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Gayger-Dias V, Vizuete AFK, Rodrigues L, Wartchow KM, Bobermin L, Leite MC, Quincozes-Santos A, Kleindienst A, Gonçalves CA. How S100B crosses brain barriers and why it is considered a peripheral marker of brain injury. Exp Biol Med (Maywood) 2023; 248:2109-2119. [PMID: 38058025 PMCID: PMC10800124 DOI: 10.1177/15353702231214260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Abstract
S100B is a 21-kDa protein that is produced and secreted by astrocytes and widely used as a marker of brain injury in clinical and experimental studies. The majority of these studies are based on measurements in blood serum, assuming an associated increase in cerebrospinal fluid and a rupture of the blood-brain barrier (BBB). Moreover, extracerebral sources of S100B are often underestimated. Herein, we will review these interpretations and discuss the routes by which S100B, produced by astrocytes, reaches the circulatory system. We discuss the concept of S100B as an alarmin and its dual activity as an inflammatory and neurotrophic molecule. Furthermore, we emphasize the lack of data supporting the idea that S100B acts as a marker of BBB rupture, and the need to include the glymphatic system in the interpretations of serum changes of S100B. The review is also dedicated to valorizing extracerebral sources of S100B, particularly adipocytes. Furthermore, S100B per se may have direct and indirect modulating roles in brain barriers: on the tight junctions that regulate paracellular transport; on the expression of its receptor, RAGE, which is involved in transcellular protein transport; and on aquaporin-4, a key protein in the glymphatic system that is responsible for the clearance of extracellular proteins from the central nervous system. We hope that the data on S100B, discussed here, will be useful and that it will translate into further health benefits in medical practice.
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Affiliation(s)
- Vitor Gayger-Dias
- Graduate Program in Biochemistry, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre 90.035-003, Brazil
| | - Adriana FK Vizuete
- Graduate Program in Biochemistry, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre 90.035-003, Brazil
| | - Letícia Rodrigues
- Graduate Program in Neurosciences, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre 90.035-003, Brazil
| | - Krista Minéia Wartchow
- Brain Health Imaging Institute, Department of Radiology, Weill Cornell Medicine, New York, NY 10044, USA
| | - Larissa Bobermin
- Graduate Program in Neurosciences, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre 90.035-003, Brazil
| | - Marina Concli Leite
- Graduate Program in Biochemistry, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre 90.035-003, Brazil
| | - André Quincozes-Santos
- Graduate Program in Biochemistry, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre 90.035-003, Brazil
| | - Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander University, 91054 Erlangen, Germany
| | - Carlos-Alberto Gonçalves
- Graduate Program in Biochemistry, Institute of Basic Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre 90.035-003, Brazil
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Krisanapan P, Tangpanithandee S, Thongprayoon C, Pattharanitima P, Kleindienst A, Miao J, Craici IM, Mao MA, Cheungpasitporn W. Safety and Efficacy of Vaptans in the Treatment of Hyponatremia from Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH): A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:5483. [PMID: 37685548 PMCID: PMC10488023 DOI: 10.3390/jcm12175483] [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: 08/12/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
The utilization of vasopressin receptor antagonists, known as vaptans, in the management of hyponatremia among patients afflicted with the syndrome of inappropriate antidiuretic hormone (SIADH) remains a contentious subject. This meta-analysis aimed to evaluate the safety and efficacy of vaptans for treating chronic hyponatremia in adult SIADH patients. Clinical trials and observational studies were identified by a systematic search using MEDLINE, EMBASE, and Cochrane Database from inception through September 2022. The inclusion criteria were the studies that reported vaptans' safety or efficacy outcomes compared to placebo or standard therapies. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD 42022357307). Five studies were identified, comprising three RCTs and two cohort studies, enrolling a total of 1840 participants. Regarding short-term efficacy on days 4-5, vaptans exhibited a significant increase in serum sodium concentration from the baseline in comparison to the control group, with a weighted mean difference of 4.77 mmol/L (95% CI, 3.57, 5.96; I2 = 34%). In terms of safety outcomes, the pooled incidence rates of overcorrection were 13.1% (95% CI 4.3, 33.6; I2 = 92%) in the vaptans group and 3.3% (95% CI 1.6, 6.6; I2 = 27%) in the control group. Despite the higher correction rate linked to vaptans, with an OR of 5.72 (95% CI 3.38, 9.70; I2 = 0%), no cases of osmotic demyelination syndrome were observed. Our meta-analysis comprehensively summarizes the efficacy and effect size of vaptans in managing SIADH. While vaptans effectively raise the serum sodium concentration compared to placebo/fluid restriction, clinicians should exercise caution regarding the potential for overcorrection.
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Affiliation(s)
- Pajaree Krisanapan
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand;
- Division of Nephrology, Department of Internal Medicine, Thammasat University Hospital, Pathum Thani 12120, Thailand
| | - Supawit Tangpanithandee
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
| | - Pattharawin Pattharanitima
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand;
| | - Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, 91054 Erlangen, Germany;
| | - Jing Miao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
| | - Iasmina M. Craici
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (S.T.); (C.T.); (J.M.); (I.M.C.)
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Wartchow KM, Rodrigues L, Swierzy I, Buchfelder M, de Souza DO, Gonçalves CA, Kleindienst A. Amyloid-β Processing in Aged S100B Transgenic Mice Is Sex Dependent. Int J Mol Sci 2021; 22:ijms221910823. [PMID: 34639161 PMCID: PMC8509484 DOI: 10.3390/ijms221910823] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/02/2021] [Accepted: 10/04/2021] [Indexed: 12/16/2022] Open
Abstract
(1) Background: Calcium-binding protein S100B is involved in neuroregeneration but has also been associated with neurodegeneration. These contrasting effects may result from concentration or duration of exposure. We investigated the effect of long-term increased S100B levels on amyloid-β processing in one-year-old transgenic (tg) mice with 12 copies of the murine S100B gene with specific consideration of sex and specific brain regions. (2) Methods: S100B and amyloid-β 42 (Aβ42) were quantified in serum, cerebrospinal fluid (CSF), adipose tissue, and different brain regions by ELISA in wild-type (wt) and S100Btg mice (each n = 7 per group). Thioflavin T (ThT) and Aβ immunostaining were performed for visualization of Aβ deposition. (3) Results: S100B in serum, CSF, and brain was significantly increased in S100Btg mice of both sexes. Aβ42 was significantly increased in the hippocampus of male S100Btg mice (p = 0.0075), and the frontal cortex of female S100Btg mice (p = 0.0262). ThT and Aβ immunostaining demonstrated Aβ deposition in different brain regions in S100Btg mice of both sexes and female wt. (4) Conclusion: Our data validate this experimental model for studying the role of S100B in neurodegeneration and indicate that Aβ processing is sex-dependent and brain region-specific, which deserves further investigation of signaling pathways and behavioral responses.
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Affiliation(s)
- Krista Minéia Wartchow
- Department of Biochemistry, Federal University of Rio Grande do Sul, Porto Alegre 90035-003, Brazil; (K.M.W.); (L.R.); (D.O.d.S.); (C.-A.G.)
- Department of Neurosurgery, Friedrich-Alexander University, 91054 Erlangen, Germany; (I.S.); (M.B.)
| | - Leticia Rodrigues
- Department of Biochemistry, Federal University of Rio Grande do Sul, Porto Alegre 90035-003, Brazil; (K.M.W.); (L.R.); (D.O.d.S.); (C.-A.G.)
- Department of Neurosurgery, Friedrich-Alexander University, 91054 Erlangen, Germany; (I.S.); (M.B.)
| | - Izabela Swierzy
- Department of Neurosurgery, Friedrich-Alexander University, 91054 Erlangen, Germany; (I.S.); (M.B.)
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander University, 91054 Erlangen, Germany; (I.S.); (M.B.)
| | - Diogo Onofre de Souza
- Department of Biochemistry, Federal University of Rio Grande do Sul, Porto Alegre 90035-003, Brazil; (K.M.W.); (L.R.); (D.O.d.S.); (C.-A.G.)
| | - Carlos-Alberto Gonçalves
- Department of Biochemistry, Federal University of Rio Grande do Sul, Porto Alegre 90035-003, Brazil; (K.M.W.); (L.R.); (D.O.d.S.); (C.-A.G.)
| | - Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander University, 91054 Erlangen, Germany; (I.S.); (M.B.)
- Correspondence:
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Kleindienst A, Laut FM, Roeckelein V, Buchfelder M, Dodoo-Schittko F. Treatment of posttraumatic syringomyelia: evidence from a systematic review. Acta Neurochir (Wien) 2020; 162:2541-2556. [PMID: 32820376 PMCID: PMC7496040 DOI: 10.1007/s00701-020-04529-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/04/2020] [Indexed: 01/29/2023]
Abstract
Background Following spinal cord injury (SCI), the routine use of magnetic resonance imaging (MRI) resulted in an incremental diagnosis of posttraumatic syringomyelia (PTS). However, facing four decades of preferred surgical treatment of PTS, no clear consensus on the recommended treatment exists. We review the literature on PTS regarding therapeutic strategies, outcomes, and complications. Methods We performed a systematic bibliographic search on (“spinal cord injuries” [Mesh] AND “syringomyelia” [Mesh]). English language literature published between 1980 and 2020 was gathered, and case reports and articles examining syrinx due to other causes were excluded. The type of study, interval injury to symptoms, severity and level of injury, therapeutic procedure, duration of follow-up, complications, and outcome were recorded. Results Forty-three observational studies including 1803 individuals met the eligibility criteria. The time interval from SCI to the diagnosis of PTS varied between 42 and 264 months. Eighty-nine percent of patients were treated surgically (n = 1605) with a complication rate of 26%. Symptoms improved in 43% of patients postoperatively and in 2% treated conservatively. Stable disease was documented in 50% of patients postoperatively and in 88% treated conservatively. The percentage of deterioration was similar (surgery 16%, 0.8% dead; conservative 10%). Detailed analysis of surgical outcome with regard to symptoms revealed that pain, motor, and sensory function could be improved in 43 to 55% of patients while motor function deteriorated in around 25%. The preferred methods of surgery were arachnoid lysis (48%) and syrinx drainage (31%). Conclusion Even diagnosing PTS early in its evolution with MRI, to date, no satisfactory standard treatment exists, and the present literature review shows similar outcomes, regardless of the treatment modality. Therefore, PTS remains a neurosurgical challenge. Additional research is required using appropriate study designs for improving treatment options.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nurnberg, Erlangen, Germany
- Department of Spine Surgery, Krankenhaus Rummelsberg, Schwarzenbruck, Germany
| | | | - Verena Roeckelein
- Department of Spine Surgery, Krankenhaus Rummelsberg, Schwarzenbruck, Germany
| | - Michael Buchfelder
- Department of Spine Surgery, Krankenhaus Rummelsberg, Schwarzenbruck, Germany
| | - Frank Dodoo-Schittko
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany
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Kleindienst A, Georgiev S, Schlaffer SM, Buchfelder M. Tolvaptan Versus Fluid Restriction in the Treatment of Hyponatremia Resulting from SIADH Following Pituitary Surgery. J Endocr Soc 2020; 4:bvaa068. [PMID: 32666012 PMCID: PMC7326480 DOI: 10.1210/jendso/bvaa068] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/08/2020] [Indexed: 12/21/2022] Open
Abstract
Context The relevance of hyponatremia has been acknowledged by guidelines from the United States (2013) and Europe (2014). However, treatment recommendations differ due to limited evidence. Objective In hyponatremia following pituitary surgery-caused by the syndrome of inappropriate antidiuretic hormone (SIADH) secretion-we compared fluid restriction with the pharmacological increase of water excretion by blocking the vasopressin 2 receptors with tolvaptan at a low and a moderate dose. Design Prospective observational study. Setting Neurosurgical Department of a University hospital with more than 200 surgical pituitary procedures per year. Patients Patients undergoing pituitary surgery and developing serum sodium below 136 mmol/L. The diagnosis of SIADH was established by euvolemia (daily measurement of body weight and fluid balance), inappropriately concentrated urine (specific gravity), and exclusion of adrenocorticotropic and thyroid-stimulating hormone deficiency. Intervention Patients were treated with fluid restriction (n = 40) or tolvaptan at 3.75 (n = 38) or 7.5 mg (n = 48). Main Outcome Measures Treatment efficacy was assessed by the duration of hyponatremia, sodium nadir, and length of hospitalization. Safety was established by a sodium increment below 10 mmol/L per day and exclusion of side effects. Results Treatment with 7.5 mg of tolvaptan resulted in a significant attenuation of hyponatremia and in a significant overcorrection of serum sodium in 30% of patients. The duration of hospitalization did not differ between treatment groups. Conclusions Tolvaptan at a moderate dose is more effective than fluid restriction in the treatment of SIADH. Overcorrection of serum sodium may be a side effect of tolvaptan even at low doses.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
| | - Simeon Georgiev
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
| | - Sven Martin Schlaffer
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Nürnberg-Erlangen, Erlangen, Germany
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Baecker J, Wartchow K, Sehm T, Ghoochani A, Buchfelder M, Kleindienst A. Treatment with the Neurotrophic Protein S100B Increases Synaptogenesis after Traumatic Brain Injury. J Neurotrauma 2020; 37:1097-1107. [DOI: 10.1089/neu.2019.6475] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Justus Baecker
- Department of Neurosurgery, Friedrich-Alexander University, Erlangen, Germany
| | - Krista Wartchow
- Department of Biochemistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Tina Sehm
- Department of Neurosurgery, Friedrich-Alexander University, Erlangen, Germany
| | - Ali Ghoochani
- Department of Radiology, Canary Center, Stanford University School of Medicine, Palo Alto, California
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander University, Erlangen, Germany
| | - Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander University, Erlangen, Germany
- Department of Spine Surgery, Klinikum Rummelsberg, Schwarzenbruck, Germany
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Stadlbauer A, Oberndorfer S, Zimmermann M, Renner B, Buchfelder M, Heinz G, Doerfler A, Kleindienst A, Roessler K. Physiologic MR imaging of the tumor microenvironment revealed switching of metabolic phenotype upon recurrence of glioblastoma in humans. J Cereb Blood Flow Metab 2020; 40:528-538. [PMID: 30732550 PMCID: PMC7026844 DOI: 10.1177/0271678x19827885] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Treating recurrent glioblastoma (GB) is one of the challenges in modern neurooncology. Hypoxia, neovascularization, and energy metabolism are of crucial importance for therapy failure and recurrence. Twenty-one patients with initially untreated GB who developed recurrence were examined with a novel MRI approach for noninvasive visualization of the tumor microenvironment (TME). Imaging biomarker information about oxygen metabolism (mitochondrial oxygen tension) and neovascularization (microvascular density and type) were fused for classification of five different TME compartments: necrosis, hypoxia with/without neovascularization, oxidative phosphorylation, and glycolysis. Volume percentages of these TME compartments were compared between untreated and recurrent GB. At initial diagnosis, all 21 GB showed either the features of a glycolytic dominant phenotype with a high percentage of functional neovasculature (N = 12) or those of a necrotic/hypoxic dominant phenotype with a high percentage of defective tumor neovasculature (N = 9). At recurrence, all 21 GB revealed switching of the initial metabolic phenotype: either from the glycolytic to the necrotic/hypoxic dominant phenotype or vice-versa. A necrotic/hypoxic phenotype at recurrence was associated with a higher rate of multifocality of the recurrent lesions. Our MRI approach may be helpful for a better understanding of treatment-induced metabolic phenotype switching and for future studies developing targeted therapeutic strategies for recurrent GB.
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Affiliation(s)
- Andreas Stadlbauer
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany.,Institute of Medical Radiology, University Clinic of St. Pölten, St. Pölten, Austria
| | - Stefan Oberndorfer
- Department of Neurology, University Clinic of St. Pölten, St. Pölten, Austria
| | - Max Zimmermann
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Bertold Renner
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Gertraud Heinz
- Institute of Medical Radiology, University Clinic of St. Pölten, St. Pölten, Austria
| | - Arnd Doerfler
- Department of Neuroradiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Andrea Kleindienst
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Karl Roessler
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
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Megele R, Riemenschneider MJ, Dodoo-Schittko F, Feyrer M, Kleindienst A. Intra-tumoral treatment with oxygen-ozone in glioblastoma: A systematic literature search and results of a case series. Oncol Lett 2018; 16:5813-5822. [PMID: 30344733 PMCID: PMC6176341 DOI: 10.3892/ol.2018.9397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 08/30/2018] [Indexed: 12/20/2022] Open
Abstract
Despite progress in surgery and radiochemotherapy, the prognosis of glioblastoma (GB) remains poor. GB cells exhibit a preference for hypoxia to maintain their tumor-forming capacity. Treatment strategies utilizing oxygen (O2) or ozone (O3) and generating reactive oxygen species induce cell growth inhibition and apoptosis. The anti-tumorigenic properties of O2-O3 are accompanied by a key role in regulating immunogenicity. The present study reported a case series of an intra-tumoral O2-O3 application in recurrent GB. Following surgery in combination with standard radiochemotherapy, O2-O3 (5 ml at 40 µg/ml) was applied every four weeks into the tumor vicinity. The patients received a median of 27 (range, 3–44) O2-O3 applications. In addition, a systematic literature search was performed in order to evaluate the role of O3 in the treatment of malignancies. The median overall survival rate was 40 (range, 16–53) months. The median survival rate following the first recurrence or the initiation of the O2-O3 treatment, respectively, was 34 (range, 12–53) months. In one patient, a local infection and in another, hemorrhage occurred, necessitating in both the temporary removal of the reservoir. The data from the present study support the potential benefit of an intra-tumoral O2-O3 application in recurrent GB. The scientific literature revealed by the bibliographic search suggests that O3 may be considered a viable adjuvant therapy in oncological patients. The present study may serve as a starting point for further observational and clinical studies elucidating the cellular and systemic effects of O2 and/or O3 and demonstrating their efficacy and safety in larger patient samples.
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Affiliation(s)
- Richard Megele
- Department of Neurosurgery, Klinikum St. Marien, D-92224 Amberg, Germany
| | | | - Frank Dodoo-Schittko
- Medical Sociology, Institute of Epidemiology and Preventative Medicine, University of Regensburg, D-93053 Regensburg, Germany
| | - Matthias Feyrer
- Department of Radiology, Klinikum St. Marien, D-92224 Amberg, Germany
| | - Andrea Kleindienst
- Department of Neurosurgery, Klinikum St. Marien, D-92224 Amberg, Germany.,Department of Neurosurgery, University of Erlangen-Nürnberg, D-91054 Erlangen, Germany
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Zoicas F, Kleindienst A, Mayr B, Buchfelder M, Megele R, Schöfl C. Screening for Acromegaly in Patients with Carpal Tunnel Syndrome: A Prospective Study (ACROCARP). Horm Metab Res 2016; 48:452-6. [PMID: 26849823 DOI: 10.1055/s-0042-100913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Early diagnosis of acromegaly prevents irreversible comorbidities and facilitates surgical cure. Carpal tunnel syndrome (CTS) is common in acromegaly and patients have often undergone surgery for CTS prior to the diagnosis of acromegaly. We hypothesized that screening CTS-patients for acromegaly could facilitate active case-finding. We prospectively enrolled 196 patients [135 women, 56.9 (range 23-103) years] who presented with CTS for surgery. Patients were asked about 6 symptoms suggestive of acromegaly using a questionnaire calculating a symptom score (0-6 points), and insulin-like-growth factor 1 (IGF-1) was measured. If IGF-1 was increased, IGF-1 measurement was repeated, and random growth hormone (GH) and/or an oral glucose tolerance test (OGTT) with assessment of GH-suppression were performed. The mean symptom score was 1.7±1.3 points. Three patients reported the maximal symptom score of 6 points, but none of them had an increased IGF-1. There was no correlation between the symptom score and IGF-1-SDS (standard deviation score) (r=0.026; p=0.71). Four patients had an IGF-1>2 SDS. In 2 patients acromegaly was ruled out using random GH and OGTT. One patient had normal IGF-1 and random GH at follow-up. One patient refused further diagnostics. In this prospective cohort of patients with CTS, the observed frequency of acromegaly was at most 0.51% (95% CI 0.03 to 2.83%). In this prospective study, none of the 196 patients with CTS had proven acromegaly. Thus, we see no evidence to justify general screening of patients with CTS for acromegaly.
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Affiliation(s)
- F Zoicas
- Division of Endocrinology and Diabetes, Department of Medicine 1, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - A Kleindienst
- Department of Neurosurgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - B Mayr
- Division of Endocrinology and Diabetes, Department of Medicine 1, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - M Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - R Megele
- Department of Neurosurgery, Klinikum St. Marien, Amberg, Germany
| | - C Schöfl
- Division of Endocrinology and Diabetes, Department of Medicine 1, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Abstract
Hyponatremia is frequent in patients suffering from traumatic brain injury, subarachnoid hemorrhage, or following intracranial procedures, with approximately 20% having a decreased serum sodium concentration to <125 mmol/L. The pathophysiology of hyponatremia in neurotrauma is not completely understood, but in large part is explained by the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The abnormal water and/or sodium handling creates an osmotic gradient promoting the shift of water into brain cells, thereby worsening cerebral edema and precipitating neurological deterioration. Unless hyponatremia is corrected promptly and effectively, morbidity and mortality increases through seizures, elevations in intracranial pressure, and/or herniation. The excess mortality in patients with severe hyponatremia (<125 mmol/L) extends beyond the time frame of hospital admission, with a reported mortality of 20% in hospital and 45% within 6 months of follow-up. Current options for the management of hyponatremia include fluid restriction, hypertonic saline, mineralocorticoids, and osmotic diuretics. However, the recent development of vasopressin receptor antagonists provides a more physiological tool for the management of excess water retention and consequent hyponatremia, such as occurs in SIADH. This review summarizes the existing literature on the pathophysiology, clinical features, and management of hyponatremia in the setting of neurotrauma.
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Affiliation(s)
- Andrea Kleindienst
- 1 Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nürenberg , Erlangen, Germany .,2 Department of Neurosurgery, Klinikum Amberg, Amberg, Germany
| | | | - Michael Buchfelder
- 1 Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nürenberg , Erlangen, Germany
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Brandner S, Thaler C, Lelental N, Buchfelder M, Kleindienst A, Maler JM, Kornhuber J, Lewczuk P. Ventricular and lumbar cerebrospinal fluid concentrations of Alzheimer's disease biomarkers in patients with normal pressure hydrocephalus and posttraumatic hydrocephalus. J Alzheimers Dis 2015; 41:1057-62. [PMID: 24748118 DOI: 10.3233/jad-132708] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Little information is available on the rostro-caudal concentration gradient of Alzheimer's disease (AD) biomarkers. OBJECTIVE We studied the concentrations of amyloid-β (Aβ) peptides 1-42 and 1-40 as well as the Tau and pTau proteins in simultaneously collected ventricular and lumbar cerebrospinal fluid (CSF) samples. METHODS The samples were simultaneously collected from the ventricle and the lumbar spinal canal in two groups of patients: 10 subjects being treated for normal pressure hydrocephalus (NPH) by the placement of a ventriculo-peritoneal shunt and 5 patients treated simultaneously with an external ventricular drain and a lumbar CSF drain due to posttraumatic hydrocephalus (PTH). RESULTS The ventricular-lumbar (V/L) concentration ratio for Aβ1-40 was 0.81 in NPH patients and 0.71 in PTH patients. The V/L-ratio for Aβ1-42 was 0.84 in NPH, reflecting significantly higher concentrations in lumbar CSF than in ventricular CSF, and 1.02 in PTH patients. The V/L-ratios for Tau and pTau differed significantly depending on the diagnostic group: the median V/L-ratio for Tau was 6.83 in NPH patients but only 0.97 in PTH patients. The median V/L-ratio for pTau was 2.36 in NPH patients and 0.91 in PTH patients. CONCLUSIONS We conclude that the rostro-caudal concentration gradient for brain-derived proteins (Tau and pTau in this study) depends on the diagnosis and clinical status of the patient, which were largely neglected in the previously postulated models.
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Affiliation(s)
- Sebastian Brandner
- Department of Neurosurgery, Universitätsklinikum Erlangen, and Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Christian Thaler
- Department of Neurosurgery, Universitätsklinikum Erlangen, and Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Natalia Lelental
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen, and Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Universitätsklinikum Erlangen, and Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Andrea Kleindienst
- Department of Neurosurgery, Universitätsklinikum Erlangen, and Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Juan Manuel Maler
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen, and Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen, and Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Piotr Lewczuk
- Department of Psychiatry and Psychotherapy, Universitätsklinikum Erlangen, and Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
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Zoicas F, Kleindienst A, Wenzl M, Mayr B, Buchfelder M, Megele R, Schoefl C. Acromegaly in patients with carpal tunnel syndrome: A prospective study (ACROCARP). Exp Clin Endocrinol Diabetes 2015. [DOI: 10.1055/s-0035-1547666] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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Klinger A, Buchfelder M, Schlaffer SM, Kremenevskaja N, Kleindienst A. Infection surveillance in transsphenoidal pituitary surgery - comparison of lipopolysaccharide-binding-protein, interleukin 6, C-reactive protein, white blood cell count, erythrocyte sedimentation rate and body temperature. Acta Neurochir (Wien) 2013; 155:2177-82; discussion 2182. [PMID: 24026232 DOI: 10.1007/s00701-013-1875-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 08/10/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND One of the major concerns in transsphenoidal surgery are infections because the approach to the pituitary includes a route of microbial colonization. To minimize the associated morbidity and mortality, a surveillance program is crucial to monitor for perioperative infections. METHODS For 1 year, we analysed body temperature (BT), erythrocyte sedimentation rate (ESR), white blood cell count (WBC), C-reactive protein (CRP), interleukin 6 (IL-6) and lipopolysaccharide-binding-protein (LBP) following elective transsphenoidal pituitary surgery. Samples were collected on admission, day 1, 3 and 7 as well as 3 months postoperatively. RESULTS In 116 patients, all data were available. No postoperative infections occurred within the first postoperative week. BT (37.6 ± 0.6, baseline 37.0 ± 0.5 °C), WBC (11,366 ± 2,541, baseline 6,861 ± 2,123/μl), CRP (25.3 ± 22.6, baseline 3.1 ± 6 mg/l), IL-6 (12 ± 13, baseline 2.7 ± 2.6 pg/ml), and LBP (11.3 ± 4.9, baseline 5.7 ± 2.7 μg/ml) peaked on day 1 postoperatively (each p = 0.001), while ESR peaked on day 3 (25 ± 16, baseline 13 ± 11 mm/h, p = 0.001). BT and IL-6 normalized by day 3 and CRP by day 7, while ESR (23 ± 16 mm/h, p = 0.001), WBC (7,807 ± 2,750/μl, p = 0.001) and LBP (7.3 ± 2.6 μg/ml, p = 0.028) were still increased by day 7. CONCLUSION The present study establishes normative values for an infection surveillance following transsphenoidal pituitary surgery. CRP, a convenient and reasonable priced parameter, is affected by the procedure for the first postoperative week. IL-6 is more robust and allows a close monitoring on the expense of additional pricing. ESR, WBC and LBP are sustained affected by surgery, and do not offer any advantage. Since no infections were observed, we were unable to calculate the respective sensitivity and specificity.
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14
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Farah C, Kleindienst A, Bolea G, Meyer G, Gayrard S, Geny B, Obert P, Cazorla O, Tanguy S, Reboul C. Exercise-induced cardioprotection: a role for eNOS uncoupling and NO metabolites. Basic Res Cardiol 2013; 108:389. [PMID: 24105420 DOI: 10.1007/s00395-013-0389-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 07/08/2013] [Accepted: 09/20/2013] [Indexed: 02/07/2023]
Abstract
Exercise is an efficient strategy for myocardial protection against ischemia-reperfusion (IR) injury. Although endothelial nitric oxide synthase (eNOS) is phosphorylated and activated during exercise, its role in exercise-induced cardioprotection remains unknown. This study investigated whether modulation of eNOS activation during IR could participate in the exercise-induced cardioprotection against IR injury. Hearts isolated from sedentary or exercised rats (5 weeks training) were perfused with a Langendorff apparatus and IR performed in the presence or absence of NOS inhibitors [N-nitro-L-arginine methyl ester, L-NAME or N5-(1-iminoethyl)-L-ornithine, L-NIO] or tetrahydrobiopterin (BH₄). Exercise training protected hearts against IR injury and this effect was abolished by L-NAME or by L-NIO treatment, indicating that exercise-induced cardioprotection is eNOS dependent. However, a strong reduction of eNOS phosphorylation at Ser1177 (eNOS-PSer1177) and of eNOS coupling during early reperfusion was observed in hearts from exercised rats (which showed higher eNOS-PSer1177 and eNOS dimerization at baseline) in comparison to sedentary rats. Despite eNOS uncoupling, exercised hearts had more S-nitrosylated proteins after early reperfusion and also less nitro-oxidative stress, indexed by lower malondialdehyde content and protein nitrotyrosination compared to sedentary hearts. Moreover, in exercised hearts, stabilization of eNOS dimers by BH4 treatment increased nitro-oxidative stress and then abolished the exercise-induced cardioprotection, indicating that eNOS uncoupling during IR is required for exercise-induced myocardial cardioprotection. Based on these results, we hypothesize that in the hearts of exercised animals, eNOS uncoupling associated with the improved myocardial antioxidant capacity prevents excessive NO synthesis and limits the reaction between NO and O₂·- to form peroxynitrite (ONOO⁻), which is cytotoxic.
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Affiliation(s)
- C Farah
- Laboratoire de Pharm-Ecologie Cardiovasculaire (EA4278), Faculty of Sciences, Avignon University, 33 rue Louis Pasteur, 84000, Avignon, France
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Brandner S, Thaler C, Lewczuk P, Lelental N, Buchfelder M, Kleindienst A. Neuroprotein dynamics in the cerebrospinal fluid: intraindividual concomitant ventricular and lumbar measurements. Eur Neurol 2013; 70:189-94. [PMID: 23969528 DOI: 10.1159/000352032] [Citation(s) in RCA: 23] [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] [Received: 03/27/2013] [Accepted: 05/05/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The measurement of neuromarker/neuroproteins in the cerebrospinal fluid (CSF) is gaining increased popularity. However, insufficient information is available on the rostrocaudal distribution of neuroproteins in the CSF to guarantee an appropriate interpretation of ventricular versus lumbar concentrations. METHODS In 10 patients treated with both an external ventricular and a lumbar CSF drain, we collected concomitant CSF samples. We measured CSF concentrations of the glial S100B protein, the neuron-specific enolase (Cobas e411®; Roche Diagnostics), the leptomeningeal β-trace protein (BN Pro Spec®; Dade Behring/Siemens), and the blood-derived albumin (Immage; Beckman Coulter). Statistical analysis was performed with a paired Wilcoxon signed ranks test. RESULTS In patients with a free CSF circulation without any recent neurosurgical procedure, S100B and neuron-specific enolase concentrations did not differ between the ventricular and lumbar CSF while β-trace and albumin levels were significantly higher in the lumbar than in the ventricular CSF (p=0.008 and p=0.005). Following posterior fossa tumor surgery, all proteins accumulate in the lumbar CSF. CONCLUSION For brain-derived proteins, we could not confirm a rostrocaudal CSF gradient while lepto-meningeal and blood-derived proteins accumulate in the lumbar CSF. We conclude that for the interpretation of protein CSF concentrations, the source of the sample is of crucial importance.
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Affiliation(s)
- Sebastian Brandner
- Department of Neurosurgery, University of Erlangen-Nürnberg, Erlangen, Germany
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Kleindienst A, Grünbeck F, Buslei R, Emtmann I, Buchfelder M. Intraperitoneal treatment with S100B enhances hippocampal neurogenesis in juvenile mice and after experimental brain injury. Acta Neurochir (Wien) 2013; 155:1351-60. [PMID: 23649988 DOI: 10.1007/s00701-013-1720-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [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: 11/11/2012] [Accepted: 04/08/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neurogenesis is documented in adult mammals including humans, is promoted by neurotrophic factors, and constitutes an innate repair mechanism following brain injury. The glial neurotrophic protein S100B is released following various types of brain injuries, enhances hippocampal neurogenesis and improves cognitive function following brain injury in rats when applied intrathecally. The present study was designed to elucidate whether the beneficial effect of S100B on injury-induced neurogenesis can be confirmed in mice when applied intraperitoneally (i.p.), and whether this effect is dose-dependent. METHODS Male juvenile mice were subjected to a unilateral parietal cryolesion or sham injury, and treated with S100B at 20nM, 200nM or vehicle i.p. once daily. Hippocampal progenitor cell proliferation was quantified following labelling with bromo-deoxyuridine (BrdU, 50 mg/KG i.p.) in the germinative area of the dentate gyrus, the subgranular zone (SGZ), on day 4 as well as on cell survival and migration to the granular cell layer (GCL) on day 28. Progenitor cell differentiation was assessed following colabelling with the glial marker GFAP and the neuronal marker NeuN. RESULTS S100B enhanced significantly the early progenitor cell proliferation in the SGZ as well as cell survival and migration to the GCL, and promoted neuronal differentiation. While these effects were predominately dose-dependent, 200nM S100B failed to enhance the proliferation in the SGZ on day 4 post-injury. CONCLUSION We conclude that S100B participates in hippocampal neurogenesis after injury at lower nanomolar concentrations. Therefore S100B may serve as a potential adjunct treatment to promote neuroregeneration following brain damage.
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Affiliation(s)
- Andrea Kleindienst
- Departments of Neurosurgery and Neuropathology, Friedrich-Alexander University of Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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Brandner S, Thaler C, Buchfelder M, Kleindienst A. Brain-derived protein concentrations in the cerebrospinal fluid: contribution of trauma resulting from ventricular drain insertion. J Neurotrauma 2013; 30:1205-10. [PMID: 23390981 DOI: 10.1089/neu.2012.2621] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
In recent years, the measurement of biomarkers following neurotrauma assisted in improving outcome prediction and guiding therapy. The use of neuroproteins as diagnostic parameters requires a detailed knowledge of their dynamics in biological fluids for an appropriate interpretation. S100B is the most widely studied neuromarker, and its concentration in serum and cerebrospinal fluid (CSF) reflects the extent of brain damage. Neuron-specific enolase (NSE) is considered reflecting neuronal damage, while Beta-Trace is a lepto-meningeal protein used to diagnose CSF leakage. In five patients treated with an external ventricular drain (EVD) because of aneurysmal subarachnoid hemorrhage (SAH, n=3) or postinfectious hydrocephalus (n=2), an EVD exchange was performed 8 to 12 days after initial insertion. S100B and NSE were measured with the Cobas e411(®) electrochemiluminescence assay (Roche Diagnostics, Mannheim, Germany) and Beta-Trace with the BN Pro Spec(®) nephelometer (Dade Behring/Siemens, Germany) 1 h before EVD exchange, upon the insertion of the new drain, and 1, 3, 6, 12, 18, 24 and 48 h after EVD exchange. Before EVD exchange, S100B CSF concentrations were within the normal range in all patients (1.48 ± 0.37 μg/L), while NSE CSF concentrations were normal in four of five patients (6.51 ± 2.98 μg/L). Following EVD exchange, S100B and NSE CSF levels peaked significantly at 3 h after insertion of the new drain (S100B 39.02 ± 9.17 μg/L; NSE 54.80 ± 43.34 μg/L). S100B serum levels were slightly increased 6 to 24 h after EVD exchange. Beta-Trace concentrations in the CSF were not altered by EVD insertion. Our data demonstrate that EVD insertion results in a distinct increase of S100B and NSE concentrations in the CSF. Thus, the tampering of brain-derived protein concentrations in the CSF by diagnostic or therapeutic procedures has to be considered in the interpretation of neuromarker levels.
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Abstract
Craniopharyngiomas are rare benign sellar region tumors, which are diagnosed either in childhood or adolescence due to local mass effects on visual pathways, pituitary and hypothalamus, or because of an increased intracranial pressure resulting from obstructive hydrocephalus. The neurosurgeons challenge is to achieve tumor control without aggravating the symptoms. There are essentially two different surgical philosophies. Although only gross tumor resection has been proven to provide cure, the accompanying surgical hazard is substantial. Thus, less aggressive operations with partial or subtotal tumor resection or drainage of cystic portions followed by irradiation may relieve the patient's symptoms and benefit the patient more than a heroic tumor resection-since to date several variants of radiation therapy are available which also serve to control tumor progression. In the present brief review, the surgical techniques and outcomes of operations in craniopharyngiomas with special focus on the resulting morbidity and mortality are summarized.
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Affiliation(s)
- Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.
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Abstract
BACKGROUND The hormone and neuropeptide arginine-vasopressin is designated to the maintenance of osmotic homoeostasis and blood pressure regulation. While experimental data show vasopressin V(1A) receptors to regulate aquaporin (AQP)4 water channel dependent brain water movement, the specific role in vasogenic and cytotoxic edema formation remains unclear. The present study was designed to quantify the V(1A) receptor mediated regional brain edema formation in two clinically relevant experimental models, brain injury combined with secondary insult and focal ischemia. METHODS Male Sprague-Dawley rats were randomly assigned to a continuous infusion of vehicle (1 % DMSO) or the selective non-peptide V(1A) antagonist SR49059 (83nM = 1 mg/kg) starting before controlled cortical impact (CCI) injury plus hypoxia and hypotension (HH, 30 min), or middle cerebral artery (MCA) occlusion (2 h + 2 h reperfusion). RESULTS A global analysis of brain water content by the wet/dry weight method allowed optimizing the SR49059 dosage, and demonstrated the down-regulation of brain AQP4 expression by immunoblotting. Microgravimetrical quantification in 64 one mm(3) samples per animal (n = 6 per group) from bregma +2.7 to -6.3 mm analysis demonstrated brain edema to be reduced at 4 h by SR49059 treatment in the injured and contralateral cortex following CCI + HH (p = 0.007, p < 0.001) and in the infarct area following MCA occlusion (p = 0.013, p = 0.002, p = 0.004). CONCLUSIONS Our findings demonstrate that an early cytotoxic brain edema component following brain injury plus secondary insult or focal ischemia results from a vasopressin V(1A) receptor mediated response, and occurs most likely through AQP4 up-regulation. The V(1A) antagonist SR49059 offers a new avenue in brain edema treatment and prompts further study into the role of vasopressin following brain injury.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Virginia Commonwealth University, 1101 E. Marshall St., 23298, Richmond, VA, USA.
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Kleindienst A, Schlaffer SM, Sharma N, Linde L, Buchfelder M, Verbalis JG. Development of an experimental model to study the pathophysiology of cerebral salt wasting following subarachnoid hemorrhage. Acta Neurochir Suppl 2012; 114:399-403. [PMID: 22327731 DOI: 10.1007/978-3-7091-0956-4_77] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Hyponatremia is frequent following cranial -neurosurgery or acute brain injury like subarachnoid hemorrhage (SAH), and increases mortality by 30%. The patho-physiology is not understood nor does a causal therapy exist. Since clinical trials are potentially dangerous in this very ill population, we examined whether an established rat model allows studying cerebral salt wasting (CSW) following SAH. The daily urine sodium excretion as well as plasma sodium, osmolality and antidiuretic hormone (ADH) levels were measured for 10 days. Following the injection of 300 μl of blood into the great cistern (SAH(severe)), natriuresis peaked twice (days 1 and 3-5, p < 0.05) resulting in a plasma sodium nadir (day 1 - 133.9 mmol/L, day 5 - 132.6 mmol/L), while following the injection of 300 μL saline (ICP(control)), natriuresis occurred delayed on days 4-5 (p < 0.05). Following double SAH (200 μL twice, 24 h apart), a natriuresis on day 4 resulted in a hyponatremia (131.7 mmol/L, p = 0.025). Neither SAH(mild) (100 μL), the injection of hemolyzed blood (100 μL) or hypertonic saline (200 μL) replicated the effect. The immediate release of ADH (32.23 ± 34.87 pg/mL) following SAH(severe) normalized over the next few days. We conclude that first, the rat model of SAH is suitable for studying CSW, second the increase in intracranial pressure generates the delayed hyponatremia, and third, the ADH release does not mediate natriuresis.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, University Erlangen-Nuremberg, Erlangen, Germany.
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Kleindienst A, Brabant G, Morgenthaler NG, Emtmann I, Scheufler N, Buchfelder M. The atrial natriuretic peptide does not serve osmoregulation but predicts outcome following brain injury. Acta Neurochir Suppl 2012; 114:277-281. [PMID: 22327708 DOI: 10.1007/978-3-7091-0956-4_54] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Atrial natriuretic peptide (ANP) plays an important role in body fluid homeostasis. ANP has been established as a marker of cardiac dysfunction and may play a role in brain edema development after traumatic brain injury (TBI). In order to identify its specific assignment following TBI, we related clinical data and treatment variables in 63 patients to longitudinal midregional (MR) proatrail natriuretic peptide (ANP) measurements. ANP correlated significantly to age (p < 0.0001) and vasopressin release (p < 0.001). Following TBI, ANP was increased initially and on day 3 (cut-off 100 pg/L) in 22% of the patients, in 31% on day 7, and was normalized at follow-up examination. The group comparison revealed that ANP levels did not significantly differ with regard to injury severity, but that high ANP levels predicted a worse Glasgow Outcome Score at 6 months (p < 0.05). While the initially intact osmoregulation - a correlation of urine volume and high serum sodium (r = 0.536, p = 0.003) or low urine osmolality (r = -0.556, p = 0.009) - got lost post-injury, the ANP release was triggered by volume load (p < 0.005). High ANP levels correlated with the neuroendocrine stress response, i.e., high cortisol (p = 0.05) and prolactin (p < 0.001) levels. We conclude that MR-proANP measurements reveal a significant predictive function for the prognosis of TBI.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen, Germany.
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Khattak MNK, Buchfelder M, Kleindienst A, Schöfl C, Kremenevskaja N. CRH and SRIF have opposite effects on the Wnt/β-catenin signalling pathway through PKA/GSK-3β in corticotroph pituitary cells. Cancer Invest 2010; 28:797-805. [PMID: 20690801 DOI: 10.3109/07357907.2010.494318] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The Wnt/ß-catenin signalling pathway is involved in tumorigenesis including endocrine tumors. We investigated the Wnt/ß-catenin pathway's modulation by corticotropin-releasing hormone (CRH) and somatostatin or somatotropin release-inhibiting factor (SRIF) in mouse pituitary AtT-20 corticotroph cells. The Wnt/β-catenin signalling pathway was activated by CRH and inhibited by SRIF. We provide evidence that cAMP/PKA signalling is involved affecting the GSK-3β phosphorylation status at phospho-GSK-3β (Ser9), thereby altering β-catenin degradation downstream. Furthermore, CRH and SRIF showed concordant effects on cell proliferation. Our data demonstrate an important role of the Wnt/β-catenin pathway in the proliferative control of pituitary corticotroph cells and describe a mechanism for its regulation by CRH and SRIF.
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Fazzina G, Amorini AM, Marmarou CR, Fukui S, Okuno K, Dunbar JG, Glisson R, Marmarou A, Kleindienst A. The protein kinase C activator phorbol myristate acetate decreases brain edema by aquaporin 4 downregulation after middle cerebral artery occlusion in the rat. J Neurotrauma 2010; 27:453-61. [PMID: 19831719 DOI: 10.1089/neu.2008.0782] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The protein kinase C activator phorbol 12-myristate 13-acetate (PMA) is known to interact with aquaporin 4 (AQP 4), a water-selective transporting protein that is abundant in astrocytes, and has experimentally been found to decrease osmotically-induced cell swelling. The purpose of this study was to examine whether PMA reduces brain edema following focal ischemia induced by middle cerebral artery (MCA) occlusion by modulation of AQP4 expression. Male Sprague-Dawley rats were randomly assigned to either sham surgery (n = 6), or a continuous intravenous infusion of vehicle (1% dimethylsulfoxide), followed by MCA occlusion (n = 18), and administration of PMA at 50 microg/kg (n = 6) or at 200 microg/kg (n = 6) starting 60 min before or 30 min (200 microg/kg; n = 6) or 60 min (200 microg/kg; n = 6) after MCA occlusion. Cerebral blood flow was monitored with laser Doppler over the MCA territory, and confirmed a 70% reduction during occlusion. After a 2-h period of ischemia and 2 h of reperfusion, the animals were sacrificed for assessment of brain water content and sodium and potassium concentration. AQP4 expression was assessed by immunoblotting and quantified by densitometry (n = 24). Statistical analysis was performed by ANOVA followed by Tukey's post-hoc test. PMA treatment at 200 microg/kg significantly reduced brain water concentration in the infarcted area when started 60 min before or 30 min after occlusion (p < 0.001 and p = 0.022, respectively), and prevented the subsequent sodium shift (p < 0.05). PMA normalized the AQP4 upregulation in ischemia (p = 0.021). A downregulation of AQP4 in the ischemic area paralleling the reduction in brain edema formation following PMA treatment suggests that the effect was mediated by AQP4 modulation.
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Affiliation(s)
- Giovanna Fazzina
- Department of Neurosurgery, Virginia Commonwealth University Medical Center, Richmond, Virginia 23298-0508, USA
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Kleindienst A, Meissner S, Eyupoglu IY, Parsch H, Schmidt C, Buchfelder M. Dynamics of S100B release into serum and cerebrospinal fluid following acute brain injury. Acta Neurochir Suppl 2010; 106:247-50. [PMID: 19812958 DOI: 10.1007/978-3-211-98811-4_46] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
High S100B serum levels are considered to reflect brain injury severity. However, the dynamics of S100B passage from the cerebral compartment into the blood remain unclear. We examined the temporal profile of S100B release into the cerebrospinal fluid (CSF) and blood in acute brain injury.In patients treated with ventricular drainage (subarachnoid hemorrhage, SAH, n = 23; traumatic brain injury, TBI, n = 19), we measured S100B levels in the serum and CSF. The Glasgow Coma Score (GCS) was assessed daily. Statistical analysis was performed by the Mann-Whitney rank sum test for group differences and by the Pearson correlation.In normal controls (n = 6), S100B levels in the serum (0.05 +/- 0.01 microg/L) comprised around 10% of the CSF concentration (0.66 +/- 0.08 microg/L). Following brain injury, S100B levels were significantly increased in the serum (p < 0.05 in SAH day 2-5, TBI day 1-8) and excessively increased in the CSF (p < 0.05 in SAH and TBI day 1-10). For the individual patient, there was no consistent correlation between S100B levels in serum or CSF and GCS. We therefore calculated the ratio of S100B serum/CSF. Following brain injury, the S100B passage from the CSF to the blood was significantly impaired. Further, higher ratios were correlated with better neurological function (p = 0.002).Because stimulated active S100B release may serve as a repair mechanism, a higher S100B serum/CSF ratio may contribute to neurological recovery.
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Affiliation(s)
- A Kleindienst
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany.
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Kleindienst A, Brabant G, Bock C, Maser-Gluth C, Buchfelder M. Neuroendocrine function following traumatic brain injury and subsequent intensive care treatment: a prospective longitudinal evaluation. J Neurotrauma 2009; 26:1435-46. [PMID: 19459759 DOI: 10.1089/neu.2008.0601] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Neuroendocrine dysfunction following traumatic brain injury (TBI) has been described extensively. However, few studies are longitudinal and most lack subtle radiological, clinical, and repetitive endocrine assessment in the acute phase. Accordingly, we prospectively assessed neuroendocrine function in 71 patients after TBI. Injury was documented by a computed tomography (CT). During the first week, critical clinical data (Glasgow Coma Score, APACHE score), treatment variables such as duration of analgosedation for mechanical ventilation, were related to basal pituitary function. More than 2 years later, a subgroup of patients was re-evaluated using dynamic testing with ACTH and GHRH-arginine tests. The Pearson's correlation analysis and Mann-Whitney rank sum test for group differences were used for statistical analysis. None of the CT findings predicted neuroendocrine dysfunction following TBI. The adaptive response to critical illness with significantly elevated cortisol levels on admission and decreased levels thereafter in patients ventilated for more than 24 h (p < 0.05) was attenuated following severe TBI (p < 0.05). However, the coincidence of low serum cortisol and increased urinary excretion of glucocorticoid metabolites in about 80% of patients challenges the relevance of basal hormone measurements. In ventilated patients, total T3 and free T4 were decreased (p < 0.05), TSH was low on day 3 (p < 0.05), and a gonadotropic insufficiency was present (p < 0.05). The thyrotropic and gonadotropic system recovered completely within the follow-up period. With regard to the somatotropic system, neither brain injury severity nor mechanical ventilation was associated with an insufficiency during the acute phase post-injury. However, initially low GH levels predicted a persistent deficiency (r = 0.731, p < 0.001). We conclude that both severe TBI and prolonged mechanical ventilation result in hormonal disturbances early after injury, suggesting a pathophysiological response to brain injury and subsequent intensive care treatment rather than morphological damage.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, University Erlangen-Nuremberg, Erlangen, Germany.
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Rosenow F, Hojer C, Meyer-Lohmann C, Hilgers RD, Miihlhofer H, Kleindienst A, Owega A, Koning W, Heiss WD. Spontaneous intracerebral hemorrhage. Acta Neurol Scand 2009. [DOI: 10.1111/j.1600-0404.1997.tb00263.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kleindienst A, Schlaffer S, Tam H, Verbalis JG, Buchfelder M. A rat model of cerebral salt wasting. Exp Clin Endocrinol Diabetes 2008. [DOI: 10.1055/s-0028-1096329] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kreutzer J, Kleindienst A, Akutsu H, Bidlingmaier M, Schöfl C, Buchfelder M. Pituitary deficiency 3 and 12 months after traumatic brain injury or subarachnoid hemorrhage – A prospective longitudinal study on pituitary function using different methods of dynamic neuroendocrine evaluation. Exp Clin Endocrinol Diabetes 2008. [DOI: 10.1055/s-0028-1096367] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Buchfelder M, Kann PH, Wüster C, Tuschy U, Saller B, Brabant G, Kleindienst A, Nomikos P. Influence of GH substitution therapy in deficient adults on the recurrence rate of hormonally inactive pituitary adenomas: a case control study. Eur J Endocrinol 2007; 157:149-56. [PMID: 17656592 DOI: 10.1530/eje-07-0164] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Several studies documented metabolic and psychological benefits of GH substitution in deficient adults, most of them suffering from benign pituitary adenomas. Since GH substitution is considered to promote tumour regrowth, adequate treatment is performed with some reservation. Therefore, we aimed to elucidate the effect of GH replacement therapy on tumour recurrence following surgery. METHODS In patients with hormonally inactive pituitary adenomas undergoing tumour surgery, a retrospective case-control study was performed. Pre- and postoperative magnetic resonance (MR) images of GH-treated and untreated patients were matched for best fit by two independent observers. The treated patients were retrieved from the surveillance programme of the German KIMS database and the untreated from the database of the Department of Neurosurgery, University of Erlangen. A total of 55 matched pairs were followed for at least 5 years. Tumour recurrence and progression rates were determined according to the postoperative MR. RESULTS There were 16 tumour progressions in the treatment group and 12 in the control group. Statistical analysis revealed no significant increase in either recurrence (P = 0.317) or progression (P = 0.617) within the follow-up period of 5 years when GH was adequately replaced. CONCLUSIONS This study provides further observational data of substitution therapy in GH-deficient adults with pituitary adenomas. Comparing long-term surgical results, we found no evidence that GH substitution should be withheld in deficient patients. Even residual tumour does not constitute a contraindication to GH replacement. However, since pituitary tumours are slow growing, an observational period of 5 years may not have been long enough to verify any absolute influence on recurrence potential.
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Affiliation(s)
- Michael Buchfelder
- Department of Neurosurgery, University of Erlangen-Nuremberg, Schwabachanlage 6, D-91054 Erlangen, Germany.
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Kleindienst A, Weigel D, Bock C, Brabant G, Buchfelder M. Dysfunction of the anterior pituitary following traumatic brain injury: A prospective longitudinal study. Exp Clin Endocrinol Diabetes 2007. [DOI: 10.1055/s-2007-972515] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kleindienst A, Bock C, Buchfelder M, Morgenthaler NG, Struck J, Brabant G. Copeptin, a stable peptide derived from the AVP precusor, correlates with the severity of traumatic brain injury and predicts the outcome. Exp Clin Endocrinol Diabetes 2007. [DOI: 10.1055/s-2007-972220] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kleindienst A, Hesse F, Bullock MR, Buchfelder M. The neurotrophic protein S100B: value as a marker of brain damage and possible therapeutic implications. Prog Brain Res 2007; 161:317-25. [PMID: 17618987 DOI: 10.1016/s0079-6123(06)61022-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We provide a critical analysis of the value of S100B as a marker of brain damage and possible therapeutic implications. The early assessment of the injury severity and the consequent prognosis are of major concern for physicians treating patients suffering from traumatic brain injury (TBI). A reliable indicator to accurately determine the extent of the brain damage has to meet certain requirements: (i) to originate in the central nervous system (CNS) with no contribution from extracerebral sources; (ii) a passive release from damaged neurons and/or glial cells without any stimulated active release; (iii) a lack of specific effects on neurons and/or glial cells interfering with the initial injury; (iv) an unlimited passage through the blood-brain barrier (BBB). The measurement of putative biochemical markers, such as the S100B protein, has been proposed in this role. Over the past decade, numerous studies have reported a positive correlation of S100B serum levels with a poor outcome following TBI. However, some studies raise doubt whether the serum measurement of S100B is a valid biochemical marker of brain damage. We summarize the specific properties of S100B and analyze whether they support or counteract the necessary requirements to designate this protein as an indicator of brain damage. Finally, we report recent experimental findings suggesting a possible therapeutic potential of S100B.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Friedrich-Alexander-University, Erlangen-Nuremberg, Germany.
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Abstract
We provide a critical analysis of the relevance of S100B in acute brain injury emphazising the beneficial effect of its biological properties. S100B is a calcium-binding protein, primarily produced by glial cells, and exerts auto- and paracrine functions. Numerous reports indicate, that S100B is released after brain insults and serum levels are positively correlated with the degree of injury and negatively correlated with outcome. However, new data suggest that the currently held view, that serum measurement of S100B is a valid "biomarker" of brain damage in traumatic brain injury (TBI), does not acknowlege the multifaceted release pattern and effect of the blood-brain barrier disruption upon S100B levels in serum. In fact, serum and brain S100B levels are poorly correlated, with serum levels dependent primarily on the integrity of the blood-brain barrier, and not the level of S100B in the brain. The time profile of S100B release following experimental TBI, both in vitro and in vivo, suggests a role of S100B in delayed reparative processes. Further, recent findings provide evidence, that S100B may decrease neuronal injury and/or contribute to repair following TBI. Hence, S100B, far from being a negative determinant of outcome, as suggested previously in the human TBI and ischemia literature, is of potential therapeutic value that could improve outcome in patients who sustain various forms of acute brain damage.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Georg August University, Göttingen, Germany.
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Kleindienst A, Fazzina G, Amorini AM, Dunbar JG, Glisson R, Marmarou A. Modulation of AQP4 expression by the protein kinase C activator, phorbol myristate acetate, decreases ischemia-induced brain edema. Acta Neurochir Suppl 2006; 96:393-7. [PMID: 16671492 DOI: 10.1007/3-211-30714-1_81] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The protein kinase C activator, phorbol 12-myristate 13-acetate (PMA), is known to interact with aquaporin-4 (AQP4), a water-selective transporting protein abundant in astrocytes and ependymal cells, that has been found to decrease osmotically-induced swelling. The purpose of this study was to examine whether PMA given at different time points following focal ischemia induced by middle cerebral artery occlusion (MCAO) reduces brain edema by AQP4 modulation. Male Sprague-Dawley rats were randomly assigned to sham procedure, vehicle, or PMA infusion (230 microg/kg), starting either 60 minutes before, or 30 or 60 minutes after MCAO (each group n = 12). After a 2-hour period of ischemia and 2 hours of reperfusion, the animals were sacrificed for assessment of brain water content, sodium, and potassium concentrations. AQP4 expression was assessed by immunoblotting. Statistical analysis was performed by ANOVA followed by Tukey's post hoc test. PMA treatment significantly reduced brain water content concentration in the infarcted area when started before or 30 minutes post-occlusion (p < 0.001, p = 0.022) and prevented the subsequent sodium shift (p < 0.05). Furthermore, PMA reduced ischemia-induced AQP4 up-regulation (p < 0.05). Attenuation of the ischemia-induced AQP4 up-regulation by PMA suggests that the reduction in brain edema formation following PMA treatment was at least in part mediated by AQP4 modulation.
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Affiliation(s)
- A Kleindienst
- Department of Neurosurgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA 23298-0508, USA
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Kleindienst A, Dunbar JG, Glisson R, Okuno K, Marmarou A. Effect of dimethyl sulfoxide on blood-brain barrier integrity following middle cerebral artery occlusion in the rat. Acta Neurochir Suppl 2006; 96:258-62. [PMID: 16671466 DOI: 10.1007/3-211-30714-1_55] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Dimethyl sulfoxide (DMSO) is widely used as a solvent for other drugs, i.e., for the protein kinase C activator phorbol 12-myristate 13-acetate (PMA) and the V1a receptor-antagonist SR49059, to reduce brain edema. We studied the effect of DMSO on blood-brain barrier (BBB) integrity following middle cerebral artery occlusion (MCAO) and the consequences on brain edema development. Male Sprague-Dawley rats were randomly assigned to sham procedure or infusion of 1% DMSO, PMA (230 microg/kg in 1% DMSO), or SR49059 (1 mg/kg in 1% DMSO) followed by MCAO (each group n = 10). After a 2-hour period of ischemia and 2 hours reperfusion, the animals were sacrificed for assessment of brain water content, sodium, and potassium concentration. BBB integrity was assessed by Evans blue extravasation. Statistical analysis was performed by ANOVA followed by a Tukey post hoc test. Low-dose DMSO treatment following MCAO significantly opened the BBB on the ischemic side (p < 0.037). PMA and SR49059 did not have any additional effect on BBB compromise compared to DMSO (p = 1.000, p < 0.957, respectively). We conclude that DMSO as a vehicle for drug administration may increase the drug concentration into the extracellular space, but since BBB permeability is increased, it may also provide an avenue for development of vasogenic edema.
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Affiliation(s)
- A Kleindienst
- Department of Neurosurgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA 23298-0508, USA
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Kleindienst A, Fazzina G, Dunbar JG, Glisson R, Marmarou A. Protective effect of the V1a receptor antagonist SR49059 on brain edema formation following middle cerebral artery occlusion in the rat. Acta Neurochir Suppl 2006; 96:303-6. [PMID: 16671476 DOI: 10.1007/3-211-30714-1_65] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
There exists no pharmacological treatment for fulminating brain edema. Since evidence indicates that brain aquaporin-4 (AQP4) water channels are modulated by vasopressin V1a receptors, we examined the edema-reducing properties of the selective V1a receptor antagonist, SR49059, following middle cerebral artery occlusion (MCAO). Male Sprague-Dawley rats were randomly assigned to sham procedure, vehicle, or SR49059 infusion at different dosages (each n = 6,480 microL/hr, 640 microL/hr, 720 microL/hr) and starting 60 minutes before or after MCAO. After a 2-hour period of ischemia and 2 hours of reperfusion, the animals were sacrificed for assessment of brain water content, sodium, and potassium concentration. Statistics were performed using an ANOVA followed by a Tukey post hoc analysis. SR049059 treatment reduced brain water content in the infarcted area given at 640 microL/hr (p = 0.036), 720 microL/hr 60 minutes before (p = 0.002) or 60 minutes after (p = 0.005) MCAO. The consecutive sodium shift into the brain was prevented (p = 0.001), while the potassium loss was inhibited only by pre-treatment (p = 0.003). These findings imply that in ischemia-induced brain edema, the selective V1a receptor-antagonist SR49059 inhibits brain edema and the subsequent sodium shift into brain. This substance offers a new avenue in brain edema treatment and prompts further study into AQP4 modulation.
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Affiliation(s)
- A Kleindienst
- Department of Neurosurgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA 23298-0508, USA
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Kleindienst A, McGinn MJ, Harvey HB, Colello RJ, Hamm RJ, Bullock MR. Enhanced hippocampal neurogenesis by intraventricular S100B infusion is associated with improved cognitive recovery after traumatic brain injury. J Neurotrauma 2005; 22:645-55. [PMID: 15941374 DOI: 10.1089/neu.2005.22.645] [Citation(s) in RCA: 141] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Evidence of injury-induced neurogenesis in the adult hippocampus suggests that an endogenous repair mechanism exists for cognitive dysfunction following traumatic brain injury (TBI). One factor that may be associated with this restoration is S100B, a neurotrophic/mitogenic protein produced by astrocytes, which has been shown to improve memory function. Therefore, we examined whether an intraventricular S100B infusion enhances neurogenesis within the hippocampus following experimental TBI and whether the biological response can be associated with a measurable cognitive improvement. Following lateral fluid percussion or sham injury in male rats (n = 60), we infused S100B (50 ng/h) or vehicle into the lateral ventricle for 7 days using an osmotic micro-pump. Cell proliferation was assessed by injecting the mitotic marker bromodeoxyuridine (BrdU) on day 2 postinjury. Quantification of BrdU-immunoreactive cells in the dentate gyrus revealed an S100B-enhanced proliferation as assessed on day 5 post-injury (p < 0.05), persisting up to 5 weeks (p < 0.05). Using cell-specific markers, we determined the relative numbers of these progenitor cells that became neurons or glia and found that S100B profoundly increased hippocampal neurogenesis 5 weeks after TBI (p < 0.05). Furthermore, spatial learning ability, as assessed by the Morris water maze on day 30-34 post-injury, revealed an improved cognitive performance after S100B infusion (p < 0.05). Collectively, our findings indicate that an intraventricular S100B infusion induces neurogenesis within the hippocampus, which can be associated with an enhanced cognitive function following experimental TBI. These observations provide compelling evidence for the therapeutic potential of S100B in improving functional recovery following TBI.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA.
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Kleindienst A, Tolias CM, Corwin FD, Müller C, Marmarou A, Fatouros P, Bullock MR. Assessment of cerebral S100B levels by proton magnetic resonance spectroscopy after lateral fluid-percussion injury in the rat. J Neurosurg 2005; 102:1115-21. [PMID: 16028772 DOI: 10.3171/jns.2005.102.6.1115] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. After traumatic brain injury (TBI), S100B protein is released by astrocytes. Furthermore, cerebrospinal fluid (CSF) and serum S100B levels have been correlated to outcome. Given that no data exist about the temporal profile of cerebral S100B levels following TBI and their correlation to serum levels, the authors examined whether proton magnetic resonance (MR) spectroscopy is capable of measuring S100B.
Methods. Results of in vitro proton MR spectroscopy experiments (2.35-tesla magnet, 25 G/cm, point-resolved spatially localized spectroscopy) revealed an S100B-specific peak at 4.5 ppm and confirmed a positive correlation between different S100B concentrations (10 nM–1 µM) and the area under the curve (AUC) for the S100B peak (r = 0.991, p < 0.001). Thereafter, proton MR spectroscopy was performed in male Sprague—Dawley rats (7 × 5 × 5—mm voxel in each hemisphere, TR 3000 msec, TE 30 msec, 256 acquisitions). Exogenously increased CSF S100B levels (∼ 200 ng/ml) through the intraventricular infusion of S100B increased the AUC of the S100B peak from 0.06 ± 0.02 to 0.44 ± 0.06 (p < 0.05), whereas serum S100B levels remained normal. Two hours after lateral fluid-percussion injury, serum S100B levels increased to 0.61 ± 0.09 ng/ml (p < 0.01) and rapidly returned to normal levels, whereas the AUC of the S100B peak increased to 0.19 ± 0.04 at 2 hours postinjury and 0.41 ± 0.07 (p < 0.05) on Day 5 postinjury.
Conclusions. Proton MR spectroscopy proves a strong correlation between the AUC of the S100B peak and S100B concentrations. Following experimental TBI, serum S100B levels increased for only a very short period, whereas cerebral S100B levels were increased up to Day 5 postinjury. Given that experimental data indicate that S100B is actively released following TBI, proton MR spectroscopy may represent a new tool to identify increased cerebral S100B levels in patients after injury, thus allowing its biological function to be better understood.
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Affiliation(s)
- Andrea Kleindienst
- Department of Neurosurgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia 23298-0508, USA.
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Abstract
S100B protein in brain is produced primarily by astrocytes, has been used as a marker for brain injury and has also been shown to be neurotrophic and neuroprotective. Using a well characterized in vitro model of brain cell trauma, we examined the potential role of exogenous S100B in preventing delayed neuronal injury. Neuronal plus glial cultures were grown on a deformable Silastic membrane and then subjected to strain (stretch) injury produced by a 50 ms displacement of the membrane. We have previously shown that this injury causes an immediate, but transient, nuclear uptake of the fluorescent dye propidium iodide by astrocytes and a 24-48 h delayed uptake by neurons. Strain injury caused immediate release of S100-beta with further release by 24 and 48 h. Adding 10 or 100 nm S100B to injured cultures at 15 s, 6 h or 24 h after injury reduced delayed neuronal injury measured at 48 h. Exogenous S100B was present in the cultures through 48 h. These studies directly demonstrate the release and neuroprotective role of S100B after traumatic injury and that, unlike most receptor antagonists used for the treatment of trauma, S100B is neuroprotective when given at later, more therapeutically relevant time points.
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Affiliation(s)
- Karen A Willoughby
- Department of Pharmacology and Toxicology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia 23298-0613, USA
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Kleindienst A, Harvey HB, Rice AC, Müller C, Hamm RJ, Gaab MR, Bullock MR. Intraventricular Infusion of the Neurotrophic Protein S100B Improves Cognitive Recovery after Fluid Percussion Injury in the Rat. J Neurotrauma 2004; 21:541-7. [PMID: 15165362 DOI: 10.1089/089771504774129874] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Elevated serum S100B levels have been shown to be a predictor of poor outcome after traumatic brain injury (TBI). Experimental data, on the other hand, demonstrate a neuroprotective and neurotrophic effect of this calcium-binding protein. The purpose of this study was to examine the role of increased S100B levels on functional outcome after TBI. Following lateral fluid percussion or sham injury in male Sprague Dawley rats (n = 56), we infused S100B (50 ng/h) or vehicle into the cerebrospinal fluid of the ipsilateral ventricle for 7 days using an osmotic mini-pump. Assessment of cognitive performance by the Morris water maze on days 30-34 after injury revealed an improved performance of injured animals after S100B infusion (p < 0.05), when compared to vehicle infusion. Blood samples for analysis of clinical markers of brain damage, S100B and neuron specific enolase, taken at 30 min, 3 h, 4 h, 2 days, or 5 days showed a typical peak 3 h after injury (p < 0.01), and higher serum levels correlated significantly with an impaired cognitive recovery (p < 0.01). The correlation of higher serum S100B levels with poor water maze performance may result from injury induced opening of the blood-brain barrier, allowing the passage of S100B into serum. Thus while higher serum levels of S100B seem to reflect the degree of blood-brain barrier opening and severity of injury, a beneficial effect of intraventricular S100B administration on long-term functional recovery after TBI has been demonstrated for the first time. The exact mechanism by which S100B exerts its neuroprotective or neurotrophic influence remains unknown and needs to be elucidated by further investigation.
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Affiliation(s)
- Andrea Kleindienst
- Division of Neurosurgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia 23298-0508, USA.
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Kleindienst A, Hildebrandt G, Kroemer SA, Franke G, Gaab MR, Landgraf R. Hypothalamic neuropeptide release after experimental subarachnoid hemorrhage: in vivo microdialysis study. Acta Neurol Scand 2004; 109:361-8. [PMID: 15080864 DOI: 10.1046/j.1600-0404.2003.00245.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES As evidence exists about independent regulation of peripheral and central release of the vasoactive and natriuretic neuropeptides arginine-vasopressin (AVP) and oxytocin (OXT), we investigated their release patterns following subarachnoid hemorrhage (SAH). MATERIALS AND METHODS After injection of 0.1 ml arterial blood or saline into the great cistern of 33 Wistar rats, AVP and OXT levels were measured in blood and by microdialysis in the hypothalamic supraoptic (SON) and paraventricular nucleus (PVN). For statistical analysis, the analysis of variance (ANOVA) was used with Tukey HSD post hoc ANOVA tests to determine specific group differences. RESULTS Plasma AVP and OXT peaked 2 h after SAH (P < 0.05), and normalized at 4 h. In the SON, both AVP and OXT peaked 4 h after SAH (P < 0.05). In the PVN, AVP increased in both groups (P < 0.05), while no OXT release occurred. By the sham group, any effect of experimental procedure was excluded. CONCLUSIONS The SAH-specific central neuropeptide release, which exceeded peripheral release and continued longer, may contribute to pathophysiological events following SAH.
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Affiliation(s)
- A Kleindienst
- Neurosurgical Department, University of Greifswald, Greifswald, Germany.
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Kleindienst A, Harvey HB, Mater E, Bronst J, Flack J, Herenz K, Haupt WF, Schön R. Early antithrombotic prophylaxis with low molecular weight heparin in neurosurgery. Acta Neurochir (Wien) 2003; 145:1085-90; discussion 1090-1. [PMID: 14663565 DOI: 10.1007/s00701-003-0142-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [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: 01/01/2003] [Revised: 01/01/2003] [Accepted: 01/01/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Despite the high risk of venous thromboembolic events (VTE) in neuro-surgical patients, heparin prophylaxis has not been routinely established due to concern about bleeding complications. After initiating early low molecular weight heparin (LMWH) prophylaxis, we reviewed our patients in order to examine the viability of this practice. METHOD Over a 3 year period, the records of patients admitted for elective neuro-surgery (ES), head injury (HI) or spontaneous intracranial haemorrhage (ICH) were analysed. Prophylaxis was performed with certoparin (3000 U anti-factor Xa s.c.) on the evening before ES and within 24 hours after surgery or admission whenever a CT did not show a progressive haematoma. Contraindications for LMWH were prothrombin time <70%, partial thrombo-plastin time >40 s, platelet count <100.000/ml, and platelet aggregation test sum <60%. The incidence of bleeding complications, VTE, and resulting morbidity/mortality was assessed. FINDINGS 294 patients were admitted for ES, 344 for HI, and 302 for ICH. 155 of these were excluded because of contraindications. Intracranial bleeding was recorded in 1.5% (ES 1.1%, HI 3.5%, ICH 0%) and operative revision was performed in 1.1% (ES 0.7%, HI 2.8%) of patients. One case of moderate disability and no mortality occurred. The incidence of VTE and pulmonary embolism was documented in 0.2% and 0.1% of patients, with no associated mortality. No heparin induced thrombocytopenia was observed. INTERPRETATION In neurosurgical patients, antithrombotic prophylaxis with certoparin was determined to be safe and efficacious when contraindications are carefully considered and a 12-hour time interval before and after surgery was guaranteed. This retrospective analysis should encourage a prospective trial of early LMWH prophylaxis.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Brain Injuries/surgery
- Brain Neoplasms/secondary
- Brain Neoplasms/surgery
- Cerebrospinal Fluid Shunts
- Contraindications
- Disability Evaluation
- Female
- Fibrinolytic Agents/administration & dosage
- Fibrinolytic Agents/adverse effects
- Hematoma, Epidural, Cranial/chemically induced
- Hematoma, Epidural, Cranial/diagnostic imaging
- Hematoma, Epidural, Cranial/surgery
- Hematoma, Subdural/chemically induced
- Hematoma, Subdural/diagnostic imaging
- Hematoma, Subdural/surgery
- Heparin, Low-Molecular-Weight/administration & dosage
- Heparin, Low-Molecular-Weight/adverse effects
- Humans
- Injections, Subcutaneous
- Intracranial Hemorrhages/chemically induced
- Intracranial Hemorrhages/diagnostic imaging
- Intracranial Hemorrhages/surgery
- Male
- Middle Aged
- Postoperative Complications/chemically induced
- Postoperative Complications/diagnostic imaging
- Postoperative Complications/prevention & control
- Premedication
- Reoperation
- Spinal Neoplasms/surgery
- Thromboembolism/prevention & control
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- A Kleindienst
- Division of Neurosurgery, Medical College, Virginia Commonwealth University 23298-0631, USA.
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Kleindienst A, Haupt WF, Hildebrandt G. Brain death and organ donation in Germany: analysis of procurement in a neurosurgical unit and review of press reports. Acta Neurochir (Wien) 2000; 141:641-5; discussion 645-6. [PMID: 10929730 DOI: 10.1007/s007010050354] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE A prospective study was undertaken to determine the number of potential organ donors in a neurosurgical intensive care unit and to record the actual number of organ donations. The reasons for refusal of organ donations were analysed with respect to the controversial public discussion of the brain death concept and the transplantation law in Germany. METHODS From 1994 to 1997, the number of cases of brain death, and the number of cases in which relatives consented or refused to organ donation as well as the number of actual organ explantations was recorded. Over the same period, press reports of 5 German language newspapers were analysed with regard to the authors' position on brain death and transplantation law, their qualification, intention, and mode of presentation. RESULTS Annually, about 70 deaths occurred on the department's intensive care unit of which almost 30% of the patients were determined to have suffered brain death without any obvious contraindications against organ donation. The refusal rate of relatives rose from 56% up to 78%, and the rate of organ donors thus decreased from 5% in 1994 to 4% presently in the department. About 100 reports were published each year in the analysed newspapers, of which about 90% voiced approval of organ transplantation. During the review period, the depiction became more objective (57% in 1994 to 82% in 1997) and the suspicious attitude toward the technique of brain death diagnosis declined. Whereas 50% of the articles rejected the brain death concept in 1994, this figure decreased to 39% in 1997 and conversely the concept of consent rose from 33% in 1994 to 56% in 1997. CONCLUSION In Germany, the relatives refusal rate in organ donation is continuously high, presumable due to a depressing 39% of press reports rejecting the brain death concept, and resulting in a very low number of organ donations. There is hope that the transplantation law which has finally passed German parliament in 1997, confirming the brain death concept as well as the legal principle of prior consent by the donor or consent by the relatives will eventually result in an increase of organ donation especially when supported by an educational campaign which is embodied in the transplantation law.
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Affiliation(s)
- A Kleindienst
- Department of Neurosurgery, Charite, Humboldt-University of Berlin, Germany
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Kleindienst A, Hildebrandt G, Klug N, Schön R. Management of vein of Galen malformations. A review based on five neurosurgically treated cases and literature reports. Zentralbl Neurochir 2000; 60:172-82. [PMID: 10674334] [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] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The high morbidity and mortality associated with the management of vein of Galen aneurysmal malformations (VGAM) continues to pose a tremendous challenge to the neurosurgeon as well as to the attending interventional radiologist. Since 1985, five patients with VGAM have been referred to the neurosurgical unit of the University of Cologne, two neonates, one infant and two adults. Four patients underwent direct operation and two patients received a shunt. The treatment was performed without mortality. A review of the literature reflects no substantial difference between neurosurgical treatment during the last 15 years (mortality 10%) and endovascular treatment (best series mortality 6%).
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Affiliation(s)
- A Kleindienst
- Department of Neurosurgery, University of Cologne, Germany
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Abstract
The purpose of this prospective study was to determine the potential of MR imaging to depict morphologic alterations of the median nerve correlating with the stage of carpal tunnel syndrome (CTS). Eighteen wrists of normal subjects and 81 wrists of patients with CTS were examined. MR imaging was performed with proton-density- and T2-weighted spin-echo sequences. Staging of CTS was done on the basis of clinical and electrophysiological testing, including evaluation of the number of previous steroid infiltrations in conservative treatment. Median nerve flattening, cross-sectional area, and signal intensity were measured from the distal radius to the end of the carpal tunnel. Delineation and structure of the median nerve were recorded qualitatively by two experienced radiologists in consensus. Three major MR imaging criteria of early CTS were (a) isolated prestenotic and intracarpal swelling of the median nerve (P < .01), (b) the absence of significant flattening, and (c) a generalized increase in signal intensity retrograde to the distal radius (P < .01). The nerve showed sharply delineated contours and a homogeneous signal pattern. Advanced CTS was characterized by retrograde swelling of the median nerve to the distal radius (P < .01) and decreased signal intensity (P < .05). Demarcation of the nerve became poorer, and its signal pattern appeared fasciculated. After steroid infiltration, the median nerve was difficult to delineate, showed an inhomogeneous structure, and swelling was less pronounced than without steroid infiltration (P < .05). MR imaging yields typical morphologic findings that correlate with the duration and severity of median nerve compression. Hence, MR imaging allows staging of median nerve compression in CTS and thus may contribute to therapeutic decision-making.
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Affiliation(s)
- A Kleindienst
- Department of Neurosurgery, Charité, Campus Virchow, Humboldt University, Berlin, Germany
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Rosenow F, Hojer C, Meyer-Lohmann C, Hilgers RD, Mühlhofer H, Kleindienst A, Owega A, Köning W, Heiss WD. Spontaneous intracerebral hemorrhage. Prognostic factors in 896 cases. Acta Neurol Scand 1997; 96:174-82. [PMID: 9300072] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
To determine the prognostic value of etiology and localization in spontaneous intracerebral hemorrhage, 896 patients with spontaneous intracerebral hemorrhage, as proven by CT, operation or autopsy, were retrospectively studied using univariate data analysis. Etiologies were hypertension in 63.5%, cerebrovascular malformations in 8.5% and abnormal hemostasis in 15% of the patients. In 23% no etiology was determined. Main localizations were cerebral lobes in 49.2%, basal ganglia in 34.4%, brain stem in 6.9%, cerebellum in 6.7% and primary intraventricular in 2.3% of the patients. Ventricular extension was present in 47.0%. A higher case fatality correlated with: 1) ventricular extension (P < 0.00001), 2) increasing age (P = 0.00005), 3) surgical treatment (P = 0.00010), 4) localization in basal ganglia (P = 0.0108) and 5) hypertension as only etiology (P = 0.01471). A lower case fatality was found in patients with cerebrovascular malformations (P = 0.00006) and when the hemorrhage was localized to the cerebral lobes (P = 0.0050). We conclude that etiology and localization are of prognostic value in spontaneous intracerebral hemorrhage.
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Affiliation(s)
- F Rosenow
- Department of Neurology, University of Cologne, Germany
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Kleindienst A, Hamm B, Hildebrandt G, Klug N. Diagnosis and staging of carpal tunnel syndrome: comparison of magnetic resonance imaging and intra-operative findings. Acta Neurochir (Wien) 1996; 138:228-33. [PMID: 8686550 DOI: 10.1007/bf01411366] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE In order to determine the reliability of magnetic resonance imaging (MRI) in the diagnosis and staging of carpal tunnel syndrome (CTS), the most common entrapment neuropathy, the following prospective study has been performed. METHODS We compared clinical and electrophysiological studies in 58 cases of CTS with MRI investigations and confirmed the reliability by exact correspondence with intra-operative findings. RESULTS Typical MRI characteristics of the median nerve in CTS have been established. There is a significant difference in flattening (p < 0.05), swelling (p < 0.01) and signal intensity (p < 0.05) of the median nerve between early and advanced CTS. Comparison of MRI and intra-operative findings revealed that median nerve compression was diagnosed correctly in 91% of cases. Additional lesions in the carpal tunnel, which are a primary cause of nerve compression, were established by MRI in 25 cases and confirmed by surgery. CONCLUSION MRI is a reliable diagnostic tool for assessing as well as staging of CTS. Morphological changes following chronic nerve compression can be visualized. It is particularly useful in cases of suspected lesions within the carpal tunnel as a cause of CTS. The information provided may support the choice of adequate treatment modality.
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Affiliation(s)
- A Kleindienst
- Department of Neurosurgery, University of Cologne, Federal Republic of Germany
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Abstract
We examined 62 patients (72 hands) with carpal tunnel syndrome (CTS) by magnetic resonance imaging (MRI) of the carpal tunnel and latency measurements of the median nerve. In 32 of 72 hands a probable causative lesion of the CTS was identified by MRI, for example tenosynovitis, a cyst-like structure, or an aberrant muscle. The MRI findings were confirmed by surgery in 16 of 24 hands, slightly corrected in 5, and not substantiated in 3. In 65 of 72 hands, MRI disclosed pathology of the median nerve, most prominently an enlargement of the nerve at the level of the os pisiforme, a finding not seen during surgery. Oedema of the nerve was found in 14 of 72 hands. The distal latencies were prolonged in 62 of 72 hands. The sensory latencies correlated significantly with the MRI-determined cross-sectional area of the nerve at the level of the distal radius. The lack of other correlations suggests that partly independent features of the nerve lesion are demonstrated in each method or that the sensitivity and specificity of both methods are limited. Further experience with MRI in CTS is desirable. At present, the practical use of MRI in CTS should be restricted to special diagnostic problems such as carpal tunnel syndromes which do not respond adequately to conservative or surgical treatment.
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Affiliation(s)
- S Seyfert
- Department of Neurology, Klinikum Steglitz, Free University, Berlin, Germany
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