and gross motor activities were monitored. Comparison with baseline temperatures showed that TRPV1 injection immediately induced mild hypothermia (p < 0.05 in brain and p < 0.01 in body), and AMG 9810 induced immediate mild hyperthermia (not significant). However, the OLDA-induced hypothermia did not decrease lesion volume after middle carotid artery occlusion in rats. Relative to vehicle, OLDA yielded poorer outcomes and AMG 9810 yielded better outcomes in neurological scores and lesion size. Our study showed that, as an agonist of TRPV1, OLDA has suitable hypothermia-inducing properties, but did not decrease lesion volume. Therefore, the search for novel TRPV1 agonists and/or antagonists providing hypothermia and neuroprotection should continue. Further investigations should also target OLDA-induced transient hypothermia combined with long-term hypothermia maintenance with surface cooling, which mimics the anticipated clinical use of this class of drug.
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Affiliation(s)
- Maria Mercedes Tejada de Rink
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Ulrike Naumann
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Rainer Kollmar
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Barbara Dietel
- Department of Medicine 2-Cardiology and Angiology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Hideki Harada
- Neuroanesthesia Research Laboratory, Cognitive and Molecular Institute of Brain Diseases, Kurume University School of Medicine, Kurume, Japan.,Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan
| | - Miyuki Tauchi
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany.,Department of Medicine 2-Cardiology and Angiology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany.,Department of Molecular Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
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22
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van der Worp HB, Macleod MR, Bath PM, Bathula R, Christensen H, Colam B, Cordonnier C, Demotes-Mainard J, Durand-Zaleski I, Gluud C, Jakobsen JC, Kallmünzer B, Kollmar R, Krieger DW, Lees KR, Michalski D, Molina C, Montaner J, Roine RO, Petersson J, Perry R, Sprigg N, Staykov D, Szabo I, Vanhooren G, Wardlaw JM, Winkel P, Schwab S. Therapeutic hypothermia for acute ischaemic stroke. Results of a European multicentre, randomised, phase III clinical trial. Eur Stroke J 2019; 4:254-262. [PMID: 31984233 PMCID: PMC6960691 DOI: 10.1177/2396987319844690] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [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: 11/30/2018] [Accepted: 02/27/2019] [Indexed: 01/24/2023] Open
Abstract
Introduction We assessed whether modest systemic cooling started within 6 hours of symptom
onset improves functional outcome at three months in awake patients with
acute ischaemic stroke. Patients and methods In this European randomised open-label clinical trial with blinded outcome
assessment, adult patients with acute ischaemic stroke were randomised to
cooling to a target body temperature of 34.0–35.0°C, started within 6 h
after stroke onset and maintained for 12 or 24 h , versus standard
treatment. The primary outcome was the score on the modified Rankin Scale at
91 days, as analysed with ordinal logistic regression. Results The trial was stopped after inclusion of 98 of the originally intended 1500
patients because of slow recruitment and cessation of funding. Forty-nine
patients were randomised to hypothermia versus 49 to standard treatment.
Four patients were lost to follow-up. Of patients randomised to hypothermia,
15 (31%) achieved the predefined cooling targets. The primary outcome did
not differ between the groups (odds ratio for good outcome, 1.01; 95%
confidence interval, 0.48–2.13; p = 0.97). The number of
patients with one or more serious adverse events did not differ between
groups (relative risk, 1.22; 95% confidence interval, 0.65–1.94;
p = 0.52). Discussion In this trial, cooling to a target of 34.0–35.0°C and maintaining this for 12
or 24 h was not feasible in the majority of patients. The final sample was
underpowered to detect clinically relevant differences in outcomes. Conclusion Before new trials are launched, the feasibility of cooling needs to be
improved.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Malcolm R Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, UK
| | - Philip Mw Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Raj Bathula
- Stroke Department, Northwick Park Hospital, London, UK
| | - Hanne Christensen
- Department of Neurology, Bispebjerg og Frederiksberg Hospitaler, University of Copenhagen, Copenhagen, Denmark
| | - Bridget Colam
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, UK
| | - Charlotte Cordonnier
- University of Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, Centre Hospitalier Universitaire Lille, Lille, France
| | | | | | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Copenhagen, Denmark
| | - Bernd Kallmünzer
- Department of Neurology, University Medical Centre Erlangen, Erlangen, Germany
| | - Rainer Kollmar
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | | | - Kennedy R Lees
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | | | - Carlos Molina
- Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Risto O Roine
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Jesper Petersson
- Department of Neurology, Skane University Hospital, Malmö, Sweden
| | - Richard Perry
- Stroke Service, National Hospital for Neurology & Neurosurgery, Queen Square, London, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Dimitre Staykov
- Department of Neurology, University Medical Centre Erlangen, Erlangen, Germany.,Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria
| | - Istvan Szabo
- European Stroke Research Network for Hypothermia, Brussels, Belgium
| | | | - Joanna M Wardlaw
- Edinburgh Imaging, Centre for Clinical Brain Sciences and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Per Winkel
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stefan Schwab
- Department of Neurology, University Medical Centre Erlangen, Erlangen, Germany
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23
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Mäder L, Ganai A, Aroyo I, Schill J, Tröscher-Weber R, Huppert P, Kotterer O, Geletneky K, Kollmar R. Targeted Temperature Management for Subarachnoid Hemorrhage: Excellent Outcome After Severe Vasospasm-A Case Series. Ther Hypothermia Temp Manag 2019; 9:216-221. [PMID: 30912704 DOI: 10.1089/ther.2018.0049] [Citation(s) in RCA: 4] [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] [Indexed: 01/19/2023] Open
Abstract
Targeted temperature management (TTM) might improve outcome of patients with severe subarachnoid hemorrhage (SAH) in which vasospasm, delayed cerebral ischemia (DCI), and increased intracranial pressure (ICP) are frequent and severe complications. A series of patients (n = 3) with severe aneurysmatic SAH were treated by TTM if they developed ICP crisis and/or severe vasospasm diagnosed by angiography. Once these complications were detected, body core temperature (BCT) was rapidly decreased to 35°C or 33°C, if necessary. BCT induced and maintained by surface cooling remained at the desired level for at least 72 hours. Rewarming was performed by 1°C, only if the target parameters ICP and velocities in the serial Doppler sonography indicating macrovascular vasospasm improved to regular levels. In case of increase of ICP or middle cerebral arteries velocities BCT was decreased again to the last effective level. The patients developed vasospasm between days 6 and 12 after SAH. All aneurysms were treated by coiling. BCT was reduced between days 6 and 12 after SAH. Total duration of BCT <36.5°C was between 5.5 and 8 days. It remained <35°C for 4-6 days, and at 33°C for 3 days on average. ICP could be sufficiently controlled in all patients, because no ICP crisis was observed during TTM and after rewarming. Two patients developed minor DCI. Side effects of prolonged ventilation of 7-18 days included pneumonia for two patients that could be treated sufficiently. Other complications were one case of ventriculitis and two temporary deliriums. Outcome of the patients was good because no focal neurological symptoms could be detected after rehabilitation. TTM represents a promising treatment approach for severe SAH in which standard treatment is often limited and experimental. It deserves further clinical investigation in a larger cohort.
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Affiliation(s)
- Lisa Mäder
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Ajaz Ganai
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Ilia Aroyo
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Josef Schill
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Regina Tröscher-Weber
- Institut für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Peter Huppert
- Institut für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | - Otto Kotterer
- Institut für Radiologie, Neuroradiologie und Nuklearmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | | | - Rainer Kollmar
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany.,University Hospital Erlangen, Erlangen, Germany
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24
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Steigleder T, Kollmar R, Ostgathe C. Palliative Care for Stroke Patients and Their Families: Barriers for Implementation. Front Neurol 2019; 10:164. [PMID: 30894836 PMCID: PMC6414790 DOI: 10.3389/fneur.2019.00164] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 08/16/2018] [Accepted: 02/07/2019] [Indexed: 11/17/2022] Open
Abstract
Stroke is a leading cause of death, disability and is a symptom burden worldwide. It impacts patients and their families in various ways, including physical, emotional, social, and spiritual aspects. As stroke is potentially lethal and causes severe symptom burden, a palliative care (PC) approach is indicated in accordance with the definition of PC published by the WHO in 2002. Stroke patients can benefit from a structured approach to palliative care needs (PCN) and the amelioration of symptom burden. Stroke outcome is uncertain and outlook may change rapidly. Regarding these challenges, core competencies of PC include the critical appraisal of various treatment options, and openly and respectfully discussing therapeutic goals with patients, families, and caregivers. Nevertheless, PC in stroke has to date mainly been restricted to short care periods for dying patients after life-limiting complications. There is currently no integrated concept for PC in stroke care addressing the appropriate moment to initiate PC for stroke patients, and the question of how to screen for symptoms remains unanswered. Therefore, PC for stroke patients is often perceived as a stopgap in cases of unfavorable prognosis and very short survival times. In contrast, PC can provide much more for stroke patients and support a holistic approach, improve quality of life and ensure treatment according to the patient's wishes and values. In this short review we identify key aspects of PC in stroke care and current barriers to implementation. Additionally, we provide insights into our approach to PC in stroke care.
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Affiliation(s)
- Tobias Steigleder
- Department of Palliative Care, University Hospital Erlangen-Nuremberg, Erlangen, Germany
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Rainer Kollmar
- Department of Neurology and Neurointensive Care, Darmstadt Academic Hospital, Darmstadt, Germany
| | - Christoph Ostgathe
- Department of Palliative Care, University Hospital Erlangen-Nuremberg, Erlangen, Germany
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Tauchi M, Tejada de Rink MM, Fujioka H, Okayama S, Nakamura KI, Dietel B, Achenbach S, Kollmar R, Schwab S, Ushijima K, Harada H. Targeted Temperature Management: Peltier's Element-Based Focal Brain Cooling Protects Penumbra Neurons from Progressive Damage in Experimental Cerebral Ischemia. Ther Hypothermia Temp Manag 2018; 8:225-233. [DOI: 10.1089/ther.2017.0055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Miyuki Tauchi
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Molecular Neurology, and Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Medicine 2–Cardiology and Angiology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Maria Mercedes Tejada de Rink
- Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan
- Neuroanesthesia Research Laboratory, Cognitive and Molecular Institute of Brain Diseases, Kurume University School of Medicine, Kurume, Japan
| | - Hiroshi Fujioka
- Department of Neurosurgery, Kanmon Medical Center, National Hospital Organization (NHO), Yamaguchi, Japan
| | - Satoko Okayama
- Division of Microscopic and Developmental Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan
| | - Kei-ichiro Nakamura
- Division of Microscopic and Developmental Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan
| | - Barbara Dietel
- Department of Medicine 2–Cardiology and Angiology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stephan Achenbach
- Department of Medicine 2–Cardiology and Angiology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Rainer Kollmar
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Kazuo Ushijima
- Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan
| | - Hideki Harada
- Department of Anesthesiology, Kurume University School of Medicine, Kurume, Japan
- Neuroanesthesia Research Laboratory, Cognitive and Molecular Institute of Brain Diseases, Kurume University School of Medicine, Kurume, Japan
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Aroyo I, Prenosil V, Kollmar R. P126. Identification by ultrasound of a cervical nerve root edema caused by vertebral artery loop. Clin Neurophysiol 2018. [DOI: 10.1016/j.clinph.2018.04.740] [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: 10/28/2022]
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Flaherty K, De Georgia MA, Hemmen TM, Kollmar R, Krieger DW, Lyden P, Petersson J, Piironen K, Poli S, Van de Worp B, Bath PM. Abstract TMP13: Individual Patient Data Meta-analysis of Hypothermia for Acute Ischaemic Stroke. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tmp13] [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: 11/16/2022]
Abstract
Background:
It remains unclear whether inducing hypothermia is safe and effective for improving outcome after hyperacute ischaemic stroke. An individual patient data meta-analysis of completed trials was performed.
Methods:
Following electronic searches for trials comparing hypothermia to control, Chief Investigators were approached to share individual patient data (IPD). Odds ratios (OR, 95% confidence intervals, 95% CI) were analysed with ordinal logistic regression and binary logistic regression with adjustment for trial, cooling method (endovascular, surface or unknown) and age.
Results:
Data were obtained for 10 trials (320 participants): COAST-I, COAST-II, COOL AID pilot, COOL AID, COOLIST, HAIS-SE, ICTuS-L, ICTuS-2, MASCOT and MHAIS; IPD were not available for two studies. Trial designs varied and most had a small sample size, mean (SD) age 66 (11.5) years, female 42%, NIHSS 13.4 (5.3), time to treatment 4.5 (1.2) hours, thrombolysis 53%. In patients whose temperature was recorded (n=74), the lowest achieved temperature was in the hypothermia arm: 34.3
o
C vs. 36.6
o
C (p<0.001). Functional outcome (modified Rankin Scale) at day 90 did not differ between cooling vs. no cooling: n=297 OR 0.93 (95% CI 0.63-1.39, p=0.74). Serious adverse events (n=287) were increased in the cooling arm: 81.5% vs. 65.5% (p<0.001); pneumonia: 30.2% vs. 10.9% (p<0.001) and aspiration: 13.3% vs. 3.5% (p=0.004). There was no difference in death: 17.2% vs. 13.6% (p=0.21).
Conclusion:
Hypothermia lowered temperature by 2.3 C, did not alter functional outcome or mortality, but was associated with more SAEs. Larger trials are needed to assess hypothermia in hyperacute stroke.
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Affiliation(s)
- Katie Flaherty
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
| | | | | | - Rainer Kollmar
- Dept of Neurology, Univ of Erlangen-Nuernberg, Erlangen, Germany
| | - Derk W Krieger
- Section of Stroke and Neurological Critical Care, Cleveland Clinic Foundation, Cleveland, OH
| | - Patrick Lyden
- Dept of Neurology, Cedars-Sinai Med Cntr, Los Angeles, CA
| | | | - Katja Piironen
- Dept of Neurology, Helsinki Univ Central Hosp, Helsinki, Finland
| | - Sven Poli
- Stroke Unit, Dept of Neurology, Univ Hosp Heidelberg, Heidelberg, Germany
| | - Bart Van de Worp
- Dept of Neurology and Neurosurgery, Brain Cntr Rudolf Magnus, Univ Med Cntr Utrecht, Utrecht, Netherlands
| | - Philip M Bath
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
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Villiere SM, Nakase K, Kollmar R, Silverman J, Sundaram K, Stewart M. Seizure-associated central apnea in a rat model: Evidence for resetting the respiratory rhythm and activation of the diving reflex. Neurobiol Dis 2017; 101:8-15. [PMID: 28153424 DOI: 10.1016/j.nbd.2017.01.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [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: 12/04/2016] [Revised: 01/02/2017] [Accepted: 01/25/2017] [Indexed: 12/18/2022] Open
Abstract
Respiratory derangements, including irregular, tachypnic breathing and central or obstructive apnea can be consequences of seizure activity in epilepsy patients and animal models. Periods of seizure-associated central apnea, defined as periods >1s with rapid onset and offset of no airflow during plethysmography, suggest that seizures spread to brainstem respiratory regions to disrupt breathing. We sought to characterize seizure-associated central apneic episodes as an indicator of seizure impact on the respiratory rhythm in rats anesthetized with urethane and given parenteral kainic acid to induce recurring seizures. We measured central apneic period onsets and offsets to determine if onset-offset relations were a consequence of 1) a reset of the respiratory rhythm, 2) a transient pausing of the respiratory rhythm, resuming from the pause point at the end of the apneic period, 3) a transient suppression of respiratory behavior with apnea offset predicted by a continuation of the breathing pattern preceding apnea, or 4) a random re-entry into the respiratory cycle. Animals were monitored with continuous ECG, EEG, and plethysmography. One hundred ninety central apnea episodes (1.04 to 36.18s, mean: 3.2±3.7s) were recorded during seizure activity from 7 rats with multiple apneic episodes. The majority of apneic period onsets occurred during expiration (125/161 apneic episodes, 78%). In either expiration or inspiration, apneic onsets tended to occur late in the cycle, i.e. between the time of the peak and end of expiration (82/125, 66%) or inspiration (34/36, 94%). Apneic period offsets were more uniformly distributed between early and late expiration (27%, 34%) and inspiration (16%, 23%). Differences between the respiratory phase at the onset of apnea and the corresponding offset phase varied widely, even within individual animals. Each central apneic episode was associated with a high frequency event in EEG or ECG records at onset. High frequency events that were not associated with flatline plethysmographs revealed a constant plethysmograph pattern within each animal, suggesting a clear reset of the respiratory rhythm. The respiratory rhythm became highly variable after about 1s, however, accounting for the unpredictability of the offset phase. The dissociation of respiratory rhythm reset from the cessation of airflow also suggested that central apneic periods involved activation of brainstem regions serving the diving reflex to eliminate the expression of respiratory movements. This conclusion was supported by the decreased heart rate as a function of apnea duration. We conclude that seizure-associated central apnea episodes are associated with 1) a reset of the respiratory rhythm, and 2) activation of brainstem regions serving the diving reflex to suppress respiratory behavior. The significance of these conclusions is that these details of seizure impact on brainstem circuitry represent metrics for assessing seizure spread and potentially subclassifying seizure patterns.
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Affiliation(s)
- S M Villiere
- Department of Physiology & Pharmacology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States; Research Initiative for Scientific Enhancement (RISE) Program, City University of New York Medgar Evers College, 1638 Bedford Avenue, Brooklyn, NY 11225, United States
| | - K Nakase
- Department of Physiology & Pharmacology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - R Kollmar
- Department of Cell Biology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States; Department of Otolaryngology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - J Silverman
- Department of Otolaryngology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - K Sundaram
- Department of Otolaryngology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - M Stewart
- Department of Physiology & Pharmacology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States; Department of Neurology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States.
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Abstract
Intensive care unit acquired weakness (ICUAW) is a frequent and severe complication of intensive care management. Within ICUAW critical illness polyneuropathy (CIP) and myopathy (CIM) can be differentiated. The major symptom of ICUAW is progressive quadriparesis, which makes weaning from the respirator more difficult, can appear early after admission to an ICU and can often be detected several months after discharge from the ICU. The pathophysiology of ICUAW is multifactorial and complex. Potential therapeutic approaches are the early and sufficient therapy of mulitorgan dysfunction, optimal control of glucose levels as well as early and intensive physiotherapy. This review article discusses the data on incidence, pathophysiology, diagnostic approaches and prognosis of ICUAW.
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Affiliation(s)
- R Kollmar
- Klinik für Neurologie und Neurogeriatrie mit neurologischer Intensivmedizin, Grafenstrasse 9, 64289, Darmstadt, Deutschland.
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30
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Nakase K, Kollmar R, Lazar J, Arjomandi H, Sundaram K, Silverman J, Orman R, Weedon J, Stefanov D, Savoca E, Tordjman L, Stiles K, Ihsan M, Nunez A, Guzman L, Stewart M. Laryngospasm, central and obstructive apnea during seizures: Defining pathophysiology for sudden death in a rat model. Epilepsy Res 2016; 128:126-139. [PMID: 27835782 DOI: 10.1016/j.eplepsyres.2016.08.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [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: 11/17/2015] [Revised: 06/27/2016] [Accepted: 08/07/2016] [Indexed: 12/21/2022]
Abstract
Seizure spread into the autonomic nervous system can result in life-threatening cardiovascular and respiratory dysfunction. Here we report on a less-studied consequence of such autonomic derangements-the possibility of laryngospasm and upper-airway occlusion. We used parenteral kainic acid to induce recurring seizures in urethane-anesthetized Sprague Dawley rats. EEG recordings and combinations of cardiopulmonary monitoring, including video laryngoscopy, were performed during multi-unit recordings of recurrent laryngeal nerve (RLN) activity or head-out plethysmography with or without endotracheal intubation. Controlled occlusions of a tracheal tube were used to study the kinetics of cardiac and respiratory changes after sudden obstruction. Seizure activity caused significant firing increases in the RLN that were associated with abnormal, high-frequency movements of the vocal folds. Partial airway obstruction from laryngospasm was evident in plethysmograms and was prevented by intubation. Complete glottic closure (confirmed by laryngoscopy) occurred in a subset of non-intubated animals in association with the largest increases in RLN activity, and cessation of airflow was followed in all obstructed animals within tens of seconds by ST-segment elevation, bradycardia, and death. Periods of central apnea occurred in both intubated and non-intubated rats during seizures for periods up to 33s and were associated with modestly increased RLN activity, minimal cardiac derangements, and an open airway on laryngoscopy. In controlled complete airway occlusions, respiratory effort to inspire progressively increased, then ceased, usually in less than 1min. Respiratory arrest was associated with left ventricular dilatation and eventual asystole, an elevation of systemic blood pressure, and complete glottic closure. Severe laryngospasm contributed to the seizure- and hypoxemia-induced conditions that resulted in sudden death in our rat model, and we suggest that this mechanism could contribute to sudden death in epilepsy.
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Affiliation(s)
- K Nakase
- Department of Physiology & Pharmacology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - R Kollmar
- Department of Cell Biology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States; Department of Otolaryngology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - J Lazar
- Department of Medicine (Division of Cardiology), State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - H Arjomandi
- Department of Otolaryngology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - K Sundaram
- Department of Otolaryngology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - J Silverman
- Department of Otolaryngology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - R Orman
- Department of Physiology & Pharmacology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - J Weedon
- Department of Statistical Design & Analysis, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - D Stefanov
- Department of Statistical Design & Analysis, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - E Savoca
- Department of Cell Biology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States; Department of Otolaryngology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - L Tordjman
- Department of Physiology & Pharmacology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - K Stiles
- Department of Cell Biology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - M Ihsan
- Department of Medicine (Division of Cardiology), State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - A Nunez
- Department of Medicine (Division of Cardiology), State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States
| | - L Guzman
- Research Initiative for Scientific Enhancement (RISE) Program, City University of New York, Medgar Evers College, 1638 Bedford Avenue, Brooklyn, New York, 11225, United States
| | - M Stewart
- Department of Physiology & Pharmacology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States; Department of Neurology, State University of New York, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York, 11203, United States.
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Pfeilschifter W, Farahmand D, Niemann D, Ikenberg B, Hohmann C, Abruscato M, Thonke S, Strzelczyk A, Hedtmann G, Neumann-Haefelin T, Kollmar R, Singer OC, Ferbert A, Steiner T, Steinmetz H, Reihs A, Misselwitz B, Foerch C. Estimating the Quantitative Demand of NOAC Antidote Doses on Stroke Units. Cerebrovasc Dis 2016; 42:415-420. [PMID: 27438461 DOI: 10.1159/000447952] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 06/20/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The first specific antidote for non-vitamin K antagonist oral anticoagulants (NOAC) has recently been approved. NOAC antidotes will allow specific treatment for 2 hitherto problematic patient groups: patients with oral anticoagulant therapy (OAT)-associated intracerebral hemorrhage (ICH) and maybe also thrombolysis candidates presenting on oral anticoagulation (OAT). We aimed to estimate the frequency of these events and hence the quantitative demand of antidote doses on a stroke unit. METHODS We extracted data of patients with acute ischemic stroke and ICH (<24 h after symptom onset) in the years 2012-2015 from a state-wide prospective stroke inpatient registry. We selected 8 stroke units and determined the mode of OAT upon admission in 2012-2013. In 2015, the mode of OAT became a mandatory item of the inpatient registry. From the number of anticoagulated patients and the NOAC share, we estimated the current and future demand for NOAC antidote doses on stroke units. RESULTS Eighteen percent of ICH patients within 6 h of symptom onset or an unknown symptom onset were on OAT. Given a NOAC share at admission of 40%, about 7% of all ICH patients may qualify for NOAC reversal therapy. Thirteen percent of ischemic stroke patients admitted within 4 h presented on anticoagulation. Given the availability of an appropriate antidote, a NOAC share of 50% could lead to a 6.1% increase in thrombolysis rate. CONCLUSIONS Stroke units serving populations with a comparable demographic structure should prepare to treat up to 1% of all acute ischemic stroke patients and 7% of all acute ICH patients with NOAC antidotes. These numbers may increase with the mounting prevalence of atrial fibrillation and an increasing use of NOAC.
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Schill J, Kollmar R. Zerebrale Hypoxie nach Reanimation. Akt Neurol 2016. [DOI: 10.1055/s-0042-105276] [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: 10/21/2022]
Affiliation(s)
- J. Schill
- Klinik für Neurologie und Neurogeriatrie, Klinikum Darmstadt, Darmstadt
| | - R. Kollmar
- Klinik für Neurologie und Neurogeriatrie, Klinikum Darmstadt, Darmstadt
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Nakase K, Kollmar R, Sundaram K, Silverman J, Orman R, Stewart M. Obstructive apnea due to laryngospasm during seizures, but not central apnea, causes hypoxic cardiac derangements in rats. Auton Neurosci 2015. [DOI: 10.1016/j.autneu.2015.07.044] [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: 10/23/2022]
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Kuramatsu JB, Kollmar R, Gerner ST, Madžar D, Pisarčíková A, Staykov D, Kloska SP, Doerfler A, Eyüpoglu IY, Schwab S, Huttner HB. Is Hypothermia Helpful in Severe Subarachnoid Hemorrhage? An Exploratory Study on Macro Vascular Spasm, Delayed Cerebral Infarction and Functional Outcome after Prolonged Hypothermia. Cerebrovasc Dis 2015; 40:228-35. [DOI: 10.1159/000439178] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 07/30/2015] [Indexed: 11/19/2022] Open
Abstract
Background: Therapeutic hypothermia (TH) is an established treatment after cardiac arrest and growing evidence supports its use as neuroprotective treatment in stroke. Only few and heterogeneous studies exist on the effect of hypothermia in subarachnoid hemorrhage (SAH). A novel approach of early and prolonged TH and its influence on key complications in poor-grade SAH, vasospasm and delayed cerebral ischemia (DCI) was evaluated. Methods: This observational matched controlled study included 36 poor-grade (Hunt and Hess Scale >3 and World Federation of Neurosurgical Societies Scale >3) SAH patients. Twelve patients received early TH (<48 h after ictus), mild (35°C), prolonged (7 ± 1 days) and were matched to 24 patients from the prospective SAH database. Vasospasm was diagnosed by angiography, macrovascular spasm serially evaluated by Doppler sonography and DCI was defined as new infarction on follow-up CT. Functional outcome was assessed at 6 months by modified Rankin Scale (mRS) and categorized as favorable (mRS score 0-2) versus unfavorable (mRS score 3-6) outcome. Results: Angiographic vasospasm was present in 71.0% of patients. TH neither influenced occurrence nor duration, but the degree of macrovascular spasm as well as peak spastic velocities were significantly reduced (p < 0.05). Frequency of DCI was 87.5% in non-TH vs. 50% in TH-treated patients, translating into a relative risk reduction of 43% and preventive risk ratio of 0.33 (95% CI 0.14-0.77, p = 0.036). Favorable functional outcome was twice as frequent in TH-treated patients 66.7 vs. 33.3% of non-TH (p = 0.06). Conclusion: Early and prolonged TH was associated with a reduced degree of macrovascular spasm and significantly decreased occurrence of DCI, possibly ameliorating functional outcome. TH may represent a promising neuroprotective therapy possibly targeting multiple pathways of DCI development, notably macrovascular spasm, which strongly warrants further evaluation of its clinical impact.
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35
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Kollmar R. Latest evidence for the use of targeted temperature management in neurology. BMC Emerg Med 2015. [PMCID: PMC4480838 DOI: 10.1186/1471-227x-15-s1-a16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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36
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Sprügel M, Schwab S, Kollmar R. Wahrnehmung des Faches Neurologie im Laufe des Medizinstudiums: Ergebnisse einer monozentrischen Untersuchung. Akt Neurol 2015. [DOI: 10.1055/s-0034-1387541] [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: 10/24/2022]
Affiliation(s)
- M. Sprügel
- Neurologische Universitätsklinik Erlangen
| | - S. Schwab
- Neurologische Universitätsklinik Erlangen
| | - R. Kollmar
- Neurologische Universitätsklinik Erlangen
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37
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van der Worp HB, Macleod MR, Bath PMW, Demotes J, Durand-Zaleski I, Gebhardt B, Gluud C, Kollmar R, Krieger DW, Lees KR, Molina C, Montaner J, Roine RO, Petersson J, Staykov D, Szabo I, Wardlaw JM, Schwab S. EuroHYP-1: European multicenter, randomized, phase III clinical trial of therapeutic hypothermia plus best medical treatment vs. best medical treatment alone for acute ischemic stroke. Int J Stroke 2014; 9:642-5. [PMID: 24828363 DOI: 10.1111/ijs.12294] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [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: 12/02/2013] [Accepted: 03/31/2014] [Indexed: 11/30/2022]
Abstract
RATIONALE Cooling reduced infarct size and improved neurological outcomes in animal studies modeling ischemic stroke, and also improved outcome in randomized clinical trials in patients with hypoxic-ischemic brain injury after cardiac arrest. Cooling awake patients with ischemic stroke has been shown feasible in phase II clinical trials. PRIMARY AIM To determine whether systemic cooling to a target body temperature between 34·0 and 35·0°C, started within six-hours of symptom onset and maintained for 24 h, improves functional outcome at three-months in patients with acute ischemic stroke. DESIGN International, multicenter, phase III, randomized, open-label clinical trial with blinded outcome assessment in 1500 patients aged 18 years or older with acute ischemic stroke and a National Institutes of Health Stroke Scale score of 6 up to and including 18. In patients randomized to hypothermia, cooling to a target body temperature of 34-35°C will be started within six-hours after symptom onset with rapid intravenous infusion of refrigerated normal saline or a surface cooling technique and maintained for 24 h with a surface or endovascular technique. Patients randomized to hypothermia will receive pethidine and buspirone to prevent shivering and discomfort. PRIMARY OUTCOME Score on the modified Rankin Scale at 91 days, as analyzed with ordinal logistic regression and expressed as a common odds ratio. DISCUSSION With 750 patients per intervention group, this trial has 90% power to detect 7% absolute improvement at the 5% significance level. The full trial protocol is available at http://www.eurohyp1.eu. ClinicalTrials.gov Identifier: NCT01833312.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, CX Utrecht, The Netherlands
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Kallmünzer B, Tauchi M, Schlachetzki JC, Machold K, Schmidt A, Winkler J, Schwab S, Kollmar R. Granulocyte colony-stimulating factor does not promote neurogenesis after experimental intracerebral haemorrhage. Int J Stroke 2013; 9:783-8. [PMID: 24920160 DOI: 10.1111/ijs.12217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 01/17/2023]
Abstract
BACKGROUND Hematopoietic growth factors have been suggested to induce neuroprotective and regenerative effects in various animal models of cerebral injury. However, the pathways involved remain widely unexplored. AIMS This study aimed to investigate effects of local and systemic administration of granulocyte colony-stimulating factor on brain damage, functional recovery, and cerebral neurogenesis in an intracerebral haemorrhage whole blood injection model in rats. METHODS Eight-week-old male Wistar rats (n = 100) underwent induction of striatal intracerebral haemorrhage by autologous whole blood injection or sham procedure and were randomly assigned to either (a) systemic treatment with granulocyte colony-stimulating factor (60 μg/kg) for five-days; (b) single intracerebral injection of granulocyte colony-stimulating factor (60 μg/kg) into the cavity; or (c) application of vehicle for five-days. Bromodeoxyuridine-labelling and immunohistochemistry were used to analyze proliferation and survival of newly born cells in the sub-ventricular zone and the hippocampal dentate gyrus. Moreover, functional deficits and lesion volume were assessed until day 42 after intracerebral haemorrhage. RESULTS Differences in lesion size or hemispheric atrophy between granulocyte colony-stimulating factor-treated and control groups did not reach statistical significance. Neither systemic, nor local granulocyte colony-stimulating factor administration induced neurogenesis within the dentate gyrus or the sub-ventricular zone. The survival of newborn cells in these regions was prevented by intracerebral granulocyte colony-stimulating factor application. A subtle benefit in functional recovery at day 14 after intracerebral haemorrhage induction was observed after granulocyte colony-stimulating factor treatment. CONCLUSION There was a lack of neuroprotective or neuroregenerative effects of granulocyte colony-stimulating factor in the present rodent model of intracerebral haemorrhage. Conflicting results from functional outcome assessment require further research.
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Affiliation(s)
- Bernd Kallmünzer
- Department of Neurology, University Medical Center Erlangen, Germany
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Dietel B, Cicha I, Achenbach S, Kollmar R, Garlichs C, Tauchi M. Different treatment settings of Granulocyte-Colony Stimulating Factor and their impact on T cell-specific immune response in experimental stroke. Immunol Lett 2013; 158:95-100. [PMID: 24333341 DOI: 10.1016/j.imlet.2013.12.006] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 12/03/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cerebral ischemia is associated with infectious complications due to immunosuppression and decreased T lymphocyte activity. G-CSF, which has neuroprotective properties, is known to modulate inflammatory processes after induced stroke. The aim of our study was to investigate the impact of G-CSF in experimental stroke and to compare two different modes of treatment, focusing on circulating T lymphocytes. METHODS Cerebral ischemia was induced in Wistar rats by occlusion of the middle cerebral artery, followed by reperfusion after 1h. G-CSF was applied either as a single dose 30 min after occlusion, or daily for seven days. Silver staining was used to determine infarct size. T lymphocytes in the peripheral blood were measured before and 7 days after induced cerebral ischemia by flow cytometry. In addition, migration of CD3-expressing T lymphocytes into the brain was investigated by immunohistochemistry. RESULTS Both single dose and daily treatment with G-CSF significantly reduced infarct size. A significant improvement of neurological outcome was only observed after single application of G-CSF. While a decrease in peripheral T lymphocytes was detected seven days after induced stroke, no reduction was observed in the G-CSF-treated groups. Apart from that, G-CSF significantly reduced the number of brain migrated T lymphocytes in both treatment settings as compared to vehicle. CONCLUSION A single dose of G-CSF exerted neuroprotective effects in ischemic stroke, which were less pronounced after daily G-CSF application. Both treatment strategies inhibited stroke-induced reduction of T lymphocytes in peripheral blood, which may have contributed to the reduction of infarct size.
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Affiliation(s)
- Barbara Dietel
- Department of Cardiology and Angiology, University Hospital Erlangen-Nuremberg, Erlangen, Germany.
| | - Iwona Cicha
- Department of Cardiology and Angiology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Stephan Achenbach
- Department of Cardiology and Angiology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany; Department of Neurology, Hospital Darmstadt, Darmstadt, Germany
| | - Christoph Garlichs
- Department of Cardiology and Angiology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
| | - Miyuki Tauchi
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany; Division of Molecular Neurology, University Hospital Erlangen-Nuremberg, Erlangen, Germany
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Kollmar R. Transiente globale Amnesie (TGA). Notf Rett Med 2013. [DOI: 10.1007/s10049-013-1706-x] [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: 10/26/2022]
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Abstract
BACKGROUND Perihemorrhagic edema (PHE) develops after intracerebral hemorrhage (ICH). It can worsen the clinical situation by its additional mass effect. Therapeutic hypothermia (TH) might be an effective method to control PHE, but has not been sufficiently studied in ICH patients. METHODS We report data on n = 25 consecutive patients with large supratentorial ICH (volume > 25 ml) who were treated by mild TH of 35 °C for 8-10 days. Body temperature was controlled by endovascular cooling catheters. We followed the clinical course during hospital stay and measured volumes of ICH and PHE in regularly performed serial cranial computed tomography. Outcome was assessed after 3 and 12 months. These data were compared to a historical group of n = 25 patients with large ICH. RESULTS While PHE continuously increased in the historical control group up to day 10, PHE volumes in the hypothermia group remained stable. There was a significant difference from day 3 after symptom onset. Shivering (36 %) and pneumonia (96 %) were the most frequent complications during TH. Mortality rate was 8.3 % in TH versus 16.7 % in the control group after 3 months and 28 versus 44 % after 1 year. CONCLUSIONS These data support the promising results of our first case series on TH in large ICH. TH prevents the development of PHE and its complications. Side effects of TH appeared often, but could be treated sufficiently. Therefore, TH might represent a new therapy for PHE after large ICH, but has to be further tested in randomized trials.
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Affiliation(s)
- Dimitre Staykov
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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Ringelstein EB, Thijs V, Norrving B, Chamorro A, Aichner F, Grond M, Saver J, Laage R, Schneider A, Rathgeb F, Vogt G, Charissé G, Fiebach JB, Schwab S, Schäbitz WR, Kollmar R, Fisher M, Brozman M, Skoloudik D, Gruber F, Serena Leal J, Veltkamp R, Köhrmann M, Berrouschot J. Granulocyte colony-stimulating factor in patients with acute ischemic stroke: results of the AX200 for Ischemic Stroke trial. Stroke 2013; 44:2681-7. [PMID: 23963331 DOI: 10.1161/strokeaha.113.001531] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Granulocyte colony-stimulating factor (G-CSF; AX200; Filgrastim) is a stroke drug candidate with excellent preclinical evidence for efficacy. A previous phase IIa dose-escalation study suggested potential efficacy in humans. The present large phase IIb trial was powered to detect clinical efficacy in acute ischemic stroke patients. METHODS G-CSF (135 µg/kg body weight intravenous over 72 hours) was tested against placebo in 328 patients in a multinational, multicenter, randomized, and placebo-controlled trial (NCT00927836; www.clinicaltrial.gov). Main inclusion criteria were ≤9-hour time window after stroke onset, infarct localization in the middle cerebral artery territory, baseline National Institutes of Health Stroke Scale score range of 6 to 22, and baseline diffusion-weighted imaging lesion size ≥15 mL. Primary and secondary end points were the modified Rankin scale score and the National Institutes of Health Stroke Scale score at day 90, respectively. Data were analyzed using a prespecified model that adjusted for age, National Institutes of Health Stroke Scale score at baseline, and initial infarct volume (diffusion-weighted imaging). RESULTS G-CSF treatment failed to meet the primary and secondary end points of the trial. For additional end points such as mortality, Barthel index, or infarct size at day 30, G-CSF did not show efficacy either. There was, however, a trend for reduced infarct growth in the G-CSF group. G-CSF showed the expected peripheral pharmacokinetic and pharmacodynamic profiles, with a strong increase in leukocytes and monocytes. In parallel, the cytokine profile showed a significant decrease of interleukin-1. CONCLUSIONS G-CSF, a novel and promising drug candidate with a comprehensive preclinical and clinical package, did not provide any significant benefit with respect to either clinical outcome or imaging biomarkers. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00927836.
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Affiliation(s)
- E Bernd Ringelstein
- From the Department of Neurology, University of Münster, Münster, Germany (E.B.R.); Department of Neurology, University of Leuven, Leuven, Belgium (V.T.); Vesalius Research Center, VIB, Leuven, Belgium (V.T.); Department of Clinical Sciences, Section of Neurology, Lund University, Lund, Sweden (B.N.); Department of Neurology, University of Barcelona, Barcelona, Spain (A.C.); Department of Neurology, Nervenklinik Wagner-Jauregg, Linz, Austria (F.A.); Department of Neurology, Kreiskrankenhaus Siegen, Siegen, Germany (M.G.); Department of Neurology, University of California, Los Angeles (J.S.); Clinical Research Department, SYGNIS Bioscience GmbH, Heidelberg, Germany (R.L., A.S., F.R., G.V., G.C.); Center for Stroke Research, Charité, Berlin, Germany (J.B.F.); Department of Neurology, Evangelisches Krankenhaus Bielefeld, Bielefeld, Germany (W.-R.S.); Department of Neurology, UMass Memorial Medical Center, Worcester, MA (M.F.); Department of Neurology, Medical Faculty Hospital Nitra, Nitra, Slovakia (M.B.); Department of Neurology, University Ostrava, Ostrava, Czech Republic (D.S.); Department of Neurology, Allgemeines Krankenhaus Linz, Linz, Austria (F.G.); Department of Neurology, Hospital Universitario Dr Josep Trueta de Girona, Girona, Spain (J.S.L.); Department of Neurology, University of Heidelberg, Heidelberg, Germany (R.V.); Department of Neurology, University of Erlangen, Erlangen, Germany (S.S., R.K., M.K.); and Department of Neurologie, Klinikum Altenburger Land GmbH, Altenburg, Germany (J.B.)
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Shah SM, Patel CH, Feng AS, Kollmar R. Lithium alters the morphology of neurites regenerating from cultured adult spiral ganglion neurons. Hear Res 2013; 304:137-44. [PMID: 23856237 DOI: 10.1016/j.heares.2013.07.001] [Citation(s) in RCA: 10] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 06/23/2013] [Accepted: 07/01/2013] [Indexed: 01/13/2023]
Abstract
The small-molecule drug lithium (as a monovalent ion) promotes neurite regeneration and functional recovery, is easy to administer, and is approved for human use to treat bipolar disorder. Lithium exerts its neuritogenic effect mainly by inhibiting glycogen synthase kinase 3, a constitutively-active serine/threonine kinase that is regulated by neurotrophin and "wingless-related MMTV integration site" (Wnt) signaling. In spiral ganglion neurons of the cochlea, the effects of lithium and the function of glycogen synthase kinase 3 have not been investigated. We, therefore, set out to test whether lithium modulates neuritogenesis from adult spiral ganglion neurons. Primary cultures of dissociated spiral ganglion neurons from adult mice were exposed to lithium at concentrations between 0 and 12.5 mM. The resulting neurite morphology and growth-cone appearance were measured in detail by using immunofluorescence microscopy and image analysis. We found that lithium altered the morphology of regenerating neurites and their growth cones in a differential, concentration-dependent fashion. Low concentrations of 0.5-2.5 mM (around the half-maximal inhibitory concentration for glycogen synthase kinase 3 and the recommended therapeutic serum concentration for bipolar disorder) enhanced neurite sprouting and branching. A high concentration of 12.5 mM, in contrast, slowed elongation. As the lithium concentration rose from low to high, the microtubules became increasingly disarranged and the growth cones more arborized. Our results demonstrate that lithium selectively stimulates phases of neuritogenesis that are driven by microtubule reorganization. In contrast, most other drugs that have previously been tested on spiral ganglion neurons are reported to inhibit neurite outgrowth or affect only elongation. Lithium sensitivity is a necessary, but not sufficient condition for the involvement of glycogen synthase kinase 3. Our results are, therefore, consistent with, but do not prove lithium inhibiting glycogen synthase kinase 3 activity in spiral ganglion neurons. Experiments with additional drugs and molecular-genetic tools will be necessary to test whether glycogen synthase kinase 3 regulates neurite regeneration from spiral ganglion neurons, possibly by integrating neurotrophin and Wnt signals at the growth cone.
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Affiliation(s)
- S M Shah
- Department of Molecular and Integrative Physiology, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; Neuroscience Graduate Program, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; Medical Scholars Program, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
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Speck V, Noble A, Kollmar R, Schenk T. Diagnosis of spontaneous cervical artery dissection may be associated with increased prevalence of posttraumatic stress disorder. J Stroke Cerebrovasc Dis 2013; 23:335-42. [PMID: 23849487 DOI: 10.1016/j.jstrokecerebrovasdis.2013.03.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [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: 11/27/2012] [Revised: 03/08/2013] [Accepted: 03/29/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Receiving information that one has a dissected cervical artery, which can cause a stroke at any time, is obviously traumatic, but details about the psychiatric and psychosocial sequelae are not known. We investigated the prevalence of and risk factors for posttraumatic stress disorder (PTSD) in patients with spontaneous cervical artery dissection (CD) and the impact of PTSD on their psychosocial functioning. METHODS Patients admitted because of CD between 2006 and 2010 were retrospectively examined using a diagnostic PTSD measure (Posttraumatic Diagnostic Scale). Patients between 2011 and 2012 were examined prospectively. To identify potential predictors for PTSD, we examined all patients' stress coping strategies (brief COPE inventory), anxiety and depression (Hospital Anxiety and Depression Scale), impairment by preventive medication, time since diagnosis and their neurologic (modified Rankin Scale) and cognitive status. To identify the psychosocial impact of PTSD, we examined quality of life (Short-Form 36). RESULTS Data of 47 retrospectively contacted patients and 15 prospectively examined patients were included. Twenty-eight patients (45.2%) met the diagnostic criteria for PTSD. A significantly reduced health-related quality of life (HRQoL) was found in 27 patients (43.5%) for mental health and in 8 patients (12.9%) for physical health. Results of logistic regression analysis revealed that the use of maladaptive coping strategies was predictive of the disorder (P < .0001). Age, sex, mRS score, impairment caused by medication, and time since diagnosis were not predictive for PTSD. The presence of PTSD itself was the only significant predictor for reduced mental HRQol (P = .0004). Age, sex, mRS score, impairment caused by medication, and total Hospital Anxiety and Depression Scale score were not predictive for reduced mental HRQoL. CONCLUSIONS PTSD seems to occur frequently in patients with CD and is associated with reduced mental HRQoL. Because the presence of a maladaptive coping style is correlated with PTSD, teaching patients better coping skills might be helpful.
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Affiliation(s)
- Verena Speck
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Adam Noble
- Institute for Psychiatry, King's College London, London, United Kingdom
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Thomas Schenk
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany.
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Neugebauer H, Kollmar R, Niesen WD, Bösel J, Schneider H, Hobohm C, Zweckberger K, Heuschmann PU, Schellinger PD, Jüttler E. DEcompressive Surgery plus hypoTHermia for Space-Occupying Stroke (DEPTH-SOS): A Protocol of a Multicenter Randomized Controlled Clinical Trial and a Literature Review. Int J Stroke 2013; 8:383-7. [DOI: 10.1111/ijs.12086] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Rationale Although decompressive hemicraniectomy clearly reduces mortality in severe space-occupying middle cerebral artery infarction (so-called malignant middle cerebral artery infarction), every fifth patient still dies in the acute phase and every third patient is left with moderate to severe disability. Therapeutic hypothermia is a neuroprotective and antiedematous treatment option that has shown promising effects in severe stroke. A combination of both treatment strategies may have the potential to further reduce mortality and morbidity in malignant middle cerebral artery infarction, but needs evaluation of its efficacy within the setting of a randomized clinical trial. Aims The DEcompressive surgery Plus hypoTHermia for Space-Occupying Stroke (DEPTH-SOS) trial aims to investigate safety and feasibility of moderate therapeutic hypothermia (33°C ± 1) over at least 72 h in addition to early decompressive hemicraniectomy (≤48 hours after symptom onset) in patients with malignant middle cerebral artery infarction. Design The DEcompressive surgery Plus hypoTHermia for Space-Occupying Stroke is a prospective, multicenter, open, two-arm (1:1) comparative, randomized, controlled trial. Study outcomes The primary end-point is mortality at day 14. The secondary end-points include functional outcome at day 14 and at 12 months follow-up, and complications related to hypothermia. Discussion The results of this trial will provide data on safety and feasibility of moderate hypothermia in addition to decompressive hemicraniectomy in malignant middle cerebral artery infarction. Furthermore, efficacy data on early mortality and long-term functional outcome will be obtained, forming the basis of subsequent trials.
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Affiliation(s)
- Hermann Neugebauer
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Berlin, Germany
- Department of Neurology, University Hospital, Ulm, Germany
| | - Rainer Kollmar
- Department of Neurology, University Hospital, Erlangen, Germany
| | | | - Julian Bösel
- Department of Neurology, University Hospital, Heidelberg, Germany
| | - Hauke Schneider
- Department of Neurology, Dresden University of Technology, Germany
| | - Carsten Hobohm
- Department of Neurology, University Hospital, Leipzig, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | - Peter U. Heuschmann
- Institute for Clinical Epidemiology and Biometry, Center for Clinical Studies, and Comprehensive Heart Failure Center, University of Wurzburg, Wurzburg, Germany
| | | | - Eric Jüttler
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin, Berlin, Germany
- Department of Neurology, University Hospital, Ulm, Germany
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Abstract
Induced therapeutic hypothermia (TH) is defined as a controlled reduction of the core body temperature below the physiological range. While TH is neuroprotective in many different models of brain injury, it is only recommended for patients after cardiopulmonary resuscitation and newborns suffering from perinatal hypoxic-ischemic encephalopathy (HIE). Although a strong association exists between elevated body core temperature (fever) and worsening of outcome, TH has so far not been proven to influence outcome after ischemic stroke, intracerebral hemorrhage or subarachnoidal hemorrhage because of insufficient clinical data. This review summarizes the data on TH for different clinical indications and discusses relevant aspects of its use in neurological intensive care units.
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Affiliation(s)
- B Kallmünzer
- Neurologische Universitätsklinik Erlangen, Schwabachanlage 6, 91054 Erlangen, Deutschland
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Dietel B, Cicha I, Kallmünzer B, Tauchi M, Yilmaz A, Daniel WG, Schwab S, Garlichs CD, Kollmar R. Suppression of dendritic cell functions contributes to the anti-inflammatory action of granulocyte-colony stimulating factor in experimental stroke. Exp Neurol 2012; 237:379-87. [PMID: 22750328 DOI: 10.1016/j.expneurol.2012.06.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 06/14/2012] [Accepted: 06/20/2012] [Indexed: 11/20/2022]
Abstract
Cerebral ischemia provokes an inflammatory cascade, which is assumed to secondarily worsen ischemic tissue damage. Linking adaptive and innate immunity dendritic cells (DCs) are key regulators of the immune system. The hematopoietic factor G-CSF is able to modulate DC-mediated immune processes. Although G-CSF is under investigation for the treatment of stroke, only limited information exists about its effects on stroke-induced inflammation. Therefore, we investigated the impact of G-CSF on cerebral DC migration and maturation as well as on the mediated immune response in an experimental stroke model in rats by means of transient middle cerebral artery occlusion (tMCAO). Immunohistochemistry and quantitative PCR were performed of the ischemic brain and flow cytometrical analysis of peripheral blood. G-CSF led to a reduction of the infarct size and an improved neurological outcome. Immunohistochemistry confirmed a reduced migration of DCs and mature antigen-presenting cells after G-CSF treatment. Compared to the untreated tMCAO group, G-CSF led to an inhibited DC activation and maturation. This was shown by a significantly decreased cerebral transcription of TLR2 and the DC maturation markers, CD83 and CD86, as well as by an inhibition of stroke-induced increase in immunocompetent DCs (OX62⁺OX6⁺) in peripheral blood. Cerebral expression of the proinflammatory cytokine TNF-α was reduced, indicating an attenuation of cerebral inflammation. Our data suggest an induction of DC migration and maturation under ischemic conditions and identify DCs as a potential target to modulate postischemic cerebral inflammation. Suppression of both enhanced DC migration and maturation might contribute to the neuroprotective action of G-CSF in experimental stroke.
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Affiliation(s)
- Barbara Dietel
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
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Hemmen T, Rapp K, Raman R, Concha M, Brössner G, Schmutzhard E, Tafreshi G, Misra V, Cruz-Flores S, Kollmar R, Brown D, Altafullah I, Michel P, Alexandrov A, Smith C, Jurf J, Hess MJ, Grotta J, Lyden PD. Phase 2/3 study of intravenous thrombolysis and hypothermia for acute treatment of ischemic stroke (ICTuS 2/3). Crit Care 2012. [PMCID: PMC3389473 DOI: 10.1186/cc11271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Koehn J, Kollmar R, Cimpianu CL, Kallmünzer B, Moeller S, Schwab S, Hilz MJ. Head and neck cooling decreases tympanic and skin temperature, but significantly increases blood pressure. Stroke 2012; 43:2142-8. [PMID: 22627986 DOI: 10.1161/strokeaha.112.652248] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Localized head and neck cooling might be suited to induce therapeutic hypothermia in acute brain injury such as stroke. Safety issues of head and neck cooling are undetermined and may include cardiovascular autonomic side effects that were identified in this study. METHODS Ten healthy men (age 35±13 years) underwent 120 minutes of combined head and neck cooling (Sovika, HVM Medical). Before and after onset of cooling, after 60 and 120 minutes, we determined rectal, tympanic, and forehead skin temperatures, RR intervals, systolic and diastolic blood pressures (BP), laser-Doppler skin blood flow at the index finger and cheek, and spectral powers of mainly sympathetic low-frequency (0.04-0.15 Hz) and parasympathetic high-frequency (0.15-0.5 Hz) RR interval oscillations and sympathetic low-frequency oscillations of BP. We compared values before and during cooling using analysis of variance with post hoc analysis; (significance, P<0.05). RESULTS Forehead skin temperature dropped by 5.5±2.2°C with cooling onset and by 12.4±3.2°C after 20 minutes. Tympanic temperature decreased by 4.7±0.7°C within 40 minutes, and rectal temperature by only 0.3±0.3°C after 120 minutes. Systolic and diastolic BP increased immediately on cooling onset and rose by 15.3±20.8 mm Hg and 16.5±13.4 mm Hg (P=0.004) after 120 minutes, whereas skin blood flow fell significantly during cooling. RR intervals and parasympathetic RR interval high-frequency powers increased with cooling onset and were significantly higher after 60 and 120 minutes than they were before cooling. CONCLUSIONS Head and neck cooling prominently reduced tympanic temperature and thus might also induce intracerebral hypothermia; however, it did not significantly lower body core temperature. Profound skin temperature decrease induced sympathetically mediated peripheral vasoconstriction and prominent BP increases that are not offset by simultaneous parasympathetic heart rate slowing. Prominent peripheral vasoconstriction and BP increase must be considered as possibly harmful during head and neck cooling.
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Affiliation(s)
- Julia Koehn
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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Kollmar R, Juettler E, Huttner HB, Dörfler A, Staykov D, Kallmuenzer B, Schmutzhard E, Schwab S, Broessner G. Cooling in intracerebral hemorrhage (CINCH) trial: protocol of a randomized German-Austrian clinical trial. Int J Stroke 2012; 7:168-72. [PMID: 22264371 DOI: 10.1111/j.1747-4949.2011.00707.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intracerebral hemorrhage accounts for up to 15% of all strokes and is frequently associated with poor functional outcome and high mortality. So far, there is no clear evidence for a specific therapy, apart from general stroke unit or neurointensive care and management of secondary complications. Promising experimental and pilot clinical data support the use of therapeutic hypothermia after intracerebral hemorrhage. AIMS The study aims to determine if therapeutic hypothermia improves survival rates and reduces cerebral lesion volume after large intracerebral hemorrhage compared with conventional treatment. MATERIAL AND METHODS The Cooling in IntraCerebral Hemorrhage trial is a prospective, multicenter, interventional, randomized, parallel, two-arm (1 : 1) phase II trial with blinded end-point adjudication. Enrolment: 50 patients (age: 18 to 65 years) with large (25 to 64 ml on cranial computertomography), primary intracerebral hemorrhage of the basal ganglia or thalamus within 6 to 18 h after symptom onset are randomly allocated to therapeutic hypothermia for eight-days or conventional temperature management. In the therapeutic hypothermia group, a target temperature of 35.0°C is achieved by endovascular catheters and followed by slow controlled rewarming. Data analysis is based on the intent-to-treat population. The primary outcome measure of the study is the development in total lesion volume on cranial computertomography (intracerebral hemorrhage plus perihemorrhagic edema on day 8 ± 0.5 and day 1 ± 0.5 after intracerebral hemorrhage) and the mortality after 30 days. Secondary end-points are the in-hospital mortality, mortality, and functional outcome (modified Rankin Scale and Barthel-Index) after 90 and 180 days. Safety measures include any adverse events associated with therapeutic hypothermia. DISCUSSION In the face of a lack of evidence-based therapies for patients with large intracerebral hemorrhage, new promising approaches are desperately needed, but need evaluation in randomized controlled trials. CONCLUSION The results of Cooling in IntraCerebral Hemorrhage trial are believed to directly influence future therapy of large intracerebral hemorrhage.
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Affiliation(s)
- Rainer Kollmar
- Department of Neurology, University Hospital Erlangen; Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
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