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Gouvea Bogossian E, Battaglini D, Fratino S, Minini A, Gianni G, Fiore M, Robba C, Taccone FS. The Role of Brain Tissue Oxygenation Monitoring in the Management of Subarachnoid Hemorrhage: A Scoping Review. Neurocrit Care 2023; 39:229-240. [PMID: 36802011 DOI: 10.1007/s12028-023-01680-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Abstract
Monitoring of brain tissue oxygenation (PbtO2) is an important component of multimodal monitoring in traumatic brain injury. Over recent years, use of PbtO2 monitoring has also increased in patients with poor-grade subarachnoid hemorrhage (SAH), particularly in those with delayed cerebral ischemia. The aim of this scoping review was to summarize the current state of the art regarding the use of this invasive neuromonitoring tool in patients with SAH. Our results showed that PbtO2 monitoring is a safe and reliable method to assess regional cerebral tissue oxygenation and that PbtO2 represents the oxygen available in the brain interstitial space for aerobic energy production (i.e., the product of cerebral blood flow and the arterio-venous oxygen tension difference). The PbtO2 probe should be placed in the area at risk of ischemia (i.e., in the vascular territory in which cerebral vasospasm is expected to occur). The most widely used PbtO2 threshold to define brain tissue hypoxia and initiate specific treatment is between 15 and 20 mm Hg. PbtO2 values can help identify the need for or the effects of various therapies, such as hyperventilation, hyperoxia, induced hypothermia, induced hypertension, red blood cell transfusion, osmotic therapy, and decompressive craniectomy. Finally, a low PbtO2 value is associated with a worse prognosis, and an increase of the PbtO2 value in response to treatment is a marker of good outcome.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Sara Fratino
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Giuseppina Gianni
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Fiore
- Department of Women, Child, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
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Sangeetha R, Ramesh V, Kamath S, Chakrabarti D, Christopher R, Aravinda H, Bhat D. Effect of remote ischemic preconditioning on cerebral oxygen saturation in aneurysmal subarachnoid hemorrhage: Secondary analysis of a randomized controlled trial. J Clin Neurosci 2022; 98:78-82. [DOI: 10.1016/j.jocn.2022.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/07/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022]
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Raper DMS, Abla AA. Commentary: The Importance of the Temporary Clip Removal Phase on Exposure to Hypoxia: On-Line Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms. Neurosurgery 2022; 90:e84-e85. [PMID: 35118997 DOI: 10.1227/neu.0000000000001870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Daniel M S Raper
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Silva PA, Dias C, Vilarinho A, Cerejo A, Vaz R. Effects of Temporary Clipping as an Expression of Circulatory Individuality: Online Measurement of Temporal Lobe Oxygen Levels During Surgery for Middle Cerebral Artery Aneurysms. World Neurosurg 2021; 152:e765-e775. [PMID: 34175487 DOI: 10.1016/j.wneu.2021.06.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Despite its widespread use, much is left to understand about the repercussions of parent artery temporary clipping in neurosurgery. This study seeks a better comprehension of the subject by aiming at the online measurement of brain tissue oxygen pressure (PbtO2) during such events. METHODS This was a prospective observational study. Patients submitted to surgery for middle cerebral artery aneurysms (both ruptured and unruptured) were continuously monitored under Intensive Care Monitoring+ software, in order to obtain temporal (downstream) PbtO2 levels while temporary clips were applied. Separate PbtO2 curve events were identified, extracted, and processed. These were studied for assessing intraindividual and interindividual variability and the potential impact of repeated clipping and previous aneurysmal rupture. RESULTS Eighty-six temporary clippings (from 20 patients) were recorded with a mean duration of 140.8 (41 - 238) seconds. Temporary arterial occlusion at the M1 segment of the middle cerebral artery produced specifically shaped trajectories, characterized by a preclipping PbtO2 level, rapid downward sigmoid-shaped curve, succession of progressively angled slopes, and lower plateau. The steepest slope of the curve correlated strongly with PbtO2 range (P < 0.001, r = 0.944). These features were highly reproducible only intraindividually and did not vary significantly with repeated clippings. CONCLUSIONS The effects of temporary arterial occlusion on temporal lobe oxygenation demonstrate a high degree of singularity, highlighting the potential benefits of assessing individual available collateral circulation intraoperatively. The "PbtO2 steepest slope" predicted the severity of PbtO2 decrease and was available within the first minute.
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Affiliation(s)
- Pedro Alberto Silva
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal; Department of Clinical Neurosciences, University of Porto, Porto, Portugal.
| | - Celeste Dias
- Department of Intensive Medicine, Academic Hospital Centre São João, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - António Vilarinho
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal; Department of Clinical Neurosciences, University of Porto, Porto, Portugal
| | - António Cerejo
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal; Department of Clinical Neurosciences, University of Porto, Porto, Portugal
| | - Rui Vaz
- Department of Neurosurgery, Academic Hospital Centre São João, Porto, Portugal; Department of Clinical Neurosciences, University of Porto, Porto, Portugal
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Sangeetha RP, Venkatapura RJ, Kamath S, Christopher R, Bhat DI, Arvinda HR, Chakrabarti D. Effect of remote ischemic preconditioning on cerebral vasospasm, biomarkers of cerebral ischemia, and functional outcomes in aneurysmal subarachnoid hemorrhage (ERVAS): A randomized controlled pilot trial. Brain Circ 2021; 7:104-110. [PMID: 34189353 PMCID: PMC8191538 DOI: 10.4103/bc.bc_13_21] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/07/2021] [Accepted: 04/15/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND: Cerebral vasospasm can complicate aneurysmal subarachnoid hemorrhage (aSAH), contributing to cerebral ischemia. We explored the role of remote ischemic preconditioning (RIPC) in reducing cerebral vasospasm and ischemia and improving outcomes after aSAH. MATERIALS AND METHODS: Patients with ruptured cerebral aneurysm undergoing surgical clipping and meeting the trial criteria were randomized to true RIPC (n = 13) (inflating upper extremity blood pressure cuff thrice to 30 mmHg above systolic pressure for 5 min) or sham RIPC (n = 12) (inflating blood pressure cuff thrice to 30 mmHg for 5 min) after ethical approval. A blinded observer assessed outcome measures-cerebral vasospasm and biomarkers of cerebral ischemia. We also evaluated the feasibility and safety of RIPC in aSAH and Glasgow Outcome Scale-Extended (GOSE). RESULTS: Angiographic vasospasm was seen in 9/13 (69%) patients; 1/4 patients (25%) in true RIPC group, and 8/9 patients (89%) in sham RIPC group (P = 0.05). Vasospasm on transcranial Doppler study was diagnosed in 5/25 (20%) patients and 1/13 patients (7.7%) in true RIPC and 4/12 patients (33.3%) in sham RIPC group, (P = 0.16). There was no difference in S100B and neuron-specific enolase (NSE) levels over various time-points within groups (P = 0.32 and 0.49 for S100B, P = 0.66 and 0.17 for NSE in true and sham groups, respectively) and between groups (P = 0.56 for S100B and P = 0.31 for NSE). Higher GOSE scores were observed with true RIPC (P = 0.009) unlike sham RIPC (P = 0.847) over 6-month follow-up with significant between group difference (P = 0.003). No side effects were seen with RIPC. CONCLUSIONS: RIPC is feasible and safe in patients with aSAH and results in a lower incidence of vasospasm and better functional outcome.
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Affiliation(s)
- R P Sangeetha
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Ramesh J Venkatapura
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Sriganesh Kamath
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Rita Christopher
- Department of Neurochemistry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | | | - H R Arvinda
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhritiman Chakrabarti
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Chelluboina B, Vemuganti R. Therapeutic potential of nutraceuticals to protect brain after stroke. Neurochem Int 2020; 142:104908. [PMID: 33220386 DOI: 10.1016/j.neuint.2020.104908] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023]
Abstract
Stroke leads to significant neuronal death and long-term neurological disability due to synergistic pathogenic mechanisms. Stroke induces a change in eating habits and in many cases, leads to undernutrition that aggravates the post-stroke pathology. Proper nutritional regimen remains a major strategy to control the modifiable risk factors for cardiovascular and cerebrovascular diseases including stroke. Studies indicate that nutraceuticals (isolated and concentrated form of high-potency natural bioactive substances present in dietary nutritional components) can act as prophylactic as well as adjuvant therapeutic agents to prevent stroke risk, to promote ischemic tolerance and to reduce post-stroke consequences. Nutraceuticals are also thought to regulate blood pressure, delay neurodegeneration and improve overall vascular health. Nutraceuticals potentially mediate these effects by their powerful antioxidant and anti-inflammatory properties. This review discusses the studies that have highlighted the translational potential of nutraceuticals as stroke therapies.
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Affiliation(s)
- Bharath Chelluboina
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Raghu Vemuganti
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA; William S. Middleton Veterans Administration Hospital, Madison, WI, USA.
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Sangeetha RP, Ramesh VJ, Kamath S, Christopher R, Bhat DI, Arvinda HR, Chakrabarti D. Effect of remote ischemic preconditioning on cerebral vasospasm and biomarkers of cerebral ischemia in aneurysmal subarachnoid hemorrhage (ERVAS): A protocol for a randomized, controlled pilot trial. Brain Circ 2019; 5:12-18. [PMID: 31001595 PMCID: PMC6458778 DOI: 10.4103/bc.bc_26_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/16/2018] [Accepted: 01/14/2019] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION: Cerebral vasospasm is a dreaded complication of aneurysmal subarachnoid hemorrhage (aSAH) predisposing to delayed cerebral ischemia. We intend to study the cerebroprotective effects of remote ischemic preconditioning (RIPC) in patients with aSAH. MATERIALS AND METHODS: This is a single-center, prospective, parallel group, randomized, pilot trial, approved by the Institutional Ethics Committee. Patients with aSAH admitted to our hospital for surgical clipping; fulfilling the trial inclusion criteria will be randomized to true RIPC (n = 12) (inflating upper extremity blood pressure cuff thrice for 5 min to 30 mmHg above systolic blood pressure) or sham RIPC (n = 12) (inflating blood pressure cuff thrice for 5 min to 30 mmHg) in 1:1 allocation ratio using a computerized random allocation sequence and block randomization. RESULTS: Our primary outcome measure is vasospasm on cerebral angiography and transcranial Doppler study, and concentration of serum S100B and neuron-specific enolase at 24 h after RIPC and on day 7 of ictus. Our secondary outcomes are safety of RIPC, cerebral oxygen saturation, and Glasgow coma score, and extended Glasgow outcome scale scores at discharge and at 1, 3, and 6 months following discharge. Outcome measures will be assessed by an observer blinded to the study intervention. CONCLUSION: If our preliminary results demonstrate a beneficial effect of RIPC, this would serve as a clinically applicable and safe preemptive method of protection against cerebral ischemia.
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Affiliation(s)
- R P Sangeetha
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - V J Ramesh
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Sriganesh Kamath
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Rita Christopher
- Department of Neurochemistry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - H R Arvinda
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhritiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Zhao JJ, Xiao H, Zhao WB, Zhang XP, Xiang Y, Ye ZJ, Mo MM, Peng XT, Wei L. Remote Ischemic Postconditioning for Ischemic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Chin Med J (Engl) 2018; 131:956-965. [PMID: 29664057 PMCID: PMC5912063 DOI: 10.4103/0366-6999.229892] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Remote ischemic postconditioning (RIPostC) appears to protect distant organs from ischemia-reperfusion injury (IRI). However, cerebral protection results have remained inconclusive. In the present study, a meta-analysis was performed to compare stroke patients with and without RIPostC. Methods: CNKI, WanFang, VIP, CBM, PubMed, and Cochrane Library databases were searched up to July 2016. Data were analyzed using both fixed-effects and random-effects models by Review Manager. For each outcome, risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI) were calculated. Results: A total of 13 randomized controlled trials that enrolled a total of 794 study participants who suffered from or are at risk for brain IRI were selected. Compared with controls, RIPostC significantly reduced the recurrence of stroke or transient ischemic attacks (RR = 0.37; 95% CI: 0.26–0.55; P < 0.00001). Moreover, it can reduce the levels of the National Institutes of Health Stroke Scale score (MD: 1.96; 95% CI: 2.18–1.75; P < 0.00001), modified Rankin Scale score (MD: 0.73; 95% CI: 1.20–0.25; P = 0.00300), and high-sensitivity C-reactive protein (MD: 4.17; 95% CI: 4.71–3.62; P < 0.00001) between the two groups. There was no side effect of RIPostC using tourniquet cuff around the limb on ischemic stroke treating based on different intervention duration. Conclusion: The present meta-analysis suggests that RIPostC might offer cerebral protection for stroke patients suffering from or are at risk of brain IRI.
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Affiliation(s)
- Jing-Jing Zhao
- Department of Nursing, Chongqing Medical and Pharmaceutical College, Chongqing 401331, China
| | - Hui Xiao
- Nursing Department, Guangdong Province Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Wen-Bo Zhao
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510632, China
| | - Xiao-Pei Zhang
- Department of Neurology, Guangdong Province Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Yu Xiang
- Department of Neurology, Huaihua Hospital of Traditional Chinese Medicine, Huaihua, Hunan 418000, China
| | - Zeng-Jie Ye
- Department of Economics and Management, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Miao-Miao Mo
- Department of Neurology, Guangdong Province Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Xue-Ting Peng
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Lin Wei
- Department of Neurology, Guangdong Province Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510120, China
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Soares RN, McLay KM, George MA, Murias JM. Differences in oxidative metabolism modulation induced by ischemia/reperfusion between trained and untrained individuals assessed by NIRS. Physiol Rep 2017; 5:5/19/e13384. [PMID: 29038351 PMCID: PMC5641926 DOI: 10.14814/phy2.13384] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/20/2017] [Indexed: 11/24/2022] Open
Abstract
Endurance training is associated with skeletal muscle adaptations that regulate the oxidative metabolism during ischemia/reperfusion. The aim of this study was to noninvasively assess in vivo differences in the oxidative metabolism activity during ischemia/reperfusion between trained and untrained individuals, using near infrared spectroscopy (NIRS) combined with a vascular occlusion test (VOT) technique (NIRS-VOT). Sixteen untrained (26.3 ± 5.1 year) and seventeen trained (29.4 ± 4.9 year) healthy young adult men were submitted to a VOT (2 min baseline, 5 min occlusion, and 8 min reperfusion). Oxygen utilization was estimated from the area under the curve of the NIRS-derived deoxyhemoglobin [HHb] signal during occlusion (AUCocc). Muscle reperfusion was derived from the area above the curve (AACrep) of the [HHb] signal after cuff release. The AUCocc of the untrained participants (21010 ± 9553 % · s) was significantly larger than the AUCocc of their trained counterparts (12320 ± 3283 % · s); P = 0.001). The AACrep of the untrained participants (5928 ± 3769 % · s) was significantly larger than the AACrep of the trained participants (3745 ± 1900 % · s; P = 0.042). There was a significant correlation between AUCocc and AACrep (r = 0.840; P = 0.001). NIRS assessment of oxidative metabolism showed that trained individuals are more efficient in shifting between oxidative and anaerobic metabolism in response to ischemia and reperfusion.
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Affiliation(s)
- Rogério N Soares
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Kaitlin M McLay
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Mitchell A George
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Juan M Murias
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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Sales AHA, Barz M, Bette S, Wiestler B, Ryang YM, Meyer B, Bretschneider M, Ringel F, Gempt J. Impact of ischemic preconditioning on surgical treatment of brain tumors: a single-center, randomized, double-blind, controlled trial. BMC Med 2017; 15:137. [PMID: 28738862 PMCID: PMC5525340 DOI: 10.1186/s12916-017-0898-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/22/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Postoperative ischemia is a frequent phenomenon in patients with brain tumors and is associated with postoperative neurological deficits and impaired overall survival. Particularly in the field of cardiac and vascular surgery, the application of a brief ischemic stimulus not only in the target organ but also in remote tissues can prevent subsequent ischemic damage. We hypothesized that remote ischemic preconditioning (rIPC) in patients with brain tumors undergoing elective surgical resection reduces the incidence of postoperative ischemic tissue damage and its consequences. METHODS Sixty patients were randomly assigned to two groups, with 1:1 allocation, stratified by tumor type (glioma or metastasis) and previous treatment with radiotherapy. rIPC was induced by inflating a blood pressure cuff placed on the upper arm three times for 5 min at 200 mmHg in the treatment group after induction of anesthesia. Between the cycles, the blood pressure cuff was released to allow reperfusion. In the control group no preconditioning was performed. Early postoperative magnetic resonance images (within 72 h after surgery) were evaluated by a neuroradiologist blinded to randomization for the presence of ischemia and its volume. RESULTS Fifty-eight of the 60 patients were assessed for occurrence of postoperative ischemia. Of these 58 patients, 44 had new postoperative ischemic lesions. The incidence of new postoperative ischemic lesions was significantly higher in the control group (27/31) than in the rIPC group (17/27) (p = 0.03). The median infarct volume was 0.36 cm3 (interquartile range (IR): 0.0-2.35) in the rIPC group compared with 1.30 cm3 (IR: 0.29-3.66) in the control group (p = 0.09). CONCLUSIONS Application of rIPC was associated with reduced incidence of postoperative ischemic tissue damage in patients undergoing elective brain tumor surgery. This is the first study indicating a benefit of rIPC in brain tumor surgery. TRIAL REGISTRATION German Clinical Trials Register, DRKS00010409 . Retrospectively registered on 13 October 2016.
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Affiliation(s)
- Arthur H A Sales
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Melanie Barz
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stefanie Bette
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Benedikt Wiestler
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Martin Bretschneider
- Department of Anesthesiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Florian Ringel
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Department of Neurosurgery, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
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Abstract
OPINION STATEMENT Preconditioning is the premise that controlled preemptive exposure to sub-lethal doses of a stressor and can condition an organism or organ to later withstand a lethal dose. This process relies on marshaling endogenous survival resources that have evolved as part of an organism's evolutionary struggle to overcome at times harsh environmental conditions. This preconditioning response occurs through activation of myriad complex mechanisms that run the gamut from alterations in gene expression to the de novo synthesis and post-translational modification of proteins, and it may occur across exposure to a wide variety of stressors (i.e., ischemia, hypoxia, hypothermia, drugs). This review will focus on preconditioning in relation to an ischemic stressor (ischemic preconditioning) and how this process may be harnessed as a protective method to ameliorate targeted acute neurologic diseases especially. There has been considerable eagerness to translate ischemic preconditioning to the bedside, and to that end there have been recent trials examining its efficacy in various clinical settings. However, some of these trials have reached diverging conclusions with a protective effect seen in studies targeting acute kidney injury solely while no benefit was seen in larger trials targeting combined endpoints including cardio-, neuro-, and renoprotection in a cohort of patients undergoing cardiac surgery. While an extensive body of pre-clinical research offers ischemic preconditioning as a robust and highly faithful protective phenomenon, its clinical utility remains unproven. This current state may be due to persisting gaps in our understanding of how best to harness its power. This review will provide an overview of the biological mechanisms proposed to underlie ischemic preconditioning, explore initial disease targets, examine the challenges we must overcome to optimally engage this system, and report findings of recent clinical trials.
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Affiliation(s)
- Maranatha Ayodele
- Department of Neurology, University of Miami, Miller School of Medicine, 1120 NW 14th Street, CRB 1353, Miami, FL, 33136, USA.
| | - Sebastian Koch
- Department of Neurology, University of Miami, Miller School of Medicine, 1120 NW 14th Street, CRB 1365, Miami, FL, 33136, USA
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12
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Can Intraoperative Neurological Preconditioning Occur After Intraoperative Hypotensive Episodes? J Neurosurg Anesthesiol 2017; 29:188-189. [DOI: 10.1097/ana.0000000000000278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Ischemic disorders, such as myocardial infarction, stroke, and peripheral vascular disease, are the most common causes of debilitating disease and death in westernized cultures. The extent of tissue injury relates directly to the extent of blood flow reduction and to the length of the ischemic period, which influence the levels to which cellular ATP and intracellular pH are reduced. By impairing ATPase-dependent ion transport, ischemia causes intracellular and mitochondrial calcium levels to increase (calcium overload). Cell volume regulatory mechanisms are also disrupted by the lack of ATP, which can induce lysis of organelle and plasma membranes. Reperfusion, although required to salvage oxygen-starved tissues, produces paradoxical tissue responses that fuel the production of reactive oxygen species (oxygen paradox), sequestration of proinflammatory immunocytes in ischemic tissues, endoplasmic reticulum stress, and development of postischemic capillary no-reflow, which amplify tissue injury. These pathologic events culminate in opening of mitochondrial permeability transition pores as a common end-effector of ischemia/reperfusion (I/R)-induced cell lysis and death. Emerging concepts include the influence of the intestinal microbiome, fetal programming, epigenetic changes, and microparticles in the pathogenesis of I/R. The overall goal of this review is to describe these and other mechanisms that contribute to I/R injury. Because so many different deleterious events participate in I/R, it is clear that therapeutic approaches will be effective only when multiple pathologic processes are targeted. In addition, the translational significance of I/R research will be enhanced by much wider use of animal models that incorporate the complicating effects of risk factors for cardiovascular disease. © 2017 American Physiological Society. Compr Physiol 7:113-170, 2017.
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Affiliation(s)
- Theodore Kalogeris
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Christopher P. Baines
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, Missouri, USA
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri, USA
- Department of Biomedical Sciences, University of Missouri College of Veterinary Medicine, Columbia, Missouri, USA
| | - Maike Krenz
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, Missouri, USA
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri, USA
| | - Ronald J. Korthuis
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, Missouri, USA
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri, USA
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14
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Tülü S, Mulino M, Pinggera D, Luger M, Würtinger P, Grams A, Bodner T, Beer R, Helbok R, Matteucci-Gothe R, Unterhofer C, Gizewski E, Schmutzhard E, Thomé C, Ortler M. Remote ischemic preconditioning in the prevention of ischemic brain damage during intracranial aneurysm treatment (RIPAT): study protocol for a randomized controlled trial. Trials 2015; 16:594. [PMID: 26714784 PMCID: PMC4696326 DOI: 10.1186/s13063-015-1102-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 12/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The treatment of intracranial aneurysms may be associated with cerebral ischemia. We hypothesize that pre-interventional remote ischemic preconditioning (RIPC) reduces ischemic cerebral tissue damage in patients undergoing elective intracranial aneurysm treatment. METHODS/DESIGN This study is a single-center, prospective, randomized, double-blind explorative trial. Patients with an unruptured intracranial aneurysm admitted to Innsbruck Medical University Hospital for coiling or clipping will be consecutively randomized to either the intervention group (= RIPC by inflating an upper extremity blood-pressure cuff for 3 x 5 min to 200 mmHg) or the control group after induction of anesthesia. Participants will be randomized 1:1 to either the preconditioning group or the sham group using a random allocation sequence and block randomization. The precalculated sample size is n = 24 per group. The primary endpoint is the area-under-the-curve concentration of serum biomarkers (S100B, NSE, GFAP, MMP9, MBP, and cellular microparticles) in the first five days after treatment. Secondary endpoints are the number and volume of new ischemic lesions in magnetic resonance imaging and clinical outcome evaluated with the National Institutes of Health Stroke Scale, the modified Rankin Scale, and neuropsychological tests at six and twelve months. All outcome variables will be determined by observers blinded to group allocation. This study was approved by the local institutional Ethics Committee (UN5164), version 3.0 of the study protocol, dated 20 October 2013. DISCUSSION This study uses the elective treatment of intracranial aneurysms as a paradigmatic situation to explore the neuroprotective effects of RIPC. If effects are demonstrable in this pilot trial, a larger, prospective phase III trial will be considered.
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Affiliation(s)
- Selma Tülü
- Department of Neurosurgery, Medical University of Innsbruck, 35, Anichstrasse, Innsbruck, 6020, Austria.
| | - Miriam Mulino
- Department of Neurosurgery, Medical University of Innsbruck, 35, Anichstrasse, Innsbruck, 6020, Austria.
| | - Daniel Pinggera
- Department of Neurosurgery, Medical University of Innsbruck, 35, Anichstrasse, Innsbruck, 6020, Austria.
| | - Markus Luger
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, 6020, Austria.
| | - Philipp Würtinger
- Central Institute for Medical and Chemical Laboratory Diagnostics, Medical University of Innsbruck, Innsbruck, 6020, Austria.
| | - Astrid Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, 6020, Austria.
| | - Thomas Bodner
- Department of Neurology, Medical University of Innsbruck, Innsbruck, 6020, Austria.
| | - Ronny Beer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, 6020, Austria.
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, 6020, Austria.
| | - Raffaella Matteucci-Gothe
- Department of Public Health and Health Technology Assessment, UMIT Health and Life Sciences University, Hall in Tirol, Austria.
| | - Claudia Unterhofer
- Department of Neurosurgery, Medical University of Innsbruck, 35, Anichstrasse, Innsbruck, 6020, Austria.
| | - Elke Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, 6020, Austria.
| | - Erich Schmutzhard
- Department of Neurology, Medical University of Innsbruck, Innsbruck, 6020, Austria.
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 35, Anichstrasse, Innsbruck, 6020, Austria.
| | - Martin Ortler
- Department of Neurosurgery, Medical University of Innsbruck, 35, Anichstrasse, Innsbruck, 6020, Austria.
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15
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Kim YW, Zipfel GJ, Ogilvy CS, Pricola KL, Welch BG, Shakir N, Patel B, Reavey-Cantwell JF, Kelman CR, Albuquerque FC, Kalani MYS, Hoh BL. Preconditioning effect on cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. Neurosurgery 2014; 74:351-8; discussion 358-9. [PMID: 24378827 DOI: 10.1227/neu.0000000000000282] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recent experimental evidence indicates that endogenous mechanisms against cerebral vasospasm can be induced via preconditioning. OBJECTIVE To determine whether these vascular protective mechanisms are also present in vivo in humans with aneurysmal subarachnoid hemorrhage. METHODS A multicenter retrospective cohort of patients with aneurysmal subarachnoid hemorrhage was examined for ischemic preconditioning stimulus: preexisting steno-occlusive cerebrovascular disease (CVD) and/or previous cerebral infarct. Generalized estimating equation models were performed to determine the effect of the preconditioning stimulus on the primary end points of radiographic vasospasm, symptomatic vasospasm, and vasospasm-related delayed cerebral infarction and the secondary end point of discharge modified Rankin Scale score. RESULTS Of 1043 patients, 321 (31%) had preexisting CVD and 437 (42%) had radiographic vasospasm. Patients with preexisting CVD were less likely to develop radiographic vasospasm (odds ratio = 0.67; 95% confidence interval = 0.489-0.930; P = .02) but had no differences in other end points. In terms of the secondary end point, patients with preexisting CVD did not differ significantly from patients without preexisting CVD in mortality or unfavorable outcome in multivariate analyses, although patients with preexisting CVD were marginally more likely to die (P = .06). CONCLUSION This retrospective case-control study suggests that endogenous protective mechanisms against cerebral vasospasm-a preconditioning effect-may exist in humans, although these results could be the effect of atherosclerosis or some combination of preconditioning and atherosclerosis. Additional studies investigating the potential of preconditioning in aneurysmal subarachnoid hemorrhage are warranted.
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Affiliation(s)
- Young Woo Kim
- *Department of Neurosurgery, Bucheon St. Mary's Hospital, Catholic University of Korea, Bucheon, Republic of Korea; ‡Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri; §Neurovascular Service, Massachusetts General Hospital, Boston, Massachusetts; ¶Department of Radiology, UT Southwestern Medical Center, Dallas, Texas; ‖Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia; #Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; **Department of Neurosurgery, University of Florida, Gainesville, Florida
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16
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Healy DA, Clarke Moloney M, McHugh SM, Grace PA, Walsh SR. Remote ischaemic preconditioning as a method for perioperative cardioprotection: Concepts, applications and future directions. Int J Surg 2014; 12:1093-9. [DOI: 10.1016/j.ijsu.2014.08.352] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 08/11/2014] [Indexed: 12/25/2022]
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17
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Abstract
Diverse preconditioning (PC) stimuli protect against a wide variety of neuronal insults in animal models, engendering enthusiasm that PC could be used to protect the brain clinically. Candidate clinical applications include cardiac and vascular surgery, after subarachnoid hemorrhage, and prior to conditions in which acute neuronal injury is anticipated. However, disappointments in clinical validation of multiple neuroprotectants suggest potential problems translating animal data into successful human therapies. Thus, despite strong promise of preclinical PC studies, caution should be maintained in translating these findings into clinical applications. The Stroke Therapy Academic Industry Roundtable (STAIR) working group and the National institute of Neurological Diseases and Stroke (NINDS) proposed working guidelines to improve the utility of preclinical studies that form the foundation of therapies for neurological disease. Here, we review the applicability of these consensus criteria to preconditioning studies and discuss additional considerations for PC studies. We propose that special attention should be paid to several areas, including 1) safety and dosage of PC treatments; 2) meticulously matching preclinical modeling to the human condition to be tested; and 3) timing of both the initiation and discontinuation of the PC stimulus relative to injury ictus.
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Affiliation(s)
- Michael M Wang
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA ; Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA ; Neurology Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan USA
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18
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McCafferty K, Byrne C, Yaqoob MM. Ischaemic conditioning strategies for the nephrologist: a promise lost in translation? Nephrol Dial Transplant 2014; 29:1827-40. [PMID: 24589718 DOI: 10.1093/ndt/gfu034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Over the last quarter of a century, a huge effort has been made to develop interventions that can minimise ischaemia reperfusion injury. The most potent of these are the ischaemic conditioning strategies, which comprise ischaemic preconditioning, remote ischaemic preconditioning and ischaemic postconditioning. While much of the focus for these interventions has been on protecting the myocardium, other organs including the kidney can be similarly protected. However, translation of these beneficial effects from animal models into routine clinical practice has been less straightforward than expected. In this review, we examine the role of ischaemic conditioning strategies in reducing tissue injury from the 'bench to the bedside' and discuss the barriers to their greater translation.
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Affiliation(s)
- Kieran McCafferty
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University London, London, UK
| | - Conor Byrne
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University London, London, UK
| | - Muhammad M Yaqoob
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University London, London, UK
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19
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Stetler RA, Leak RK, Gan Y, Li P, Zhang F, Hu X, Jing Z, Chen J, Zigmond MJ, Gao Y. Preconditioning provides neuroprotection in models of CNS disease: paradigms and clinical significance. Prog Neurobiol 2014; 114:58-83. [PMID: 24389580 PMCID: PMC3937258 DOI: 10.1016/j.pneurobio.2013.11.005] [Citation(s) in RCA: 146] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 11/18/2013] [Accepted: 11/18/2013] [Indexed: 12/14/2022]
Abstract
Preconditioning is a phenomenon in which brief episodes of a sublethal insult induce robust protection against subsequent lethal injuries. Preconditioning has been observed in multiple organisms and can occur in the brain as well as other tissues. Extensive animal studies suggest that the brain can be preconditioned to resist acute injuries, such as ischemic stroke, neonatal hypoxia/ischemia, surgical brain injury, trauma, and agents that are used in models of neurodegenerative diseases, such as Parkinson's disease and Alzheimer's disease. Effective preconditioning stimuli are numerous and diverse, ranging from transient ischemia, hypoxia, hyperbaric oxygen, hypothermia and hyperthermia, to exposure to neurotoxins and pharmacological agents. The phenomenon of "cross-tolerance," in which a sublethal stress protects against a different type of injury, suggests that different preconditioning stimuli may confer protection against a wide range of injuries. Research conducted over the past few decades indicates that brain preconditioning is complex, involving multiple effectors such as metabolic inhibition, activation of extra- and intracellular defense mechanisms, a shift in the neuronal excitatory/inhibitory balance, and reduction in inflammatory sequelae. An improved understanding of brain preconditioning should help us identify innovative therapeutic strategies that prevent or at least reduce neuronal damage in susceptible patients. In this review, we focus on the experimental evidence of preconditioning in the brain and systematically survey the models used to develop paradigms for neuroprotection, and then discuss the clinical potential of brain preconditioning.
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Affiliation(s)
- R Anne Stetler
- State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai Medical College, Shanghai 200032, China; Department of Neurology and Center of Cerebrovascular Disease Research, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA; Geriatric Research, Educational and Clinical Center, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, PA 15261, USA
| | - Rehana K Leak
- Division of Pharmaceutical Sciences, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA 15282, USA
| | - Yu Gan
- State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai Medical College, Shanghai 200032, China; Department of Neurology and Center of Cerebrovascular Disease Research, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
| | - Peiying Li
- State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai Medical College, Shanghai 200032, China; Department of Neurology and Center of Cerebrovascular Disease Research, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
| | - Feng Zhang
- State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai Medical College, Shanghai 200032, China; Department of Neurology and Center of Cerebrovascular Disease Research, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA; Geriatric Research, Educational and Clinical Center, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, PA 15261, USA
| | - Xiaoming Hu
- Department of Neurology and Center of Cerebrovascular Disease Research, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA; Geriatric Research, Educational and Clinical Center, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, PA 15261, USA
| | - Zheng Jing
- Department of Neurology and Center of Cerebrovascular Disease Research, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA; Geriatric Research, Educational and Clinical Center, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, PA 15261, USA
| | - Jun Chen
- State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai Medical College, Shanghai 200032, China; Department of Neurology and Center of Cerebrovascular Disease Research, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA; Geriatric Research, Educational and Clinical Center, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, PA 15261, USA
| | - Michael J Zigmond
- State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai Medical College, Shanghai 200032, China; Department of Neurology and Center of Cerebrovascular Disease Research, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, USA
| | - Yanqin Gao
- State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai Medical College, Shanghai 200032, China.
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20
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Affiliation(s)
- Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, 48109-2200, USA,
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21
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Abstract
Preconditioning (PC) describes a phenomenon whereby a sub-injury inducing stress can protect against a later injurious stress. Great strides have been made in identifying the mechanisms of PC-induced protection in animal models of brain injury. While these may help elucidate potential therapeutic targets, there are questions over the clinical utility of cerebral PC, primarily because of questions over the need to give the PC stimulus prior to the injury, narrow therapeutic windows and safety. The object of this review is to address the question of whether there may indeed be a clinical use for cerebral PC and to discuss the deficiencies in our knowledge of PC that may hamper such clinical translation.
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22
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Della-Morte D, Cacciatore F, Salsano E, Pirozzi G, Del Genio MT, D'Antonio I, Gargiulo G, Palmirotta R, Guadagni F, Rundek T, Abete P. Age-related reduction of cerebral ischemic preconditioning: myth or reality? Clin Interv Aging 2013; 8:1055-61. [PMID: 24204128 PMCID: PMC3817003 DOI: 10.2147/cia.s47462] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Stroke is one of the leading causes of death in industrialized countries for people older than 65 years of age. The reasons are still unclear. A reduction of endogenous mechanisms against ischemic insults has been proposed to explain this phenomenon. The “cerebral” ischemic preconditioning mechanism is characterized by a brief episode of ischemia that renders the brain more resistant against subsequent longer ischemic events. This ischemic tolerance has been shown in numerous experimental models of cerebral ischemia. This protective mechanism seems to be reduced with aging both in experimental and clinical studies. Alterations of mediators released and/or intracellular pathways may be responsible for age-related ischemic preconditioning reduction. Agents able to mimic the “cerebral” preconditioning effect may represent a new powerful tool for the treatment of acute ischemic stroke in the elderly. In this article, animal and human cerebral ischemic preconditioning, its age-related difference, and its potential therapeutical applications are discussed.
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Affiliation(s)
- David Della-Morte
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA ; Department of Advanced Biotechnologies and Bioimaging, IRCCS San Raffaele, Rome, Italy
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23
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Della-Morte D, Guadagni F, Palmirotta R, Ferroni P, Testa G, Cacciatore F, Abete P, Rengo F, Perez-Pinzon MA, Sacco RL, Rundek T. Genetics and genomics of ischemic tolerance: focus on cardiac and cerebral ischemic preconditioning. Pharmacogenomics 2013; 13:1741-57. [PMID: 23171338 DOI: 10.2217/pgs.12.157] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A subthreshold ischemic insult applied to an organ such as the heart and/or brain may help to reduce damage caused by subsequent ischemic episodes. This phenomenon is known as ischemic tolerance mediated by ischemic preconditioning (IPC) and represents the most powerful endogenous mechanism against ischemic injury. Various molecular pathways have been implicated in IPC, and several compounds have been proposed as activators or mediators of IPC. Recently, it has been established that the protective phenotype in response to ischemia depends on a coordinated response at the genomic, molecular, cellular and tissue levels by introducing the concept of 'genomic reprogramming' following IPC. In this article, we sought to review the genetic expression profiles found in cardiac and cerebral IPC studies, describe the differences between young and aged organs in IPC-mediated protection, and discuss the potential therapeutic application of IPC and pharmacological preconditioning based on the genomic response.
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Affiliation(s)
- David Della-Morte
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA.
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24
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Bilgin-Freiert A, Dusick JR, Stein NR, Etchepare M, Vespa P, Gonzalez NR. Muscle microdialysis to confirm sublethal ischemia in the induction of remote ischemic preconditioning. Transl Stroke Res 2012; 3:266-72. [PMID: 24323782 DOI: 10.1007/s12975-012-0153-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 03/09/2012] [Accepted: 03/13/2012] [Indexed: 11/30/2022]
Abstract
Exposure of one tissue to ischemia-reperfusion confers a systemic protective effect, referred to as remote ischemic preconditioning (RIPC). Confirmation that the desired effect of ischemia is occurring in tissues used to induce RIPC requires an objective demonstration before this technique can be used consistently in the clinical practice. Enrolled patients underwent three to four RIPC sessions on non-consecutive days. Sessions consisted of 4 cycles of 5 min of leg cuff inflation to 30 mmHg above the systolic blood pressure followed by reperfusion. Absence of leg pulse was confirmed by Doppler evaluation. To evaluate limb transient ischemia, patients were monitored with muscle microdialysis. Glucose, lactate, lactate/pyruvate ratio, and glycerol levels were measured. Fourteen microdialysis sessions were performed in seven patients undergoing RIPC (42.8 % male; mean age, 51.8; Fisher grade 4 in all seven patients, Hunt and Hess grade 5 in five patients, four in one patient and one in one patient). An average follow-up of 29 days demonstrated no complications associated with the procedure. Muscle microdialysis during RIPC sessions showed a significant increase in lactate/pyruvate ratio (21.2 to 26.8, p = 0.001) and lactate (3.0 to 3.9 mmol/L, p = 0.002), indicating muscle ischemia. There was no significant variation in glycerol (234 to 204 μg/L, p = 0.43), indicating no permanent cell damage. The RIPC protocol used in this study is safe, well tolerated, and induces transient metabolic changes consistent with sublethal ischemia. Muscle microdialysis can be used safely as a confirmatory tool in the induction of RIPC.
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Affiliation(s)
- Arzu Bilgin-Freiert
- Departments of Neurosurgery and Radiology, UCLA David Geffen School of Medicine, 10833 LeConte Ave., Room 18-251 Semel, Los Angeles, CA, 90095-7039, USA
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25
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Kalogeris T, Baines CP, Krenz M, Korthuis RJ. Cell biology of ischemia/reperfusion injury. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2012; 298:229-317. [PMID: 22878108 PMCID: PMC3904795 DOI: 10.1016/b978-0-12-394309-5.00006-7] [Citation(s) in RCA: 1353] [Impact Index Per Article: 112.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Disorders characterized by ischemia/reperfusion (I/R), such as myocardial infarction, stroke, and peripheral vascular disease, continue to be among the most frequent causes of debilitating disease and death. Tissue injury and/or death occur as a result of the initial ischemic insult, which is determined primarily by the magnitude and duration of the interruption in the blood supply, and then subsequent damage induced by reperfusion. During prolonged ischemia, ATP levels and intracellular pH decrease as a result of anaerobic metabolism and lactate accumulation. As a consequence, ATPase-dependent ion transport mechanisms become dysfunctional, contributing to increased intracellular and mitochondrial calcium levels (calcium overload), cell swelling and rupture, and cell death by necrotic, necroptotic, apoptotic, and autophagic mechanisms. Although oxygen levels are restored upon reperfusion, a surge in the generation of reactive oxygen species occurs and proinflammatory neutrophils infiltrate ischemic tissues to exacerbate ischemic injury. The pathologic events induced by I/R orchestrate the opening of the mitochondrial permeability transition pore, which appears to represent a common end-effector of the pathologic events initiated by I/R. The aim of this treatise is to provide a comprehensive review of the mechanisms underlying the development of I/R injury, from which it should be apparent that a combination of molecular and cellular approaches targeting multiple pathologic processes to limit the extent of I/R injury must be adopted to enhance resistance to cell death and increase regenerative capacity in order to effect long-lasting repair of ischemic tissues.
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Affiliation(s)
- Theodore Kalogeris
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, USA
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26
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Pedersen KR, Ravn HB, Povlsen JV, Schmidt MR, Erlandsen EJ, Hjortdal VE. Failure of remote ischemic preconditioning to reduce the risk of postoperative acute kidney injury in children undergoing operation for complex congenital heart disease: a randomized single-center study. J Thorac Cardiovasc Surg 2011; 143:576-83. [PMID: 21955475 DOI: 10.1016/j.jtcvs.2011.08.044] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 08/08/2011] [Accepted: 08/26/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate whether remote ischemic preconditioning can protect kidney function in children undergoing operation for complex congenital heart disease. METHODS Children (n = 113) aged 0 to 15 years admitted for complex congenital heart disease were randomly allocated according to age to remote ischemic preconditioning and control groups. After exclusion of 8 patients, we conducted the analysis on 105 patients (remote ischemic preconditioning group, n = 54; control group, n = 51). Before surgery, remote ischemic preconditioning was performed as 4 cycles of 5 minutes of ischemia by inflating a cuff around a leg to 40 mm Hg above the systolic pressure. End points were development of acute kidney injury, initiation of dialysis, plasma creatinine, estimated glomerular filtration rate, plasma cystatin C, plasma and urinary neutrophil gelatinase-associated lipocalin, and urinary output. Secondary end points included postoperative blood pressure, inotropic score, and mortality, as well as morbidity reflected by reoperation and stays in the intensive care unit and hospital. RESULTS Overall, 57 of the children (54%) had acute kidney injury develop, with 27 (50%) in the remote ischemic preconditioning group and 30 (59%) in the control group (P > .2). Remote ischemic preconditioning was not associated with improvement in either any of the renal biomarkers or any of the secondary end points. CONCLUSIONS We found no evidence that remote ischemic preconditioning provided protection of kidney function in children undergoing operation for complex congenital heart disease.
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Affiliation(s)
- Kirsten Rønholt Pedersen
- Department of Cardiothoracic and Vascular Surgery, Århus University Hospital, Skejby, Århus, Denmark
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27
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Mergenthaler P, Dirnagl U. Protective conditioning of the brain: expressway or roadblock? J Physiol 2011; 589:4147-55. [PMID: 21708907 DOI: 10.1113/jphysiol.2011.209718] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The brain responds to noxious stimulation with protective signalling. Over the last decades, a number of experimental strategies have been established to study endogenous brain protection. Pre-, per-, post- and remote 'conditioning' are now widely used to unravel the underlying mechanisms of endogenous neuroprotection. Some of these strategies are currently being tested in clinical trials to protect the human brain against anticipated damage or to boost protective responses during or after injury. Here we summarize the principles of 'conditioning' research and current efforts to translate this knowledge into effective treatment of patients. Conditioning to induce protected brain states provides an experimental window into endogenous brain protection and can lead to the discovery of drugs mimicking the effects of conditioning. Mechanisms of endogenous brain tolerance can be activated through a wide variety of stimuli that signal 'danger' to the brain. These danger signals lead to the induction of regulator and effector mechanisms, which suppress death and induce survival pathways, decrease metabolism, as well as increase substrate delivery. We conclude that preclinical research on endogenous brain protection has greatly benefited from conditioning strategies, but that clinical applications are challenging, and that we should not prematurely rush into ill-designed and underpowered clinical trials.
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Affiliation(s)
- Philipp Mergenthaler
- Center for Stroke Research Berlin (CSB), Department of Neurology and Experimental Neurology, Charité - University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
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28
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Poon WS. Great hospitals of Asia: neurosurgery at Prince of Wales Hospital. World Neurosurg 2011; 75:383-6. [PMID: 21600469 DOI: 10.1016/j.wneu.2011.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 02/08/2011] [Indexed: 10/18/2022]
Abstract
Prince of Wales Hospital, a 1400-bed regional referral center, was established in 1984 as the primary teaching hospital of the second medical school in Hong Kong at the Chinese University of Hong Kong. The Academic Division of Neurosurgery was given an autonomous status, the support of 40 acute beds, and a well-equipped and well-staffed intensive care unit (ICU), in developing neurosurgery as a distinct surgical specialty. Over this short 26-year history, we have gone through the difficult time of one-man-band neurosurgery, excelled in emergency neurosurgery, and evolved to an era of organized neurosurgical practice, where clinical services, teaching of undergraduate and postgraduate students, and clinical and translational research have been brought up to international standards.
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Affiliation(s)
- Wai S Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
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29
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Koch S, Katsnelson M, Dong C, Perez-Pinzon M. Remote ischemic limb preconditioning after subarachnoid hemorrhage: a phase Ib study of safety and feasibility. Stroke 2011; 42:1387-91. [PMID: 21415404 DOI: 10.1161/strokeaha.110.605840] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Making a limb transiently ischemic has been shown to induce ischemic tolerance in a distant organ. This phenomenon is known as remote ischemic limb preconditioning. We conducted a Phase IB study of remote ischemic limb preconditioning to determine the safety and feasibility of increasing durations of limb ischemia in patients with subarachnoid hemorrhage. METHODS Patients with aneurysmal subarachnoid hemorrhage underwent limb preconditioning every 24 to 48 hours for 14 days. Limb preconditioning consisted of 3 5-minute inflations of a blood pressure cuff to 200 mm Hg around a limb followed by 5 minutes of reperfusion. In the lead-in phase, we preconditioned the upper extremities, but this proved impractical and we began preconditioning the leg in a similar manner. Ischemia times were then escalated to 7.5 and 10 minutes. After each session, a visual analog scale was obtained and the extremity examined for neurovascular complications. RESULTS A total of 33 patients completed the study. Mean age was 53±12 years and mean Hunt Hess score was 2.4±0.9. In the lead-in phase, an average of 7.7±2.4 preconditioning sessions was completed with mean visual analog scale 3.6±3.4. In the dose escalation phase, an average of 8.6±2.1 preconditioning sessions was done with mean visual analog scale 1.8±2.2 and 2.5±2.9 for the 7.5- and 10-minute cohorts, respectively. No session was prematurely terminated due to subject discomfort. No objective signs of neurovascular injury were observed. CONCLUSIONS We found limb preconditioning to be safe and well tolerated, even at ischemia times of 10 minutes, in critically ill patients with subarachnoid hemorrhage.
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Affiliation(s)
- Sebastian Koch
- Department of Neurology, University of Miami, Miller School of Medicine, 1150 NW 14th Street, Suite 609, Professional Arts Center, Miami, FL 33136, USA.
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Hu H, Yamashita S, Hua Y, Keep RF, Liu W, Xi G. Thrombin-induced neuronal protection: role of the mitogen activated protein kinase/ribosomal protein S6 kinase pathway. Brain Res 2010; 1361:93-101. [PMID: 20846511 DOI: 10.1016/j.brainres.2010.09.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Revised: 09/02/2010] [Accepted: 09/03/2010] [Indexed: 10/19/2022]
Abstract
Our previous studies have found that intracerebral pretreatment with a low dose of thrombin (thrombin preconditioning, TPC) reduces infarct volume and attenuates brain edema after focal cerebral ischemia. In this study, we examined whether TPC protects against the neuronal death induced by oxygen glucose deprivation (OGD), and whether the protection is through thrombin receptors and the p44/42 mitogen activated protein kinases (MAPK)/ribosomal protein S6 kinases (p70 S6K) pathway. Expression of protease-activated receptors (PARs) mRNA was detected in cultured primary rat neurons and thrombin upregulated PAR-1 and PAR-4 mRNA expression. TPC reduced OGD-induced neuronal death (e.g. dead cells: 52.5 ± 5.4% vs. 72.3 ± 7.2% in the control group, n=6, p<0.01). Agonists of PAR-1 and PAR-4 mimicked the effects of thrombin and reduced OGD-induced neuronal death. Pretreatment with thrombin or PAR agonists induced the upregulation of activated p44/42 MAPK and p70S6K (Thr 421/Ser 424). PD98059, an inhibitor of p44/42 MAPK kinase, blocked thrombin-induced upregulation of activated p44/42 MAPK and p70S6K. It also reduced TPC-induced neuronal protection (e.g. dead cells: 68.2 ± 5.2% vs. 56.9 ± 4.6% in vehicle+TPC group, n=6, p<0.05). These results suggest that TPC-induced ischemic tolerance is through activation of thrombin receptors and the p44/42 MAPK/p70S6K pathway.
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Affiliation(s)
- Haitao Hu
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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Walsh SR, Nouraei SA, Tang TY, Sadat U, Carpenter RH, Gaunt ME. Remote ischemic preconditioning for cerebral and cardiac protection during carotid endarterectomy: results from a pilot randomized clinical trial. Vasc Endovascular Surg 2010; 44:434-9. [PMID: 20484064 DOI: 10.1177/1538574410369709] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Remote ischemic preconditioning (RIPC) is a physiological mechanism whereby brief ischemia-reperfusion episodes attenuate damage by subsequent prolonged ischemic insults. It reduces myocardial injury following cardiac and aortic aneurysm surgery. We aimed to determine whether RIPC affects neurological or cardiac injury following carotid endarterectomy (CEA). Patients were preconditioned using 10 minutes of lower limb ischemia-reperfusion. The primary neurological outcome was saccadic latency deterioration. The primary cardiac outcome measure was increased in serum troponin I >0.15 mg/dL. In all, 70 patients were randomized, of whom 55 completed the neurological surveillance protocol. Although there were fewer saccadic latency deteriorations in the RIPC arm, this did not reach statistical significance (32% versus 53%; P = .11). The primary cardiac outcome occurred in 1 patient in each arm (P = .97). There were no adverse events related to the preconditioning protocol. Remote ischemic preconditioning appears safe in patients with CEA. Large-scale trials are required to determine whether RIPC confers clinical benefits.
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Affiliation(s)
- Stewart R Walsh
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge, United Kingdom.
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Liu XQ, Sheng R, Qin ZH. The neuroprotective mechanism of brain ischemic preconditioning. Acta Pharmacol Sin 2009; 30:1071-80. [PMID: 19617892 DOI: 10.1038/aps.2009.105] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Brain ischemia is one of the most common causes of death and the leading cause of adult disability in the world. Brain ischemic preconditioning (BIP) refers to a transient, sublethal ischemia which results in tolerance to later, otherwise lethal, cerebral ischemia. Many attempts have been made to understand the molecular and cellular mechanisms underlying the neuroprotection offered by ischemic preconditioning. Many studies have shown that neuroprotective mechanisms may involve a series of molecular regulatory pathways including activation of the N-methyl-D-aspartate (NMDA) and adenosine receptors; activation of intracellular signaling pathways such as mitogen activated protein kinases (MAPK) and other protein kinases; upregulation of Bcl-2 and heat shock proteins (HSPs); and activation of the ubiquitin-proteasome pathway and the autophagic-lysosomal pathway. A better understanding of the processes that lead to cell death after stroke as well as of the endogenous neuroprotective mechanisms by which BIP protects against brain ischemic insults could help to develop new therapeutic strategies for this devastating neurological disease. The purpose of the present review is to summarize the neuroprotective mechanisms of BIP and to discuss the possibility of mimicking ischemic preconditioning as a new strategy for preventive treatment of ischemia.
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Della Morte D, Abete P, Gallucci F, Scaglione A, D'Ambrosio D, Gargiulo G, De Rosa G, Dave KR, Lin HW, Cacciatore F, Mazzella F, Uomo G, Rundek T, Perez-Pinzon MA, Rengo F. Transient ischemic attack before nonlacunar ischemic stroke in the elderly. J Stroke Cerebrovasc Dis 2009; 17:257-62. [PMID: 18755403 DOI: 10.1016/j.jstrokecerebrovasdis.2008.03.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 03/07/2008] [Accepted: 03/12/2008] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Several studies suggest transient ischemic attack (TIA) may be neuroprotective against ischemic stroke analogous to preinfarction angina's protection against acute myocardial infarction. However, this protective ischemic preconditioning-like effect may not be present in all ages, especially among the elderly. The purpose of this study was to determine the neuroprotective effect of TIAs (clinical equivalent of cerebral ischemic preconditioning) to neurologic damage after cerebral ischemic injury in patients over 65 years of age. METHODS We reviewed the medical charts of patients with ischemic stroke for presence of TIAs within 72 hours before stroke onset. Stroke severity was evaluated by the National Institutes of Health Stroke Scale and disability by a modified Rankin scale. RESULTS We evaluated 203 patients (>or=65 years) with diagnosis of acute ischemic stroke and categorized them according to the presence (n = 42, 21%) or absence (n = 161, 79%) of TIAs within 72 hours of stroke onset. Patients were monitored until discharged from the hospital (length of hospital stay 14.5 +/- 4.8 days). No significant differences in the National Institutes of Health Stroke Scale and modified Rankin scale scores were observed between those patients with TIAs and those without TIAs present before stroke onset at admission or discharge. CONCLUSION These results suggest that the neuroprotective mechanism of cerebral ischemic preconditioning may not be present or functional in the elderly.
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Affiliation(s)
- David Della Morte
- Department of Internal Medicine, Cardiovascular Sciences, and Immunology, University Federico II, Naples, Italy.
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Walsh SR, Tang TY, Sadat U, Gaunt ME. Remote ischemic preconditioning in major vascular surgery. J Vasc Surg 2008; 49:240-3. [PMID: 18829224 DOI: 10.1016/j.jvs.2008.07.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Revised: 07/10/2008] [Accepted: 07/11/2008] [Indexed: 12/17/2022]
Abstract
Remote ischemic preconditioning is a physiologic mechanism in mammalian species whereby brief exposure to nonlethal ischemia in one tissue confers protection against a prolonged ischemic insult in a distant tissue. First described almost 15 years ago, it has been slow to translate into clinical practice. Several clinical trials have recently reported that remote ischemic preconditioning reduces myocardial injury after major cardiovascular surgery. In addition, a randomized trial in patients undergoing open abdominal aortic aneurysm repair reported a significant reduction in perioperative myocardial infarctions. Remote ischemic preconditioning is easily performed and likely to prove highly cost-effective. large-scale trials of the technique are warranted in patients undergoing major vascular surgery.
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Affiliation(s)
- Stewart R Walsh
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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Hoff JT, Keep RF, Xi G. Brain edema. Neurosurg Focus 2007. [DOI: 10.3171/foc.2007.22.5.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Steiger HJ, Hänggi D. Ischaemic preconditioning of the brain, mechanisms and applications. Acta Neurochir (Wien) 2007; 149:1-10. [PMID: 17151832 DOI: 10.1007/s00701-006-1057-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2006] [Accepted: 10/11/2006] [Indexed: 01/25/2023]
Abstract
BACKGROUND The concept of ischaemic preconditioning was introduced in the late 1980s. The concept emerged that a brief subcritical ischaemic challenge could mobilize intrinsic protective mechanisms that increased tolerance against subsequent critical ischaemia. Tissues with a high sensitivity against ischaemia, i.e. myocardium and central nervous system, present the most promising targets for therapeutic application of ischaemic preconditioning. During the last years the mechanisms of neuronal preconditioning were systematically studied and a number of molecular regulation pathways were discovered to participate in preconditioning. The purpose of the present review is to survey the actual knowledge on cerebral preconditioning, and to define the practical impact for neurosurgery. METHODS A systematic medline search for the terms preconditioning and postconditioning was filed. Publications related to the nervous system were selected and analysed. FINDINGS Preconditioning can be subdivided into early and late mechanisms, depending on whether the effect appears immediately after the nonlethal stress or with a delay of some hours or days. In general early effects can be linked to adaptation of membrane receptors whereas late effects are the result of gene up- or downregulation. Not only subcritical ischaemia can trigger preconditioning but also hypoxia, hyperthermia, isoflurane and other chemical substances. Although a vast amount of knowledge has been accumulated regarding neural preconditioning, it is unknown whether the effects can be potentiated by pharmacological or hypothermic neuroprotection during the critical ischaemia. Furthermore, although the practical importance of these findings is obvious, the resulting protective manipulations have so far not been transferred into clinical neurosurgery. Postconditioning and remote ischaemic preconditioning are additional emerging concepts. Postconditioning with a series of mechanical interruptions of reperfusion can apparently reduce ischaemic damage. Remote ischaemic preconditioning refers to the concept that transient ischaemia for example of a limb can lead to protection of the myocardium and possibly the brain. CONCLUSION Possible cumulative neuroprotection by preconditioning and pharmacological protection during critical ischaemia should be studied systematically. Easy to apply methods of preconditioning, such as the application of volatile anaesthetics or erythropoietin some hours or days prior to planned temporary ischaemia, should be introduced into the practice of operative neurosurgery.
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Affiliation(s)
- H-J Steiger
- Department of Neurosurgery, University Hospital, Heinrich-Heine University, Düsseldorf, Germany.
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