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Ahmed N, Mazya M, Nunes AP, Moreira T, Ollikainen JP, Escudero-Martinez I, Bigliardi G, Dorado L, Dávalos A, Egido JA, Tassi R, Strbian D, Zini A, Nichelli P, Herzig R, Jurák L, Hurtikova E, Tsivgoulis G, Peeters A, Nevšímalová M, Brozman M, Cavallo R, Lees KR, Mikulik R, Toni D, Holmin S. Safety and outcomes of routine endovascular thrombectomy in large artery occlusion recorded in the SITS Register: An observational study. J Intern Med 2021; 290:646-654. [PMID: 33999451 DOI: 10.1111/joim.13302] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/26/2021] [Accepted: 03/31/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVE We aimed to evaluate the safety and outcomes of thrombectomy in anterior circulation acute ischaemic stroke recorded in the SITS-International Stroke Thrombectomy Register (SITS-ISTR) and compare them with pooled randomized controlled trials (RCTs) and two national registry studies. METHODS We identified centres recording ≥10 consecutive patients in the SITS-ISTR with at least 70% of available modified Rankin Scale (mRS) at 3 months during 2014-2019. We defined large artery occlusion as intracranial internal carotid artery, first and second segment of middle cerebral artery and first segment of anterior cerebral artery. Outcome measures were functional independence (mRS score 0-2) and death at 3 months and symptomatic intracranial haemorrhage (SICH) per modified SITS-MOST. RESULTS Results are presented in the following order: SITS-ISTR, RCTs, MR CLEAN Registry and German Stroke Registry (GSR). Median age was 73, 68, 71 and 75 years; baseline NIHSS score was 16, 17, 16 and 15; prior intravenous thrombolysis was 62%, 83%, 78% and 56%; onset to reperfusion time was 289, 285, 267 and 249 min; successful recanalization (mTICI score 2b or 3) was 86%, 71%, 59% and 83%; functional independence at 3 months was 45.5% (95% CI: 44-47), 46.0% (42-50), 38% (35-41) and 37% (35-41), respectively; death was 19.2% (19-21), 15.3% (12.7-18.4), 29.2% (27-32) and 28.6% (27-31); and SICH was 3.6% (3-4), 4.4% (3.0-6.4), 5.8% (4.7-7.1) and not available. CONCLUSION Thrombectomy in routine clinical use registered in the SITS-ISTR showed safety and outcomes comparable to RCTs, and better functional outcomes and lower mortality than previous national registry studies.
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Affiliation(s)
- N Ahmed
- From the, Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - M Mazya
- From the, Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - A P Nunes
- Stroke Unit, Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
| | - T Moreira
- From the, Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - J P Ollikainen
- Department of Neurology, Tampere University Hospital, Tampere, Finland
| | - I Escudero-Martinez
- Department of Neurology, University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Sevilla, Spain
| | - G Bigliardi
- Department of Neurology, Ospedale Civile "S.Agostino-Estense" - Azienda Ospedaliera Universitaria di Modena, Modena, Italy
| | - L Dorado
- Department of Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - A Dávalos
- Department of Neurology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - J A Egido
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
| | - R Tassi
- Stroke Unit Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - D Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - A Zini
- Department of Neurology and Stroke Center, Maggiore Hospital, IRCCS Istituto di Scienze Neurologiche di Bologna, Bologna, Italy
| | - P Nichelli
- Department of Biomedical, Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Modena, Italy
| | - R Herzig
- Department of Neurology, Comprehensive Stroke Centre, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - L Jurák
- Neurocentre, Regional Hospital Liberec, Liberec, Czech Republic
| | - E Hurtikova
- Department of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - G Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, Athens, Greece
| | - A Peeters
- Department of Neurology, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - M Nevšímalová
- Department of Neurology, Nemocnice Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - M Brozman
- Faculty of Social Sciences and Health, Constantine the Philosopher University Nitra, Nitra, Slovakia
| | - R Cavallo
- Department of Neurology, Ospedale San Giovanni Bosco, Turin, Italy
| | - K R Lees
- School of Medicine, Nursing and Dentistry, University of Glasgow, Glasgow, UK
| | - R Mikulik
- International Clinical Research Center and Department of Neurology, St. Anne's University Hospital and Masaryk University, Brno, Czech Republic
| | - D Toni
- Department of Human Neurosciences, La Sapienza, Rome, Italy
| | - S Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
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Chireh A, Grankvist R, Sandell M, Mukarram AK, Jaff N, Berggren I, Persson H, Linde C, Arnberg F, Lundberg J, Ugander M, La Manno G, Jonsson S, Daub CO, Holmin S. P2790Novel endomyocardial micro-biopsy device for higher precision and reduced complication risks. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Endomyocardial biopsy (EMB) is the gold standard for diagnosis of several cardiac diseases, yet its use is limited by low diagnostic yield and significant complication risks. The size of the current devices allows only limited steering to different parts of the ventricle walls. In transplant monitoring, repeated biopsies with the current devices can cause scarring that makes it increasingly difficult to obtain adequate samples. We hypothesised that several of the shortcomings of EMB can be avoided with a smaller and more steerable device. Further, we hypothesised that the novel sampling procedure could be coupled to a low-input molecular analysis method, such as RNA-sequencing (RNA-seq), to provide molecular characterisation of the tissue without the need of large biopsy samples.
Purpose
To develop an EMB device with significantly smaller dimensions, for future use in diagnostics and research investigations. Specific aims were to test feasibility and safety of the procedure, as well as the quality of the generated molecular data.
Methods
65 “micro biopsy” (micro-EMB) device prototypes were designed and evaluated in-house. The prototypes were evaluated either in an ex-vivo simulator or in acute non-survival pig experiments (n=23). Once the final device design was reached, an in vivo trial was set up using six naive Yorkshire farm pigs. Micro-EMB, conventional EMB, skeletal muscle and blood samples were collected for RNA-seq characterisation and comparison. In half of the animals (n=3), micro-EMB was the only intervention in order to prioritise safety evaluations. The animals were monitored for one week.
Results
The final device design has an outer diameter (OD) of 0.4 mm, compared to a conventional 11 mm device (in the opened position), Fig 1A. The device can be directed to different parts of the myocardium in both ventricles. In the in vivo evaluation in swine, 81% of the biopsy attempts (n=157) were successful. High quality RNA-seq data was generated from 91% of the sequenced heart micro-biopsy samples (n=32). The gene expression signatures of samples taken with the novel device were comparable with samples taken with a conventional device, Fig 1B. No major complications were detected either during periprocedural monitoring or during the follow-up. The tissue mark after micro-biopsy was markedly smaller than after conventional endomyocardial biopsy.
A) Bioptome dimensions. B) RNA-seq data.
Conclusions
Our preliminary data suggest that the novel submillimeter biopsy device, coupled with RNA-seq, provides a feasible method to obtain molecular data from the myocardium. The method is less traumatic and has a higher flexibility compared to conventional methods, enabling safer and more specific sampling from different parts of the myocardium. In the long term, the procedure could open unprecedented diagnostic and research possibilities. Future studies should be directed to establish the capabilities of the novel method in a relevant disease model.
Acknowledgement/Funding
Family Erling Persson Foundation. The Söderberg foundations. KID (Karolinska Institutet). The 4D project. Stockholm county council. Astra Zeneca.
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Affiliation(s)
- A Chireh
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
| | - R Grankvist
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
| | - M Sandell
- Royal Institute of Technology, Department of Materials Science, Stockholm, Sweden
| | - A K Mukarram
- Karolinska Institute, Department of Biosciences and Nutrition, Stockholm, Sweden
| | - N Jaff
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
| | - I Berggren
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - H Persson
- Danderyd University Hospital, Department of Cardiology, Stockholm, Sweden
| | - C Linde
- Karolinska University Hospital, Heart and Vascular Theme, Stockholm, Sweden
| | - F Arnberg
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
| | - J Lundberg
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
| | - M Ugander
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - G La Manno
- Karolinska Institute, Department of Medical Biochemistry and Biophysics, Stockholm, Sweden
| | - S Jonsson
- Royal Institute of Technology, Department of Materials Science, Stockholm, Sweden
| | - C O Daub
- Karolinska Institute, Department of Biosciences and Nutrition, Stockholm, Sweden
| | - S Holmin
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
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3
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Ahmed M, Tegnebratt T, Tran T, Damberg P, Bone D, Lu L, Gistera A, Tarnawski L, Hedin U, Eriksson P, Holmin S, Gustafsson B, Caidahl K. P1217Zirconium-89 labelled probe for molecular imaging of inflammation in experimental atherosclerosis. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Early detection of inflamed atherosclerotic lesions by molecular imaging might improve risk assessment beyond that of vascular stenosis and plaque morphology imaging, and improve the clinical management of high-risk patients.
Purpose
To target the key features of unstable atherosclerotic lesions, we studied the feasibility of our radiotracer, based on modified human serum albumin (HSA), to identify inflamed atherosclerotic lesions by in vivo molecular imaging.
Methods
We applied a maleylated HSA (Mal-HSA) probe, recognised by scavenger receptors on macrophages, in an experimental in vivo imaging study of atherosclerosis. Mal-HSA was coupled with a positron-emittingmetal ion, Zirconium-89 (89Zr). The targeting potential of this probe was evaluated and compared with unspecific 89Zr-HSA and 18F-FDG in a mouse model of atherosclerosis (Apoe−/−, n=22) and compared with wild-type (WT) mice (C57BL/6, n=21) as controls. Radiotracer accumulation in the aortic arch was analysed in vivo by the fusion of positron emission tomography–magnetic resonance imaging (PET-MRI), radiotracer bio-distribution was measured ex vivo by gamma counter, and plaque uptake was evaluated by phosphor imaging (PI) autoradiography (ARG).
Results
PET-MRI, gamma counter measurements, and PI-ARG showed the accumulation of 89Zr-Mal-HSA in the atherosclerotic lesions of Apoe−/− mice. The maximum standardised uptake value (SUVmax) for 89Zr-Mal-HSA at 16 and 20 weeks were 26% and 20% higher (P<0.05) in Apoe−/− mice than control WT mice, whereas no difference in SUVmax was found for 18F-FDG in the same animals. 89Zr-Mal-HSA uptake in the aorta as evaluated by gamma counter 48 h post-injection was 32% higher (P<0.01) for Apoe−/− mice compared to WT mice, and the aorta-to-blood ratio was 10-fold higher (P<0.001) for 89Zr-Mal-HSA compared with unspecific 89Zr-HSA. HSA probes were mainly distributed to the liver, spleen, kidneys, bone and lymph nodes. The PI-ARG results corroborated the PET and gamma counter measurements, showing higher accumulation of 89Zr-Mal-HSA in the aortas of Apoe−/− mice compared to WT mice; 9.4±1.4 vs 0.8±0.3% (P<0.001).
Conclusions
The modified HSA-based radiotracer showed in vivo targeting of inflamed atherosclerotic lesions of mouse aorta, which could also be verified ex vivo. 89Zr-Mal-HSA seems to be a promising diagnostic tool for the identification of vascular inflammation. Further methodological studies are needed to verify its applicability for detecting rupture-prone plaques.
Acknowledgement/Funding
Swedish Research Council (22036); the Swedish HLF (20150423, 20170669); ALF (20150517, 447561, 726481); Söderberg Foundations, VINNOVA and KI
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Affiliation(s)
- M Ahmed
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - T Tegnebratt
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
| | - T Tran
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
| | - P Damberg
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
| | - D Bone
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - L Lu
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
| | - A Gistera
- Karolinska Institute, Department of Medicine Solna, Stockholm, Sweden
| | - L Tarnawski
- Karolinska Institute, Department of Medicine Solna, Stockholm, Sweden
| | - U Hedin
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - P Eriksson
- Karolinska Institute, Department of Medicine Solna, Stockholm, Sweden
| | - S Holmin
- Karolinska Institute, Department of Clinical Neuroscience, Stockholm, Sweden
| | - B Gustafsson
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - K Caidahl
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
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Lundberg J, Grankvist R, Holmin S. The creation of an endovascular exit through the vessel wall using a minimally invasive working channel in order to reach all human organs. J Intern Med 2019; 286:309-316. [PMID: 31108016 DOI: 10.1111/joim.12939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Since the establishment of the Seldinger technique for secure entry to the vascular system, there has been a rapid evolution in imaging and catheters that has made the arteries and veins internal routes to any place in the body for interventions. It is curious that a general exit from the vasculature in a similar manner has not been proposed earlier. Possibly, the simplest reason is that accidental perforation of the vasculature by guide wire or catheter is a feared adverse event in endovascular intervention. Most places in the body can be reached by ultrasonography or computed tomography-guided intervention. Some organs such as the central nervous system, the heart and pancreas are harder to access and, in some organs, like the kidney, repeated percutaneous punctions to cover large areas is not suitable. We present a new general purpose micro-endovascular device creating a working channel to these 'hard to reach' organs by an inverted Seldinger technique. This review details this trans-vessel wall technique, which has been studied in pancreas for transplantation of insulin-producing cells, for injection of contrast agent to the heart and to the brain, bowels and kidney in rat, rabbit, swine and macaque monkeys with up to one year of follow-up without adverse events. Furthermore, the payloads that can be given through such a system are briefly discussed. Drugs, cells, gene vectors and other therapeutic substances may be injected directly to the tissue to increase efficacy and decrease risk of off-site adverse effects.
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Affiliation(s)
- J Lundberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - R Grankvist
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - S Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
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5
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Grankvist R, Jensen-Urstad M, Clarke J, Lehtinen M, Little P, Lundberg J, Arnberg F, Jonsson S, Chien KR, Holmin S. Superselective endovascular tissue access using trans-vessel wall technique: feasibility study for treatment applications in heart, pancreas and kidney in swine. J Intern Med 2019; 285:398-406. [PMID: 30289186 DOI: 10.1111/joim.12841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES With the emergence of targeted cell transplantation and gene therapy, there is a need for minimally invasive tissue access to facilitate delivery of therapeutic substrate. The objective of this study was to demonstrate the suitability of an endovascular device which is able to directly access tissue and deliver therapeutic agent to the heart, kidney and pancreas without need to seal the penetration site. METHODS In vivo experiments were performed in 30 swine, including subgroups with follow-up to evaluate complications. The previously described trans-vessel wall (VW) device was modified to be sharper and not require tip detachment to seal the VW. Injections into targets in the heart (n = 13, 24-h follow-up n = 5, 72-h follow-up n = 3), kidney (n = 8, 14-day follow-up n = 3) and pancreas (n = 5) were performed. Some animals were used for multiple organ injections. Follow-up consisted of clinical monitoring, angiography and necropsy. Transvenous (in heart) and transarterial approaches (in heart, kidney and pancreas) were used. Injections were targeted towards the subepicardium, endomyocardium, pancreas head and tail, and kidney subcapsular space and cortex. RESULTS Injections were successful in target organs, visualized by intraparenchymal contrast on fluoroscopy and by necropsy. No serious complications (defined as heart failure or persistent arrhythmia, haemorrhage requiring treatment or acute kidney injury) were encountered over a total of 157 injections. CONCLUSIONS The trans-VW device can achieve superselective injections to the heart, pancreas and kidney for delivery of therapeutic substances without tip detachment. All parts of these organs including the subepicardium, pancreas tail and renal subcapsular space can be efficiently reached.
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Affiliation(s)
- R Grankvist
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - M Jensen-Urstad
- Department of Cardiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J Clarke
- Department of Cell and Molecular Biology and Medicine, Karolinska Institutet, Stockholm, Sweden
| | - M Lehtinen
- Department of Cell and Molecular Biology and Medicine, Karolinska Institutet, Stockholm, Sweden
| | - P Little
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - J Lundberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - F Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - S Jonsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Materials Science and Engineering, Royal Institute of Technology, Stockholm, Sweden
| | - K R Chien
- Department of Cell and Molecular Biology and Medicine, Karolinska Institutet, Stockholm, Sweden
| | - S Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
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6
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Tegnebratt T, Lu L, Eksborg S, Chireh A, Damberg P, Nikkhou-Aski S, Foukakis T, Rundqvist H, Holmin S, Kuiper RV, Samen E. Treatment response assessment with (R)-[ 11CPAQ PET in the MMTV-PyMT mouse model of breast cancer. EJNMMI Res 2018; 8:25. [PMID: 29616369 PMCID: PMC5882477 DOI: 10.1186/s13550-018-0380-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/23/2018] [Indexed: 02/07/2023] Open
Abstract
Background The goal of the study was to assess the potential of the vascular endothelial growth factor receptor (VEGFR)-2-targeting carbon-11 labeled (R)-N-(4-bromo-2-fluorophenyl)-6-methoxy-7-((1-methyl-3-piperidinyl)methoxy)-4-quinazolineamine ((R)-[11C]PAQ) as a positron emission tomography (PET) imaging biomarker for evaluation of the efficacy of anticancer drugs in preclinical models. Methods MMTV-PyMT mice were treated with vehicle alone (VEH), murine anti-VEGFA antibody (B20-4.1.1), and paclitaxel (PTX) in combination or as single agents. The treatment response was measured with (R)-[11C]PAQ PET as standardized uptake value (SUV)mean, SUVmax relative changes at the baseline (day 0) and follow-up (day 4) time points, and magnetic resonance imaging (MRI)-derived PyMT mammary tumor volume (TV) changes. Expression of Ki67, VEGFR-2, and CD31 in tumor tissue was determined by immunohistochemistry (IHC). Non-parametric statistical tests were used to evaluate the relation between (R)-[11C]PAQ radiotracer uptake and therapy response biomarkers. Results The (R)-[11C]PAQ SUVmax in tumors was significantly reduced after 4 days in the B20-4.1.1/PTX combinational and B20-4.1.1 monotherapy groups (p < 0.0005 and p < 0.003, respectively). No significant change was observed in the PTX monotherapy group. There was a significant difference in the SUVmax change between the VEH group and B20-4.1.1/PTX combinational group, as well as between the VEH group and the B20-4.1.1 monotherapy group (p < 0.05). MRI revealed significant decreases in TV in the B20-4.1.1/PTX treatment group (p < 0.005) but not the other therapy groups. A positive trend was observed between the (R)-[11C]PAQ SUVmax change and TV reduction in the B20-4.1.1/PTX group. Statistical testing showed a significant difference in the blood vessel density between the B20-4.1.1/PTX combinational group and the VEH group (p < 0.05) but no significant difference in the Ki67 positive signal between treatment groups. Conclusions The results of this study are promising. However, additional studies are necessary before (R)-[11C]PAQ can be approved as a predictive radiotracer for cancer therapy response.
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Affiliation(s)
- T Tegnebratt
- Department of Clinical Neuroscience, Karolinska Institutet, SE-17176, Stockholm, Sweden. .,Department of Neuroradiology, Karolinska Experimental Research and Imaging Center, Karolinska University Hospital, SE-17176, Stockholm, Sweden.
| | - L Lu
- Department of Clinical Neuroscience, Karolinska Institutet, SE-17176, Stockholm, Sweden.,Department of Comparative Medicine, Karolinska Experimental Research and Imaging Center, Karolinska University Hospital, SE-17176, Stockholm, Sweden
| | - S Eksborg
- Department of Women's and Children's Health, Karolinska Institutet, SE-17176, Stockholm, Sweden
| | - A Chireh
- Department of Clinical Neuroscience, Karolinska Institutet, SE-17176, Stockholm, Sweden
| | - P Damberg
- Department of Clinical Neuroscience, Karolinska Institutet, SE-17176, Stockholm, Sweden.,Department of Comparative Medicine, Karolinska Experimental Research and Imaging Center, Karolinska University Hospital, SE-17176, Stockholm, Sweden
| | - S Nikkhou-Aski
- Department of Clinical Neuroscience, Karolinska Institutet, SE-17176, Stockholm, Sweden.,Department of Comparative Medicine, Karolinska Experimental Research and Imaging Center, Karolinska University Hospital, SE-17176, Stockholm, Sweden
| | - T Foukakis
- Department of Oncology-Pathology, Karolinska Institutet, SE-17176, Stockholm, Sweden
| | - H Rundqvist
- Department of Cell and Molecular Biology, Karolinska Institutet, SE-17176, Stockholm, Sweden
| | - S Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, SE-17176, Stockholm, Sweden.,Department of Neuroradiology, Karolinska Experimental Research and Imaging Center, Karolinska University Hospital, SE-17176, Stockholm, Sweden
| | - R V Kuiper
- Core Facility for Morphologic Phenotype Analysis, Laboratory Medicine, Karolinska Institutet, SE-14183, Huddinge, Sweden
| | - E Samen
- Department of Clinical Neuroscience, Karolinska Institutet, SE-17176, Stockholm, Sweden.,Department of Neuroradiology, Karolinska Experimental Research and Imaging Center, Karolinska University Hospital, SE-17176, Stockholm, Sweden
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7
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Tan B, Ngiam N, Holmin S, Tan D, Chia M, Wong L, Tam H, Sim T, Ooi S, Leong B, Seet R, Teoh H, Chan B, Sharma V, Yeo L. Improvement in door-to-needle times in patients with acute ischaemic stroke via the application of a simple stroke activation protocol. J Neurol Sci 2017. [DOI: 10.1016/j.jns.2017.08.3122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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8
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Wahlgren N, Thorén M, Höjeberg B, Käll TB, Laska AC, Sjöstrand C, Höijer J, Almqvist H, Holmin S, Lilja A, Fredriksson L, Lawrence D, Eriksson U, Ahmed N. Randomized assessment of imatinib in patients with acute ischaemic stroke treated with intravenous thrombolysis. J Intern Med 2017; 281:273-283. [PMID: 27862464 PMCID: PMC5573589 DOI: 10.1111/joim.12576] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [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: 12/20/2022]
Abstract
BACKGROUND Imatinib, a tyrosine kinase inhibitor, has been shown to restore blood-brain barrier integrity and reduce infarct size, haemorrhagic transformation and cerebral oedema in stroke models treated with tissue plasminogen activator. We evaluated the safety of imatinib, based on clinical and neuroradiological data, and its potential influence on neurological and functional outcomes. METHODS A phase II randomized trial was performed in patients with acute ischaemic stroke treated with intravenous thrombolysis. A total of 60 patients were randomly assigned to four groups [3 (active): 1 (control)]; the active treatment groups received oral imatinib for 6 days at three dose levels (400, 600 and 800 mg). Primary outcome was any adverse event; secondary outcomes were haemorrhagic transformation, cerebral oedema, neurological severity on the National Institutes of Health Stroke Scale (NIHSS) at 7 days and at 3 months and functional outcomes on the modified Rankin scale (mRS). RESULTS Four serious adverse events were reported, which resulted in three deaths (one in the control group and two in the 400-mg dose group; one patient in the latter group did not receive active treatment and the other received two doses). Nonserious adverse events were mostly mild, resulting in full recovery. Imatinib ameliorated neurological outcomes with an improvement of 0.6 NIHSS points per 100 mg imatinib (P = 0.02). For the 800-mg group, the mean unadjusted and adjusted NIHSS improvements were 4 (P = 0.037) and 5 points (P = 0.012), respectively, versus controls. Functional independence (mRS 0-2) increased by 18% versus controls (61 vs. 79; P = 0.296). CONCLUSION This phase II study showed that imatinib is safe and tolerable and may reduce neurological disability in patients treated with intravenous thrombolysis after ischaemic stroke. A confirmatory randomized trial is currently underway.
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Affiliation(s)
- N Wahlgren
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - M Thorén
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - B Höjeberg
- Department of Neurology, Capio St Göran Hospital, Stockholm, Sweden
| | - T-B Käll
- Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - A-C Laska
- Department of Internal Medicine, Danderyd Hospital, Stockholm, Sweden
| | - C Sjöstrand
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - J Höijer
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - H Almqvist
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - S Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - A Lilja
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - L Fredriksson
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - D Lawrence
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - U Eriksson
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - N Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Lundberg J, Stone-Elander S, Zhang XM, Korsgren O, Jonsson S, Holmin S. Endovascular method for transplantation of insulin-producing cells to the pancreas parenchyma in swine. Am J Transplant 2014; 14:694-700. [PMID: 24517268 PMCID: PMC4285323 DOI: 10.1111/ajt.12601] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 11/04/2013] [Accepted: 11/20/2013] [Indexed: 01/25/2023]
Abstract
Insulin-producing cells are transplanted by portal vein injection as an alternative to pancreas transplantation in both clinical and preclinical trials. Two of the main limitations of portal vein transplantation are the prompt activation of the innate immunity and concomitant loss of islets and a small but significant risk of portal vein thrombosis. Furthermore, to mimic physiological release, the insulin-producing cells should instead be located in the pancreas. The trans-vessel wall approach is an endovascular method for penetrating the vessel wall from the inside. In essence, a working channel is established to the parenchyma of organs that are difficult to access by percutaneous technique. In this experiment, we accessed the extra-vascular pancreatic parenchyma in swine by microendovascular technique and injected methylene blue, contrast fluids and insulin-producing cells without acute adverse events. Further, we evaluated the procedure itself by a 1-year angiographical follow-up, without adverse events. This study shows that the novel approach utilizing endovascular minimal invasiveness coupled to accurate trans-vessel wall placement of an injection in the pancreatic parenchyma with insulin-producing cells is possible. In clinical practice, the potential benefits compared to portal vein cell transplantation should significantly improve endocrine function of the graft and potentially reduce adverse events.
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Affiliation(s)
- J Lundberg
- Department of Clinical Neuroscience, Karolinska InstitutetStockholm, Sweden,Department of Neuroradiology, Karolinska University HospitalStockholm, Sweden
| | - S Stone-Elander
- Department of Clinical Neuroscience, Karolinska InstitutetStockholm, Sweden,Department of Neuroradiology, Karolinska University HospitalStockholm, Sweden
| | - X-M Zhang
- Department of Clinical Neuroscience, Karolinska InstitutetStockholm, Sweden
| | - O Korsgren
- Division of Immunology Department of Immunology Genetics and Pathology, Uppsala UniversityUppsala, Sweden
| | - S Jonsson
- Department of Materials Science and Engineering, Royal Institute of TechnologyStockholm, Sweden
| | - S Holmin
- Department of Clinical Neuroscience, Karolinska InstitutetStockholm, Sweden,Department of Neuroradiology, Karolinska University HospitalStockholm, Sweden,* Corresponding author: Staffan Holmin,
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Söderman M, Holmin S, Andersson T, Kuntze Söderqvist Å, Turner R. E-024 The Mindframe Capture LP 3 mm and 4 mm thrombectomy device. Early clinical results: Abstract E-024 Table 1. J Neurointerv Surg 2012. [DOI: 10.1136/neurintsurg-2012-010455c.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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11
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Helyar V, Söderman M, Andersson T, Holmin S. Vertebrobasilar Dissection with Pseudo-aneurysm or Subarachnoid Hemorrhage: Intracranial Stenting as the Only Treatment. A Report of Three Cases. Interv Neuroradiol 2009; 15:87-91. [PMID: 20465935 DOI: 10.1177/159101990901500114] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 12/07/2008] [Indexed: 11/17/2022] Open
Abstract
SUMMARY Vertebrobasilar dissection may cause ischaemia or subarachnoid haemorrhage and can pose a significant treatment challenge. Endovascular treatment using stents alone has been described but there are few reports of its clinical application. We here report our experiences from three cases of vertebrobasilar dissection and pseudo-aneurysm or subarachnoid hemorrhage treated with stents alone.
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Affiliation(s)
- V Helyar
- Department of Neuroradiology, Karolinska University Hospital; Stockholm, Sweden -
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12
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Holmin S, Ozanne A, Zhao WY, Alvarez H, Krings T, Lasjaunias P. Association of cervical internal carotid artery aneurysm with ipsilateral vertebrobasilar aneurysm in two children: a segmental entity? Childs Nerv Syst 2007; 23:791-8. [PMID: 17384955 DOI: 10.1007/s00381-006-0294-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Indexed: 11/25/2022]
Abstract
INTRODUCTION A combination of cervical and intradural aneurysm in children in the absence of systemic disorders has previously not been reported. CASE REPORT We report two boys with an identical combination of fusiform cervical internal carotid aneurysm and ipsilaterally located vertebrobasilar aneurysm. They had no history of trauma, they did not display any personal or familial signs of systemic disease, and the testing for collagen disease was negative. The location and appearance of the aneurysms and the identical anatomical disposition in the patients indicated a non-randomly distributed segmental vulnerability. CONCLUSION The cases demonstrate primary morphological signs of a developmental error being expressed in two seemingly separate segments but linked by the hypoglossal artery. It suggests a segmental error related to this embryonic vessel. They also show that few phenotypes are specific for a genotypic disorder and highlight the importance of analysing different etiologies for aneurysm formation and anatomical disposition when taking treatment strategy decisions.
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Affiliation(s)
- S Holmin
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital de Bicêtre, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France
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13
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Zhao WY, Krings T, Alvarez H, Ozanne A, Holmin S, Lasjaunias P. Management of spontaneous haemorrhagic intracranial vertebrobasilar dissection: review of 21 consecutive cases. Acta Neurochir (Wien) 2007; 149:585-96; discussion 596. [PMID: 17514349 DOI: 10.1007/s00701-007-1161-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [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: 10/26/2006] [Accepted: 04/11/2007] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Haemorrhagic intracranial vertebrobasilar dissection is an uncommon cause of nontraumatic subarachnoid haemorrhage (SAH) and accounts for only 1-10% of non-traumatic SAH. Treatment in the acute phase is considered to be essential because of the high risk of rebleeding and the consequent unfavourable outcome. However, the location, the potential for involvement of eloquent vessels and the histopathological characteristics of the vessel wall make treatment demanding from both a technical and anatomical point of view. We report our experience in the management of this disease. PATIENTS AND TREATMENTS: From 1989 to June 2006, we managed 21 patients with spontaneous haemorrhagic dissection located in the intracranial vertebrobasilar system, 13 patients were treated using an endovascular approach, 1 by surgical clipping, and 7 were managed conservatively. RESULTS Among the 13 patients treated endovascularly, 7 underwent proximal occlusion, 4 underwent parent artery embolization at the site of dissection, and 2 underwent endovascular trapping. Severe, treatment-related complications due to dislodgement of the thrombus during the procedure occurred in 1 patient, who then died from brainstem ischaemia. One patient died from severe pneumonia and one patient was left disabled from vasospastic ischaemia resulting from severe initial SAH. The remaining 10 patients had satisfactory outcomes: none rebled after treatment and when discharged they had Karnovsky scores of 80-100. Of the 7 conservatively treated patients, three died of rebleeding and four were discharged with Karnovsky scores of 50-100. One patient, who was treated surgically, was discharged with a Karnovsky of 90. CONCLUSION The high rate of rebleeding and consequent mortality among the patients treated conservatively argues for treatment in the acute phase. Treatment should be guided by each patient's angiomorphology, clinical condition and the experience of the neurosurgical/neuroradiological team. Options include endovascular or surgical trapping of the dissection and proximal occlusion and embolisation of the parent artery at the site of the dissection.
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MESH Headings
- Acute Disease
- Aortic Dissection/diagnosis
- Aortic Dissection/mortality
- Aortic Dissection/therapy
- Aneurysm, Ruptured/diagnosis
- Aneurysm, Ruptured/diagnostic imaging
- Aneurysm, Ruptured/mortality
- Aneurysm, Ruptured/therapy
- Angiography, Digital Subtraction
- Cause of Death
- Cerebellum/blood supply
- Cerebral Angiography
- Cooperative Behavior
- Embolization, Therapeutic
- Glasgow Coma Scale
- Humans
- Image Processing, Computer-Assisted
- Imaging, Three-Dimensional
- Intracranial Aneurysm/diagnosis
- Intracranial Aneurysm/mortality
- Intracranial Aneurysm/therapy
- Karnofsky Performance Status
- Magnetic Resonance Imaging
- Neurologic Examination
- Outcome and Process Assessment, Health Care
- Patient Care Team
- Recurrence
- Retrospective Studies
- Subarachnoid Hemorrhage/diagnosis
- Subarachnoid Hemorrhage/mortality
- Subarachnoid Hemorrhage/therapy
- Surgical Instruments
- Survival Rate
- Tomography, X-Ray Computed
- Vertebral Artery Dissection/diagnosis
- Vertebral Artery Dissection/mortality
- Vertebral Artery Dissection/therapy
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Affiliation(s)
- W Y Zhao
- Neuroradiologie Vasculaire Diagnostique et Thérapeutique, Hôpital Bicêtre, Le Kremlin Bicêtre, France.
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Ozanne A, Wen YZ, Krings T, Alvarez H, Holmin S, Toulgoat F, Lasjaunias P. Dissections hémorragiques vertébrobasilaires spontanées: une revue de 21 cas consécutifs. J Neuroradiol 2007. [DOI: 10.1016/j.neurad.2007.01.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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15
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Ozanne A, Holmin S, Wy Z, Alvarez H, Krings T, Toulgoat F, Lasjaunias PL. Association d'un anévrisme de la carotide interne cervicale avec un anévrisme vertébrobasilaire ipsilatéral chez l'enfant: une vulnérabilité segmentaire? À propos de deux cas. J Neuroradiol 2007. [DOI: 10.1016/j.neurad.2007.01.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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16
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Fok KF, Holmin S, Alvarez H, Ozanne A, Krings T, Lasjaunias PL. Spontaneous intracerebral hemorrhage caused by an unusual association of developmental venous anomaly and arteriovenous malformation. Interv Neuroradiol 2006; 12:113-21. [PMID: 20569563 DOI: 10.1177/159101990601200205] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 05/15/2006] [Indexed: 11/16/2022] Open
Abstract
SUMMARY We describe three patients who presented with spontaneous intracerebral hemorrhage resulting from the close association of developmental venous anomaly (DVA) and arteriovenous malformation (AVM). Angioarchitecturally, either the DVA formed the draining pathway for the AVM or they shared a common venous channel. The AVMs were treated by targeted embolization and the DVAs were carefully preserved. It is suggested that the unusual association of an AVM with the less flexible DVA was the cause of hemorrhage.
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Affiliation(s)
- K F Fok
- From the Service de Neuroradiologie Diagnostique et Thérapeutique, CHU Le Kremlin Bicêtre, Paris, France - pierre.lasjauniasct.ap-hop-paris.fr
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17
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Zhao WY, Krings T, Alvarez H, Ozanne A, Holmin S, Lasjaunias PL. Spontaneous mirror dissections of cervicocephalic arteries. Pathomechanical considerations. Interv Neuroradiol 2006; 12:73-8. [PMID: 20569557 DOI: 10.1177/159101990601200115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Accepted: 02/15/2006] [Indexed: 11/16/2022] Open
Abstract
SUMMARY While so-called twin or mirror aneurysms constitute an established subgroup of multiple aneurysms, simultaneous spontaneous mirror dissections of cervicocephalic artery have not yet been reported as a particular entity. Among the patients treated at our institution since 1989, we identified 74 patients with spontaneous, nontraumatic dissections. Six of these cases presented with simultaneous bilateral dissections and four of the six patients had mirror dissections. Acute or chronic headache was present in all four cases. Additional clinical presentations consisted of impaired consciousness, cranial nerve palsy, and tinnitus. Angiography revealed irregular stenosis, dilatation or aneurysms located in the cervical ICA (internal carotid artery), VA (vertebral artery), or MCA (middle cerebral artery) without evident location bias. Although mirror dissections seems to be an exceptional finding, they may shed light on the vulnerability of different arterial segments to specific diseases. Similar to arterial aneurysm formation, pathogenesis of mirror dissection may involve an underlying "shared defect" in the endothelial cells, since these cells demonstrate a bilateral distribution during embryological development. This particular distribution therefore also provides a chronicle trail of the first trigger striking during embryonic development and demonstrates the segmental vulnerability to highly specific triggers.
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Affiliation(s)
- W Y Zhao
- Hôpital de Bicêtre, Neuroradiologie Vasculaire Diagnostique et Thérapeutique; Le Kremlin Bicêtre, France -
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18
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Rudehill S, Muhallab S, Wennersten A, von Gertten C, Al Nimer F, Sandberg-Nordqvist AC, Holmin S, Mathiesen T. Autoreactive antibodies against neurons and basal lamina found in serum following experimental brain contusion in rats. Acta Neurochir (Wien) 2006; 148:199-205; discussion 205. [PMID: 16362182 DOI: 10.1007/s00701-005-0673-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2004] [Accepted: 09/22/2005] [Indexed: 12/28/2022]
Abstract
BACKGROUND Brain trauma is a risk factor for delayed CNS degeneration which may be attenuated by anti-inflammatory treatment. CNS injuries may cause anti-brain reactivity. This study was undertaken to analyze the pattern of delayed post-traumatic anti-brain immunity in experimental brain contusion. METHOD Adult Sprague-Dawley and Lewis rats were subjected to experimental brain contusions. For B-cell investigations, serum was obtained from contused, control and naïve rats, and used for immunohistochemistry on slices of rat brains to first detect autoreactive IgG and IgM antibodies in rat serum. Secondly, anti-rat IgG and IgM antibodies were used to search for auto-antibodies already bound to the brain tissue. Double staining with rat-serum and NeuN or anti-GFAP antibody was used to detect anti-neuronal and anti-astrocytic antibodies, respectively. For T-cell reactivity, cells from brains and cervical lymph nodes of rats were used in FACS analysis and elispot with MBP and MOG stimulation. FINDINGS Anti-vascular basal lamina IgG antibodies were detected at three months in 6/8 rats, following experimental contusion. Anti-neuronal IgG antibodies were detected 2 weeks after experimental contusion and sham surgery, while naïve controls were negative. Individual rats showed a prolonged response, or an anti-astrocytic staining. Tissue bound anti-self IgG or IgM was not detected in the brain tissue. Anti-MBP or anti-MOG T-cell responses were not detectable. CONCLUSIONS Experimental brain trauma and to some degree even sham surgery lead to an individually variable pattern of specific anti-brain reactive B-cells, while a T-cell response did not seem to be a consequence of moderate experimental contusion. The mere presence of anti brain-antibodies may be epiphenomenal, but could also be pathogenic for delayed degeneration. It is reasonable to regard the presence of an actual anti-brain reactivity as a potential threat to brain tissue integrity.
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Affiliation(s)
- S Rudehill
- Department of Clinical Neuroscience, Section of Neurosurgery, Karolinska Institute, Stockholm, Sweden
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Gahm C, Holmin S, Rudehill S, Mathiesen T. Neuronal degeneration and iNOS expression in experimental brain contusion following treatment with colchicine, dexamethasone, tirilazad mesylate and nimodipine. Acta Neurochir (Wien) 2005; 147:1071-84; discussion 1084. [PMID: 16044358 DOI: 10.1007/s00701-005-0590-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2004] [Accepted: 06/08/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The pathophysiological mechanisms of secondary neurological injury after traumatic brain injury are complex. Post-traumatic biochemical reactions include parenchymal inflammation, free radical production, increased intracellular calcium and lipid peroxidation and nitric oxide production. The relative importance of each mechanism is unknown in brain contusions. This study was undertaken to investigate protection by the neuroprotective and/or anti-inflammatory drugs that have different putative mechanisms of action: colchicine, dexamethasone, tirilazad mesylate and nimodipine. METHOD A brain contusion was produced using a weight-drop model in rats. The animals were treated with either one of the drugs at previously defined relevant dosage or control. Fluoro-Jade labelling, TUNEL-staining and immunohisto-chemistry were used to study neuronal degeneration, cellular apoptosis and iNOS expression. In addition, the number of surviving neurons after 14 days was determined. FINDINGS The number of degenerating neurons was significantly reduced in all treatment groups at 24 hours while the total number of apoptotic cells including inflammatory cells and glia was unchanged. iNOS-expression was reduced in all treatment groups at 24 hours but not later. Only colchicine and tirilazad mesylate significantly enhanced neuronal survival at 14 days after injury. CONCLUSIONS The findings underscored that an early neuroprotective effect does not necessarily lead to increased long-term neuronal survival. The absence of a significant long-term effect with nimodipine and dexamethasone agrees with clinical studies. Colchicine with an anti-macrophage/anti-inflammatory activity and the free radical scavenger tirilazad mesylate were effective for amelioration of experimental contusion with moderate energy transfer. Early neuroprotection may to some extent target iNOS via different pathways since all tested drugs affected both iNOS expression and neuronal degeneration.
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Affiliation(s)
- C Gahm
- Department of Clinical Neuroscience, Section of Neurosurgery, Karolinska Institute, Stockholm, Sweden.
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21
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Holmin S, Mathiesen T, Langmoen IA, Sandberg Nordqvist AC. Depolarization induces insulin-like growth factor binding protein-2 expression in vivo via NMDA receptor stimulation. Growth Horm IGF Res 2001; 11:399-406. [PMID: 11914028 DOI: 10.1054/ghir.2001.0252] [Citation(s) in RCA: 7] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The effect of depolarization and N-methyl-D-aspartate (NMDA) receptor blockade on insulin-like growth factor-I (IGF-I), IGF binding protein-2 (IGFBP-2) and IGFBP-4 expression was analysed in vivo. Depolarization was induced in adult rat brains by applying 3 M KCl to the exposed cortex for 10 min. A subgroup of animals also received daily injections of MK-801. Four days after KCl exposure, the brains were analysed by in situ hybridization, immunohistochemistry and TUNEL. A significant upregulation of IGFBP-2 mRNA and protein was detected in astrocytes after KCl exposure This upregulation was reduced by MK-801 treatment. No alterations in IGF-I or IGFBP-4 mRNA levels were noted. We did not detect TUNEL positive cells, morphological signs of necrosis or apoptosis, or neuronal loss in the depolarized zone. Taken together, these findings indicate that upregulation of IGFBP-2 by depolarization is mediated by NMDA receptors, and, as no neuronal damage was detected, astrocytic NMDA receptors may be responsible for this upregulation.
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Affiliation(s)
- S Holmin
- Department of Clinical Neuroscience, Section of Neurosurgery, Karolinska Institutet, S-171 76 Stockholm, Sweden.
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22
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Abstract
Nestin is expressed in central nervous system (CNS) progenitor cells and its expression in mature cells represents transition to a less differentiated cellular state under cellular stress. This study was performed to corroborate the hypothesis that nestin synthesis is induced by depolarization and dependent on N-methyl-D-aspartate (NMDA)-receptor activation. Depolarization was induced with application of potassium chloride on the exposed rat cortex and nestin expression was evaluated by immunohistochemistry. Depolarization induced astrocytic nestin expression that was local, or evident in the entire ipsilateral cortex depending on the time of exposure. Nestin expression was NMDA-receptor-dependent since MK-801 treatment abolished the response. Understanding the mechanisms for nestin expression is important since this protein is expressed in reactive and less differentiated CNS cell states and also in neural stem cells. Insights into the control of nestin expression may also provide means for controlling differentiation of CNS cells either post-trauma/ischemia or in transplantation strategies.
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Affiliation(s)
- S Holmin
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institute, Stockholm, Sweden.
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Gahm C, Holmin S, Mathiesen T. Temporal profiles and cellular sources of three nitric oxide synthase isoforms in the brain after experimental contusion. Neurosurgery 2000; 46:169-77. [PMID: 10626947] [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: 02/15/2023] Open
Abstract
OBJECTIVE Nitric oxide (NO) is a universal mediator of biological effects in the brain. It has been implicated in the pathophysiological processes of traumatic brain injury. Understanding its pathophysiological role in vivo requires an understanding of the cellular sources and tissue compartments of the differentially regulated NO synthase (NOS) isoforms. This study was undertaken to investigate the cellular sources and tissue compartments of NO produced after experimental brain contusions in rats, by analysis of the early expression of the three isoforms of NOS, i.e., the inducible, endothelial, and neuronal isoforms. METHODS Focal brain contusions were produced in 24 rats using a weight-drop model. The animals were killed 6, 12, 24, 36, or 48 hours after trauma. Sections were analyzed by immunohistochemical and immunofluorescence analyses. Double staining assays were used to define which cells produced the different NOS isoforms. RESULTS Increases in endothelial NOS-, inducible NOS (iNOS)-, and neuronal NOS-positive cells were detectable by 6 hours after trauma. Endothelial NOS and iNOS levels peaked at 6 and 12 hours, respectively. Expression of neuronal NOS initially increased to a peak at 12 hours but then decreased to a level lower than that in control samples at 36 hours. Endothelial NOS was expressed exclusively in endothelial cells, whereas iNOS was expressed in neutrophils and macrophages. Neuronal NOS was predominantly detected in neurons but was also unexpectedly detected in polymorphonuclear cells. CONCLUSION In this model, the most striking finding regarding NO-producing enzymes was the expression of iNOS in polymorphonuclear cells and macrophages, cells that invade injured brain tissue. iNOS is thus implicated as a therapeutic target in contusional injuries. This pattern of NOS expression cannot be generalized to all types of brain injuries. The different compartments and cells that can produce NO are differentially regulated; therefore, compartmentalization can explain why NO is beneficial or detrimental, depending on the circumstances. A knowledge of different potential sites and sources of NO is required for any attempts to interfere with the pathophysiological properties of NO.
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Affiliation(s)
- C Gahm
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Abstract
OBJECT The proinflammatory cytokines interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNFalpha) are produced intracerebrally in brain disorders such as trauma, ischemia, meningitis, and multiple sclerosis. This investigation was undertaken to analyze the effect of intracerebral administration of IL-1beta and TNFalpha on inflammatory response, cell death, and edema development. METHODS Intracerebral microinjections of these cytokines were administered to rats. The animals were killed 24 or 72 hours after the injections, and their brains were analyzed by using deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL) with digoxigenin-labeled deoxyuridine triphosphate, immunohistochemical studies, and brain-specific gravity measurement. The IL-1beta induced a transient inflammatory response (p < 0.001) and TUNEL staining (p < 0.001), indicating cell death, in intrinsic central nervous system (CNS) cells and infiltrating inflammatory cells. In 73.8+/-6.77% of the TUNEL-positive cells, small, fragmented nuclei were found. All TUNEL-positive cells expressed the proapoptotic gene Bax, and 69.6+/-4.6% of the TUNEL-positive cells expressed the antiapoptotic gene Bcl-2; the Bax expression was stronger than the Bcl-2 expression. Taken together, the data indicate that cell death occurred via the apoptotic pathway. The TNFalpha did not induce inflammation or DNA fragmentation within the analyzed time period. Both IL-1beta (p < 0.001) and TNFalpha (p < 0.01) caused vasogenic edema, as measured by specific gravity and albumin staining. The edematous effect of TNFalpha persisted 72 hours after injection (p < 0.01), whereas the IL-1beta-treated animals had normalized by that time. CONCLUSIONS Intracerebral inflammation, death of intrinsic CNS cells, and vasogenic edema can be mediated by IL-1beta, and TNFalpha can cause vasogenic edema. Suppression of these cytokines in the clinical setting may improve outcome.
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Affiliation(s)
- S Holmin
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
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Hedeland M, Holmin S, Nygård M, Pettersson C. Chromatographic evaluation of structure selective and enantioselective retention of amines and acids on cellobiohydrolase I wild type and its mutant D214N. J Chromatogr A 1999; 864:1-16. [PMID: 10630866 DOI: 10.1016/s0021-9673(99)00968-1] [Citation(s) in RCA: 12] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The mechanisms of structure selective and enantioselective retentions of amines and acids on two chiral stationary phases based on wild type cellobiohydrolase I (CBH I) and its mutant D214N have been investigated. All the amino alcohols tested had an enantioselective site that overlaps with the catalytically active site of CBH I, whereas the enantioselectivity of prilocaine was not affected by the mutation. The hydroxyl group of the amino alcohols did not seem to be an important contributor to the total binding strength whereas a bromo substituent in the aromatic ring promotes a high enantioselectivity (alpha=7.05). Interestingly, the chiral recognition site of the acid warfarin overlaps with the binding site of the amino alcohols. Di-p-toluoyltartaric acid and dibenzoyltartaric acid were strongly retained probably due to electrostatic attraction, but no enantioselectivity was observed. The difference in retention characteristics for the amino alcohols on the two stationary phases was strongly pH-dependent. A change in elution order of different amino alcohols occurred when changing the pH from 5.0 to 7.0. The difference between the two phases was lower at low pH. The retention times could also be affected by ionic strength and by use of cellobiose as a mobile phase additive but no indication of ion-pair retention of the amines was observed, when adding hexanesulphonate as counter ion to the mobile phase. The temperature dependence of the retention of the enantiomers of propranolol at pH 7.0 on the mutant D214N was similar to what was earlier observed on the wild type CBH I at lower pH.
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Affiliation(s)
- M Hedeland
- Department of Pharmaceutical Chemistry, Analytical Pharmaceutical Chemnistry, Uppsala University, Biomedical Centre, Sweden
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Abstract
Head injury is a risk factor for development of the sporadic form of Alzheimer's disease (AD) and chronic anti-inflammatory treatment reduces the prevalence of AD. This study was undertaken to test the hypothesis that inflammatory reactions persist in the long term. Rats were subjected to moderate focal brain injury. The brains were analyzed after 3 months by immunohistochemistry. Persistent major histocompatibility complex (MHC)-II up-regulation, mononuclear phagocytes, interleukin (IL)-1-beta and tumor necrosis factor (TNF)-alpha synthesis (p < 0.01) were detected in large areas of the ipsilateral hemisphere. The fact that a long-term inflammation is detectable following experimental brain injury corroborates the hypothesis that persistent post-traumatic inflammation is a possible factor in the causative chain of traumatically induced dementia.
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Affiliation(s)
- S Holmin
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Abstract
OBJECTIVE This study was undertaken to analyze the inflammatory components in contused human brain tissue to compare the findings with previous experimental data regarding the pathogenesis of brain contusions. METHODS Contused brain tissue biopsies were obtained from 12 consecutive patients undergoing surgery for brain contusions 3 hours to 5 days after trauma. Inflammatory and immunological components were analyzed by immunohistochemistry. RESULTS In patients undergoing surgery less than 24 hours after trauma, the inflammatory response was limited to vascular margination of polymorphonuclear cells. In patients undergoing surgery 3 to 5 days after trauma, however, a massive inflammatory response consisting of monocytes/macrophages, reactive microglia, polymorphonuclear cells, and CD4- and CD8-positive T lymphocytes was detected. Human lymphocyte antigen-DQ was expressed on reactive microglia and infiltrating leukocytes in the late patient group. In addition, CD1a, which is a marker for antigen-presenting dendritic cells, was detected in a subgroup of microglial cells. CONCLUSION The results corroborated hypotheses derived from experimental data. In the early phase after contusional trauma, inflammation is mainly intravascular and dominated by polymorphonuclear cells. The inflammation was parenchymal in patients undergoing surgery 3 to 5 days after trauma. The brain swelling seemed to be biphasic, the delayed phase correlating with a parenchymal inflammation. The inflammatory cells may produce several potentially harmful effects, such as acute cellular degeneration; they may also lead to degenerative long-term effects.
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Affiliation(s)
- S Holmin
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Holmin S, Schalling M, Höjeberg B, Nordqvist AC, Skeftruna AK, Mathiesen T. Delayed cytokine expression in rat brain following experimental contusion. J Neurosurg 1997; 86:493-504. [PMID: 9046307 DOI: 10.3171/jns.1997.86.3.0493] [Citation(s) in RCA: 139] [Impact Index Per Article: 5.1] [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: 02/03/2023]
Abstract
Proinflammatory cytokines mediate brain injury in experimental studies. This study was undertaken to analyze the production of proinflammatory cytokines in experimental contusion. A brain contusion causing delayed edema was mimicked experimentally in rats using a weight-drop model. Intracerebral expression of the cytokines interleukin (IL)-1 beta, tumor necrosis factor-alpha (TNF alpha), IL-6, and interferon-gamma (IFN gamma) was studied by in situ hybridization and immunohistochemistry. The animals were killed at 6 hours or 1, 2, 4, 6, 8, or 16 days postinjury. In the injured area, no messenger (m)RNA expression was seen during the first 2 days after the trauma. On Days 4 to 6 posttrauma, however, strong IL-1 beta, TNF alpha, and IL-6 mRNA expression was detected in mononuclear cells surrounding the contusion. Expression of IFN gamma was not detected. Immunohistochemical double labeling confirmed the in situ hybridization results and demonstrated that mononuclear phagocytes and astrocytes produced IL-1 beta and that mainly astrocytes produced TNF alpha. The findings showed, somewhat unexpectedly, a late peak of intracerebral cytokine production in the injured area and in the contralateral corpus callosum, allowing for both local and global effects on the brain. An unexpected difference in the cellular sources of TNF alpha and IL-1 beta was detected. The cytokine pattern differs from that seen in other central nervous system inflammatory diseases and trauma models, suggesting that the intracerebral immune response is not a uniform event. The dominance of late cytokine production indicates that many cytokine effects are late events in an experimental contusion: Different pathogenic mechanisms may thus be operative at different times after brain injury.
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Affiliation(s)
- S Holmin
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Nordqvist AC, Holmin S, Nilsson M, Mathiesen T, Schalling M. MK-801 inhibits the cortical increase in IGF-1, IGFBP-2 and IGFBP-4 expression following trauma. Neuroreport 1997; 8:455-60. [PMID: 9080428 DOI: 10.1097/00001756-199701200-00016] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cerebral contusions increase cortical expression of insulin-like growth factor 1 (IGF-1), IGF binding protein-2 (IGFBP-2) and IGFBP-4, mRNA levels increase at the contusion site (IGF-1, IGFBP-2 and -4) and along the ipsilateral cortex (IGFBP-2 and -4). Here we explore whether this upregulation is glutamate dependent. Rats were treated with the non-competitive N-methyl-D-aspartate (NMDA) antagonist MK-801 or the non-NMDA antagonist CNQX before and after trauma, and analysed using quantitative in situ hybridization. The induction of IGF-1 expression was completely blocked by MK-801 or CNQX. IGFBP-2 mRNA levels remained high at the contusion site in the presence of either drug, but the increase was blocked in the cortex temporal to the impact by MK-801. The increase in IGFBP-4 mRNA was blocked by MK-801 but not by CNQX.
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Affiliation(s)
- A C Nordqvist
- Department of Molecular Medicine, Karolinska Hospital, Stockholm, Sweden
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Abstract
The adult brain contains a small population of central nervous system (CNS) cells in the subependyma which, like embryonic CNS progenitor cells, express the intermediate filament nestin. In this report, the differentiation capacity in vivo of these cells was analysed following a standardized trauma. Before the trauma, the subependymal cells expressed nestin but not the astrocytic and neuronal differentiation markers glial fibrillary acidic protein (GFAP) and neurofilament respectively. In response to injury, the majority of the subependymal cells coexpressed nestin and GFAP, but never nestin and neurofilament. Furthermore, cells coexpressing nestin and GFAP were found progressively further away from the subependyma and closer to the lesion at later time points after the injury, indicating that these cells migrate towards the lesion. Nestin was in addition re-expressed in reactive astrocytes near the lesion and in non-reactive astrocytes very far from the lesion throughout the ipsilateral cortex. In conclusion, our data indicate that the nestin-positive subependymal cells are an in vivo source for the generation of new astrocytes but not neurons after injury, and that nestin re-expression in astrocytes following traumatic stimuli can be used as a sensitive marker for astroglial activation.
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Affiliation(s)
- S Holmin
- Department of Clinical Neuroscience, Medical Nobel Institute, Karolinska Institute, Stockholm, Sweden
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Sandberg Nordqvist AC, von Holst H, Holmin S, Sara VR, Bellander BM, Schalling M. Increase of insulin-like growth factor (IGF)-1, IGF binding protein-2 and -4 mRNAs following cerebral contusion. Brain Res Mol Brain Res 1996; 38:285-93. [PMID: 8793117 DOI: 10.1016/0169-328x(95)00346-t] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The insulin-like growth factor (IGF) system has a role in repair following hypoxic-ischemic injury in many tissues including the brain. To study the involvement of the IGF system following head trauma, we used a rat contusion model, which produces a focal lesion of the cerebral cortex. Molecules in the IGF system were analyzed using in situ hybridization at different times following impact. We observed a dramatic up-regulation of insulin-like growth factor binding protein-2 (IGFBP-2) mRNA in cortical areas adjacent to the injury 24 h after impact, with a peak 10-fold increase engaging most of the ipsilateral cortex 2 and 3 days post-contusion. Seven days after the contusion, IGFBP-2 expression was only moderately up-regulated and again concentrated around the injury. IGFBP-4 mRNA levels increased 4-fold ipsilateral to the site of injury, with retained pattern of cortical expression. IGFBP-3, IGFBP-5 and IGFBP-6 mRNA all displayed distinct expression patterns in the brain but no significant changes were observed following injury. In contrast, IGF-1 mRNA levels were very low prior to contusion, but increased markedly at the site of injury with a peak at day 3. We were unable to detect any changes in the type 1 IGF-receptor or IGF-2 mRNA following contusion. The neuropeptide cholecystokinin (CCK) mRNA was clearly up-regulated following contusion, with an even distribution over the ipsilateral cortex. The expression pattern of molecules in the IGF system post-contusion differs in part to changes observed following hypoxic-ischemia or ischemia alone, perhaps reflecting different regulatory mechanisms depending on the type of injury.
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Abstract
The effect of anti-inflammatory treatment on monocyte/macrophage infiltration, major histocompatibility complex molecules (MHC) class II expression and delayed oedema following experimental brain contusion was studied by immunohistochemistry and tissue-specific gravity measurement in 44 rats. Colchicine, chloroquine and dexamethasone administered once daily for five days after the trauma reduced inflammation and oedema. The difference was statistically significant with colchicine and dexamethasone. The findings comprise further evidence of a pathogenetically important inflammation after experimental contusion. It is probable that anti-inflammatory agents may prevent secondary neurological damage due to elevated intracranial pressure and cell to cell- or cytokine-mediated neuronal degeneration and demyelination.
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Affiliation(s)
- S Holmin
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Abstract
The time course of edema development following experimental brain contusion was studied by measuring cortex specific gravity 1 and 12 h after the trauma, and thereafter once daily until 7 days after the trauma. A biphasic development of edema was observed; the specific gravity decreased to a minimum on day 2 (P < 0.001), increased to an almost normal level on day 4 and thereafter decreased again to a second minimum 6 days after the trauma (P < 0.01). Delayed edema formation has been recognized in clinical settings, but has not been described in experimental studies. This study, with a prolonged daily follow-up, clearly demonstrates that a secondary phase of edema is an experimentally reproducible entity. The model will enable study of the pathogenetic mechanisms.
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Affiliation(s)
- S Holmin
- Department of Neurosurgery, Karolinska Institute, Stockholm, Sweden
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Abstract
The inflammatory reaction following experimental brain contusion was studied by immunohistochemistry in 22 rats during the first 16 days after trauma. An inflammatory mononuclear cell response was evident on day 2, with a maximum on days 5-6 and signs remained still 16 days after the trauma. The time course of the cellular infiltration adjacent to the lesion correlated with blood brain barrier dysfunction in the contralateral side of the traumatized hemisphere. The cellular infiltrate comprised NK cells, T-helper cells and T-cytotoxic/suppressor cells as well as monocytes/macrophages. Most of the macrophages appeared to be activated by T-cells. Surprisingly, polymorphonuclear cells appeared less engaged than mononuclear cells in the inflammation. The demonstration of immunocompetent cells and the induction of MHC-1 and MHC-II antigen provides a substrate for inflammatory reactions similar to those that cause neurological damage in inflammatory diseases such as viral infections, multiple sclerosis and experimental allergic encephalitis. Our observations indicate that the role of the inflammatory reactions may have a role, hitherto neglected, in the pathogenesis of secondary traumatic brain injury.
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Affiliation(s)
- S Holmin
- Department of Neurosurgery, Karolinska Hospital, Stockholm, Sweden
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