1
|
Kurtz P, van den Boogaard M, Girard TD, Hermann B. Acute encephalopathy in the ICU: a practical approach. Curr Opin Crit Care 2024; 30:106-120. [PMID: 38441156 DOI: 10.1097/mcc.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Acute encephalopathy (AE) - which frequently develops in critically ill patients with and without primary brain injury - is defined as an acute process that evolves rapidly and leads to changes in baseline cognitive status, ranging from delirium to coma. The diagnosis, monitoring, and management of AE is challenging. Here, we discuss advances in definitions, diagnostic approaches, therapeutic options, and implications to outcomes of the clinical spectrum of AE in ICU patients without primary brain injury. RECENT FINDINGS Understanding and definitions of delirium and coma have evolved. Delirium is a neurocognitive disorder involving impairment of attention and cognition, usually fluctuating, and developing over hours to days. Coma is a state of unresponsiveness, with absence of command following, intelligible speech, or visual pursuit, with no imaging or neurophysiological evidence of cognitive motor dissociation. The CAM-ICU(-7) and the ICDSC are validated, guideline-recommended tools for clinical delirium assessment, with identification of clinical subtypes and stratification of severity. In comatose patients, the roles of continuous EEG monitoring and neuroimaging have grown for the early detection of secondary brain injury and treatment of reversible causes. SUMMARY Evidence-based pharmacologic treatments for delirium are limited. Dexmedetomidine is effective for mechanically ventilated patients with delirium, while haloperidol has minimal effect of delirium but may have other benefits. Specific treatments for coma in nonprimary brain injury are still lacking.
Collapse
Affiliation(s)
- Pedro Kurtz
- D'Or Institute of Research and Education
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Mark van den Boogaard
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Timothy D Girard
- Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) in the Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bertrand Hermann
- Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris - Centre (APHP-Centre)
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP), Université Paris Cité, Paris, France
| |
Collapse
|
2
|
Fan TH, Premraj L, Roberts J, Lydston M, Robba C, Hager D, Suarez JI, Battaglini D, Cho SM. In-Hospital Neurologic Complications, Neuromonitoring, and Long-Term Neurologic Outcomes in Patients With Sepsis: A Systematic Review and Meta-Analysis. Crit Care Med 2024; 52:452-463. [PMID: 37921513 PMCID: PMC10923122 DOI: 10.1097/ccm.0000000000006096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
OBJECTIVES Although delirium is well described in patients with sepsis, there are limited data on other neurologic complications. We aimed to systematically review the prevalence, neuromonitoring tools, and neurocognitive outcomes in sepsis patients with neurologic complications. DATA SOURCES MEDLINE and six other databases (Embase, Web of Science, Cochrane CENTRAL, and ClinicalTrials.gov ) were searched through January 2023. STUDY SELECTION Studies of adult patients with sepsis reported neurologic complications, use of neuromonitoring tools, neuropathology, and cognitive outcomes. DATA EXTRACTION Two independent reviewers extracted the data. Random-effect meta-analyses were used to pool data. DATA SYNTHESIS Seventy-four studies ( n = 146,855) were included. Neurologic complications were reported in 38 studies ( n = 142,193) including septic encephalopathy (36%, 95% CI, 27-46%; I 2 = 99%), ischemic stroke (5%, 95% CI, 2.1-11.5; I 2 = 99%), intracranial hemorrhage (2%, 95% CI, 1.0-4.4%; I 2 = 96%), seizures (1%, 95% CI, 0.2-7%; I 2 = 96%), posterior reversible encephalopathy syndrome (9%), and hypoxic-ischemic brain injury (7%). In the meta-regression analysis, pulmonary infection, sepsis induced by a gram-positive organism, higher sequential organ failure assessment score, acute physiology and chronic health evaluation II score at admission, and longer ICU length of stay were associated with higher risk of developing septic encephalopathy. Three studies ( n = 159) reported postmortem neuropathological findings, acute brain injury was noted in 47% of patients. Twenty-six studies ( n = 1,358) reported the use of neuromonitoring tools, electroencephalogram was the most used tool for seizure detection. Transcranial Doppler and near infrared spectroscopy were used for monitoring cerebral hemodynamic changes to detect early ischemia. Six studies reported cognitive outcomes ( n = 415) up to 12 months postdischarge and cognitive impairment (≥ one domain) was reported in 30%. CONCLUSIONS In-hospital neurologic complications are common in patients with sepsis. However, the mechanism and timing of those sepsis-associated complications are poorly understood and there are limited data on standardized neuromonitoring in this population.
Collapse
Affiliation(s)
- Tracey H Fan
- Department of Neurology, Neurocritical Care Division, Massachusetts General Hospital, Boston, MA
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Jacob Roberts
- School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Melissa Lydston
- Treadwell Virtual Library, Massachusetts General Hospital, Boston, MA
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
| | - David Hager
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jose I. Suarez
- Divisions of Neuroscience Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Denise Battaglini
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
| | - Sung-Min Cho
- Divisions of Neuroscience Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| |
Collapse
|
3
|
Wang G, Jiang X, Fu Y, Gao Y, Jiang Q, Guo E, Huang H, Liu X. Development and validation of a nomogram to predict the risk of sepsis-associated encephalopathy for septic patients in PICU: a multicenter retrospective cohort study. J Intensive Care 2024; 12:8. [PMID: 38378667 PMCID: PMC10877756 DOI: 10.1186/s40560-024-00721-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Patients with sepsis-associated encephalopathy (SAE) have higher mortality rates and longer ICU stays. Predictors of SAE are yet to be identified. We aimed to establish an effective and simple-to-use nomogram for the individual prediction of SAE in patients with sepsis admitted to pediatric intensive care unit (PICU) in order to prevent early onset of SAE. METHODS In this retrospective multicenter study, we screened 790 patients with sepsis admitted to the PICU of three hospitals in Shandong, China. Least absolute shrinkage and selection operator regression was used for variable selection and regularization in the training cohort. The selected variables were used to construct a nomogram to predict the risk of SAE in patients with sepsis in the PICU. The nomogram performance was assessed using discrimination and calibration. RESULTS From January 2017 to May 2022, 613 patients with sepsis from three centers were eligible for inclusion in the final study. The training cohort consisted of 251 patients, and the two independent validation cohorts consisted of 193 and 169 patients. Overall, 237 (38.7%) patients developed SAE. The morbidity of SAE in patients with sepsis is associated with the respiratory rate, blood urea nitrogen, activated partial thromboplastin time, arterial partial pressure of carbon dioxide, and pediatric critical illness score. We generated a nomogram for the early identification of SAE in the training cohort (area under curve [AUC] 0.82, 95% confidence interval [CI] 0.76-0.88, sensitivity 65.6%, specificity 88.8%) and validation cohort (validation cohort 1: AUC 0.80, 95% CI 0.74-0.86, sensitivity 75.0%, specificity 74.3%; validation cohort 2: AUC 0.81, 95% CI 0.73-0.88, sensitivity 69.1%, specificity 83.3%). Calibration plots for the nomogram showed excellent agreement between SAE probabilities of the observed and predicted values. Decision curve analysis indicated that the nomogram conferred a high net clinical benefit. CONCLUSIONS The novel nomogram and online calculator showed performance in predicting the morbidity of SAE in patients with sepsis admitted to the PICU, thereby potentially assisting clinicians in the early detection and intervention of SAE.
Collapse
Affiliation(s)
- Guan Wang
- Department of Pediatrics, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Xinzhu Jiang
- Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Yanan Fu
- Department of Medical Engineering, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Yan Gao
- Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China
| | - Qin Jiang
- Department of Pediatrics, Jinan Children's Hospital of Shandong University, No. 23976 Jingshi Road, Jinan, 250000, Shandong, China
| | - Enyu Guo
- Department of Pediatrics, Jining First People's Hospital, No. 6 JianKang Road, Jining, 272000, Shandong, China
| | - Haoyang Huang
- School of Public Health of Shandong University, No. 44 West Wenhua Road, Jinan, 250000, Shandong, China
| | - Xinjie Liu
- Department of Pediatrics, Qilu Hospital of Shandong University, No. 107 West Wenhua Road, Jinan, 250012, Shandong, China.
| |
Collapse
|
4
|
Pendlebury ST, Luengo-Fernandez R, Seeley A, Downer MB, McColl A, Rothwell PM. Infection, delirium, and risk of dementia in patients with and without white matter disease on previous brain imaging: a population-based study. THE LANCET. HEALTHY LONGEVITY 2024; 5:e131-e140. [PMID: 38310893 DOI: 10.1016/s2666-7568(23)00266-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND The increased risk of dementia after delirium and infection might be influenced by cerebral white matter disease (WMD). In patients with transient ischaemic attack (TIA) and minor stroke, we assessed associations between hospital admissions with delirium and 5-year dementia risk and between admissions with infection and dementia risk, stratified by WMD severity (moderate or severe vs absent or mild) on baseline brain imaging. METHODS We included patients with TIA and minor stroke (National Institutes of Health Stroke Score <3) from the Oxford Vascular Study (OXVASC), a longitudinal population-based study of the incidence and outcomes of acute vascular events in a population of 94 567 individuals, with no age restrictions, attending eight general practices in Oxfordshire, UK. Hospitalisation data were obtained through linkage to the Oxford Cognitive Comorbidity, Frailty, and Ageing Research Database-Electronic Patient Records (ORCHARD-EPR). Brain imaging was done using CT and MRI, and WMD was prospectively graded according to the age-related white matter changes (ARWMC) scale and categorised into absent, mild, moderate, or severe WMD. Delirium and infection were defined by ICD-10 coding supplemented by hand-searching of hospital records. Dementia was diagnosed using clinical or cognitive assessment, medical records, and death certificates. Associations between hospitalisation with delirium and hospitalisation with infection, and post-event dementia were assessed using time-varying Cox analysis with multivariable adjustment, and all models were stratified by WMD severity. FINDINGS From April 1, 2002, to March 31, 2012, 1369 individuals were prospectively recruited into the study. Of 1369 patients (655 with TIA and 714 with minor stroke, mean age 72 [SD 13] years, 674 female and 695 male, and 364 with moderate or severe WMD), 209 (15%) developed dementia. Hospitalisation during follow-up occurred in 891 (65%) patients of whom 103 (12%) had at least one delirium episode and 236 (26%) had at least one infection episode. Hospitalisation without delirium or infection did not predict subsequent dementia (HR 1·01, 95% CI 0·86-1·20). In contrast, hospitalisation with delirium predicted subsequent dementia independently of infection in patients with and without WMD (2·64, 1·47-4·74; p=0·0013 vs 3·41, 1·91-6·09; p<0·0001) especially in those with unimpaired baseline cognition (cognitive test score above cutoff; 4·01, 2·23-7·19 vs 3·94, 1·95-7·93; both p≤0·0001). However, hospitalisation with infection only predicted dementia in those with moderate or severe WMD (1·75, 1·04-2·94 vs 0·68, 0·39-1·20; pdiff=0·023). INTERPRETATION The increased risk of dementia after delirium is unrelated to the presence of WMD, whereas infection increases risk only in patients with WMD, suggesting differences in underlying mechanisms and in potential preventive strategies. FUNDING National Institute for Health and Care Research and Wellcome Trust.
Collapse
Affiliation(s)
- Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Departments of Acute General Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Ramon Luengo-Fernandez
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Anna Seeley
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Matthew B Downer
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Aubretia McColl
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
5
|
Gao Y, Su B, Luo Y, Tian Y, Hong S, Gao S, Xie J, Zheng X. HLA-C*07:01 and HLA-DQB1*02:01 protect against white matter hyperintensities and deterioration of cognitive function: A population-based cohort study. Brain Behav Immun 2024; 115:250-257. [PMID: 37884160 DOI: 10.1016/j.bbi.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/14/2023] [Accepted: 10/22/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Neuroinflammation and aberrant immune regulation are increasingly implicated in the pathophysiology of white matter hyperintensities (WMH), an imaging marker of cerebrovascular pathologies and predictor of cognitive impairment. The role of human leukocyte antigen (HLA) genes, critical in immunoregulation and associated with susceptibility to neurodegenerative diseases, in WMH pathophysiology remains unexplored. METHODS We performed association analyses between classical HLA alleles and WMH volume, derived from MRI scans of 38 302 participants in the UK Biobank. To identify independent functional alleles driving these associations, we conducted conditional forward stepwise regression and lasso regression. We further investigated whether these functional alleles showed consistent associations with WMH across subgroups characterized by varying levels of clinical determinants. Additionally, we validated the clinical relevance of the identified alleles by examining their association with cognitive function (n = 147 549) and dementia (n = 460 029) in a larger cohort. FINDINGS Four HLA alleles (DQB1*02:01, DRB1*03:01, C*07:01, and B*08:01) showed an association with reduced WMH volume after Bonferroni correction for multiple comparisons. Among these alleles, DQB1*02:01 exhibited the most significant association (β = -0.041, 95 % CI: -0.060 to -0.023, p = 1.04 × 10-5). Forward selection and lasso regression analyses indicated that DQB1*02:01 and C*07:01 primarily drove this association. The protective effect against WMH conferred by DQB1*02:01 and C*07:01 persisted in clinically relevant subgroups, with a stronger effect observed in older participants. Carrying DQB1*02:01 and C*07:01 was associated with higher cognitive function, but no association with dementia was found. INTERPRETATION Our population-based findings support the involvement of immune-associated mechanisms, particularly both HLA class I and class II genes, in the pathogenesis of WMH and subsequent consequence of cognitive functions.
Collapse
Affiliation(s)
- Yaqing Gao
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Binbin Su
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Yanan Luo
- Department of Global Health, School of Public Health, Peking University, Beijing, China
| | - Yaohua Tian
- Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shenda Hong
- National Institute of Health Data Science, Peking University, Beijing, China; Institute of Medical Technology, Peking University Health Science Center, Beijing, China
| | - Song Gao
- Institute of Medical Technology, Peking University Health Science Center, Beijing, China
| | - Junqing Xie
- Centre for Statistics in Medicine and NIHR Biomedical Research Centre Oxford, NDORMS, University of Oxford, Oxford, UK.
| | - Xiaoying Zheng
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China; HeSAY, Peking University, Beijing, China.
| |
Collapse
|
6
|
Wang Z, Liu L, Liu L. Vitamin C as a treatment for organ failure in sepsis. Eur J Med Res 2023; 28:222. [PMID: 37408078 DOI: 10.1186/s40001-023-01183-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023] Open
Abstract
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, with a high morbidity and mortality rate. Exogenous vitamin C supplementation is a potential therapeutic option for the treatment of multi-organ dysfunction in sepsis due to the significantly lower levels of vitamin C in the circulating blood of sepsis patients compared to healthy subjects and the importance of vitamin C in many of the physiological processes of sepsis. Vitamin C may influence the function of numerous organs and systems, including the heart, lungs, kidneys, brain, and immune defences, by reducing oxidative stress, inhibiting inflammatory factor surges, regulating the synthesis of various mediators and hormones, and enhancing immune cell function. With the development of multiple clinical randomized controlled trials, the outcomes of vitamin C treatment for critically ill patients have been discussed anew. This review's objectives are to provide an overview of how vitamin C affects various organ functions in sepsis and to illustrate how it affects each organ. Understanding the pharmacological mechanism of vitamin C and the organ damage caused by sepsis may help to clarify the conditions and clinical applications of vitamin C.
Collapse
Affiliation(s)
- Zitong Wang
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Liang Liu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050000, China
- Institute of Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lixia Liu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050000, China.
| |
Collapse
|
7
|
Wu S, Wang Y, Song Y, Hu H, Jing L, Zhu W. Application of magnetic resonance imaging-related techniques in the diagnosis of sepsis-associated encephalopathy: present status and prospect. Front Neurosci 2023; 17:1152630. [PMID: 37304016 PMCID: PMC10248056 DOI: 10.3389/fnins.2023.1152630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Sepsis-associated encephalopathy (SAE) refers to diffuse brain dysfunction secondary to systemic infection without central nervous system infection. The early diagnosis of SAE remains a major clinical problem, and its diagnosis is still exclusionary. Magnetic resonance imaging (MRI) related techniques, such as magnetic resonance spectroscopy (MRS), molecular MRI (mMRI), arterial spin-labeling (ASL), fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI), currently provide new options for the early identification of SAE. This review collected clinical and basic research and case reports related to SAE and MRI-related techniques in recent years, summarized and analyzed the basic principles and applications of MRI technology in diagnosing SAE, and provided a basis for diagnosing SAE by MRI-related techniques.
Collapse
Affiliation(s)
- Shuhui Wu
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Intensive Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuxin Wang
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yaqin Song
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Intensive Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hongjie Hu
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Intensive Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liang Jing
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Intensive Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Zhu
- Department of Emergency Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Intensive Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| |
Collapse
|
8
|
Zhou S, Li Y, Hong Y, Zhong Z, Zhao M. Puerarin protects against sepsis-associated encephalopathy by inhibiting NLRP3/Caspase-1/GSDMD pyroptosis pathway and reducing blood-brain barrier damage. Eur J Pharmacol 2023; 945:175616. [PMID: 36863556 DOI: 10.1016/j.ejphar.2023.175616] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/03/2023] [Accepted: 02/20/2023] [Indexed: 03/04/2023]
Abstract
Puerarin (Pue), an isoflavone compound extracted from Pueraria, has been shown to inhibit inflammation and reduce cerebral edema. The neuroprotective effect of puerarin has attracted much attention in recent years. Sepsis-associated encephalopathy (SAE) is a serious complication of sepsis that causes damage to the nervous system. This study aimed to investigate the effect of puerarin on SAE and elucidate the potential underlying mechanisms. A rat model of SAE was established by cecal ligation and puncture, and puerarin was injected intraperitoneally immediately after the operation. Puerarin was found to improve the survival rate and neurobehavioral score of SAE rats, alleviate symptoms, inhibit the level of brain injury markers NSE and S100β, and improve the pathological changes in rat brain tissue. Puerarin was also found to inhibit the level of factors related to the classical pathway of pyroptosis, such as NLRP3, Caspase-1, GSDMD, ASC, IL-1β, and IL-18. Puerarin also reduced the brain water content and penetration of Evan's Blue dye in SAE rats, and reduced the expression of MMP-9. In the in vitro experiments, we further confirmed the inhibitory effect of puerarin on neuronal pyroptosis by establishing a pyroptosis model in HT22 cells. Our findings suggest that puerarin may improve SAE by inhibiting the classical pathway of NLRP3/Caspase-1/GSDMD-mediated pyroptosis and reducing blood-brain barrier damage, thus playing a role in brain protection. Our study may provide a novel therapeutic strategy for SAE.
Collapse
Affiliation(s)
- Shuang Zhou
- Department of Emergency, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China.
| | - Yuhua Li
- Department of Critical Care Medicine, Wuhan Children's Hospital, Wuhan, Hubei Province, 430014, China
| | - Yi Hong
- Department of Emergency, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China
| | - Zhitao Zhong
- Department of Emergency, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China
| | - Min Zhao
- Department of Emergency, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, 110004, China.
| |
Collapse
|
9
|
Abstract
PURPOSE OF REVIEW Sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, is a leading cause of hospital and ICU admission. The central and peripheral nervous system may be the first organ system to show signs of dysfunction, leading to clinical manifestations such as sepsis-associated encephalopathy (SAE) with delirium or coma and ICU-acquired weakness (ICUAW). In the current review, we want to highlight developing insights into the epidemiology, diagnosis, prognosis, and treatment of patients with SAE and ICUAW. RECENT FINDINGS The diagnosis of neurological complications of sepsis remains clinical, although the use of electroencephalography and electromyography can support the diagnosis, especially in noncollaborative patients, and can help in defining disease severity. Moreover, recent studies suggest new insights into the long-term effects associated with SAE and ICUAW, highlighting the need for effective prevention and treatment. SUMMARY In this manuscript, we provide an overview of recent insights and developments in the prevention, diagnosis, and treatment of patients with SAE and ICUAW.
Collapse
Affiliation(s)
- Simone Piva
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
| | - Nicola Gitti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
| | - Francesco A. Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
- ’Alessandra Bono’ University Research Center on Long-term Outcome in Critical Illness Survivors, University of Brescia, Brescia, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital
- ’Alessandra Bono’ University Research Center on Long-term Outcome in Critical Illness Survivors, University of Brescia, Brescia, Italy
| |
Collapse
|
10
|
Yuechen Z, Shaosong X, Zhouxing Z, Fuli G, Wei H. A summary of the current diagnostic methods for, and exploration of the value of microRNAs as biomarkers in, sepsis-associated encephalopathy. Front Neurosci 2023; 17:1125888. [PMID: 37008225 PMCID: PMC10060640 DOI: 10.3389/fnins.2023.1125888] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/02/2023] [Indexed: 03/18/2023] Open
Abstract
Sepsis-associated encephalopathy (SAE) is an acute neurological deficit caused by severe sepsis without signs of direct brain infection, characterized by the systemic inflammation and disturbance of the blood–brain barrier. SAE is associated with a poor prognosis and high mortality in patients with sepsis. Survivors may exhibit long-term or permanent sequelae, including behavioral changes, cognitive impairment, and decreased quality of life. Early detection of SAE can help ameliorate long-term sequelae and reduce mortality. Half of the patients with sepsis suffer from SAE in the intensive care unit, but its physiopathological mechanism remains unknown. Therefore, the diagnosis of SAE remains a challenge. The current clinical diagnosis of SAE is a diagnosis of exclusion; this makes the process complex and time-consuming and delays early intervention by clinicians. Furthermore, the scoring scales and laboratory indicators involved have many problems, including insufficient specificity or sensitivity. Thus, a new biomarker with excellent sensitivity and specificity is urgently needed to guide the diagnosis of SAE. MicroRNAs have attracted attention as putative diagnostic and therapeutic targets for neurodegenerative diseases. They exist in various body fluids and are highly stable. Based on the outstanding performance of microRNAs as biomarkers for other neurodegenerative diseases, it is reasonable to infer that microRNAs will be excellent biomarkers for SAE. This review explores the current diagnostic methods for sepsis-associated encephalopathy (SAE). We also explore the role that microRNAs could play in SAE diagnosis and if they can be used to make the SAE diagnosis faster and more specific. We believe that our review makes a significant contribution to the literature because it summarizes some of the important diagnostic methods for SAE, highlighting their advantages and disadvantages in clinical use, and could benefit the field as it highlights the potential of miRNAs as SAE diagnostic markers.
Collapse
|
11
|
Pharmacological prevention of postoperative delirium in patients undergoing cardiac surgery: a bayesian network meta-analysis. J Anesth 2023; 37:294-310. [PMID: 36788134 DOI: 10.1007/s00540-023-03170-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
The incidence of postoperative delirium in patients undergoing cardiac surgery is very high and increases morbidity and mortality. The possibility of pharmacological means to reduce its incidence is very attractive. At present, there is still no clear demonstration that any drug can prevent postoperative delirium in these patients. The aim of this Bayesian network meta-analysis (NMA) was to evaluate whether there is evidence that a drug is effective in reducing the incidence of POD in cardiac surgical patients. Our NMA showed that preoperative ketamine at subanesthetic doses can significantly reduce the incidence of POD. Risperidone also decreases the incidence of POD, but not significantly.
Collapse
|
12
|
Texture Feature-Based Machine Learning Classification on MRI Image for Sepsis-Associated Encephalopathy Detection: A Pilot Study. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2023; 2023:6403556. [PMID: 36778786 PMCID: PMC9911249 DOI: 10.1155/2023/6403556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/21/2022] [Accepted: 12/26/2022] [Indexed: 02/05/2023]
Abstract
Objective The objective of this study was to assess the performance of combining MRI-based texture analysis with machine learning for differentiating sepsis-associated encephalopathy (SAE) from sepsis alone. Method Sixty-six MRI-T1WI images of an SAE patient and 125 images of patients with sepsis alone were collected. Frontal lobe, brain stem, hippocampus, and amygdala were selected as regions of interest (ROIs). 279 texture features of each ROI were obtained using MaZda software. After the dimension reduction, 30 highly discriminative features of each ROI were adopted to differentiate SAE from sepsis alone using the CatBoost model. Results The classification models of frontal, brain stem, hippocampus, and amygdala were constructed. The classification accuracy was above 0.83, and the area under the curve (AUC) exceeded 0.90 in the validation set. Conclusion The texture features differed between SAE patients and patients with sepsis alone in different anatomical locations, suggesting that MRI-based texture analysis with machine learning might be helpful in differentiating SAE from sepsis alone.
Collapse
|
13
|
Hosokawa T, Kinoshita K, Ihara S, Nakagawa K, Iguchi U, Hirabayashi M, Mutoh T, Sawada N, Kuwana T, Yamaguchi J. Relationship between brain volume reduction during the acute phase of sepsis and activities of daily living in elderly patients: A prospective cohort study. PLoS One 2023; 18:e0284886. [PMID: 37192211 DOI: 10.1371/journal.pone.0284886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 04/11/2023] [Indexed: 05/18/2023] Open
Abstract
Brain damage in acute sepsis may be associated with poor long-term outcomes that impair reintegration into society. We aimed to clarify whether brain volume reduction occurs during the acute phase of sepsis in patients with acute brain damage. In this prospective, noninterventional observational study, brain volume reduction was evaluated by comparing head computed tomography findings at admission with those obtained during hospitalization. We examined the association between brain volume reduction and performance of the activities of daily living in 85 consecutive patients (mean age, 77 ± 12.7 years) with sepsis or septic shock. The bicaudate ratio increased in 38/58 (65.5%) patients, Evans index increased in 35/58 (60.3%) patients, and brain volume by volumetry decreased in 46/58 (79.3%) patients from the first to the second measurement, with significant increases in the bicaudate ratio (P < 0.0001) and Evans index (P = 0.0005) and a significant decrease in the brain volume by volumetry (P < 0.0001). The change rate for brain volume by volumetry was significantly correlated with the Katz index (ρ = -0.3790, P = 0.0094). In the acute phase of sepsis in this sample of older patients, 60-79% of patients showed decreased brain volumes. This was associated with a decreased capacity for performing activities of daily living.
Collapse
Affiliation(s)
- Toru Hosokawa
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kosaku Kinoshita
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Shingo Ihara
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Katsuhiro Nakagawa
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Umefumi Iguchi
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Marina Hirabayashi
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tomokazu Mutoh
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Nami Sawada
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tsukasa Kuwana
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Junko Yamaguchi
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| |
Collapse
|
14
|
Sauer M, Sievert A, Wrobel M, Schmude P, Richter G. Acoustocerebrography in septic patients: A randomized and controlled pilot study. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:920674. [PMID: 36203789 PMCID: PMC9531262 DOI: 10.3389/fmedt.2022.920674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
Sepsis-associated encephalopathy (SAE) is a common organ dysfunction in patients with severe sepsis or septic shock and leads to higher mortality and longer hospital stay. The diagnosis remains an exclusion process; none of the available measurements are specific for SAE. The aim of the presented prospective and controlled clinical study was to evaluate the possible role of molecular acoustics in determining acute brain injury in septic patients using an acoustocerebrography (ACG) system. ACG is a multifrequency, transcranial ultrasound method that measures the attenuation and time of flight to detect changes in the brain tissue. After approval from the local research ethics committee (of the University Hospital of Rostock: Reg. No.: A 2016-0026), 20 patients were included in two study groups: septic shock group (SG) and control group (CG; postoperative nonseptic patients). All patients were screened several times with the ACG on different days. Blood parameters of organ function, sepsis-related organ failure assessment score, and delirium scores [Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC)] were obtained as well. A neurologist examined all patients at inclusion. Predictive analysis was done using a data-driven statistical method and by deriving a parameter from the ACG data. The study was registered under “clinicaltrials.gov” (Reg. No.: NCT03173196). All patients in the SG were CAM-ICU-positive at inclusion (ICDSC: in mean 4.0) and had clinical signs of SAE. In contrast, all patients in the CG were CAM-ICU-negative, with an ICDSC score of 0. Predictive analysis using the ACG data presented an accuracy of 83.4% with a specificity of 89.0% and a sensitivity of 75.1%. The ACG method may be helpful for the monitoring and diagnosing acute brain injury; however, the results of this first report should be verified by further clinical studies. Further investigations should include long-established instruments of SAE diagnosis, e.g., electroencephalography, MRI, and biomarkers, to compare the results with the ACG measurements.
Collapse
Affiliation(s)
- Martin Sauer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Rostock, Rostock, Germany
- Fraunhofer Institute Cell Therapy and Immunology, Leipzig, Germany
- Department of Intensive Care and Emergency Medicine, Hospital Magdeburg, Magdeburg, Germany
- Correspondence: Martin Sauer
| | - Anika Sievert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Rostock, Rostock, Germany
| | - Miroslaw Wrobel
- Fraunhofer Institute Cell Therapy and Immunology, Leipzig, Germany
| | - Paul Schmude
- Fraunhofer Institute Cell Therapy and Immunology, Leipzig, Germany
| | - Georg Richter
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Rostock, Rostock, Germany
- Fraunhofer Institute Cell Therapy and Immunology, Leipzig, Germany
- Department of Intensive Care and Emergency Medicine, Hospital Magdeburg, Magdeburg, Germany
| |
Collapse
|
15
|
Garbajs NZ, Singh TD, Valencia Morales DJ, Herasevich V, Warner DO, Martin DP, Knopman DS, Petersen RC, Hanson AC, Jennissen AJ, Schroeder DR, Weingarten TN, Gajic O, Rabinstein AA, Sprung J. Association of blood pressure variability with short- and long-term cognitive outcomes in patients with critical illness. J Crit Care 2022; 71:154107. [PMID: 35803011 DOI: 10.1016/j.jcrc.2022.154107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/20/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blood pressure variability (BPV), a modifiable risk factor, can compromise cerebral perfusion in critically ill patients. We studied the association between BPV in the intensive care unit (ICU) and short- and long-term cognitive outcomes. METHODS All patients were ≥50 years old. The short-term cognitive end points were delirium and depressed alertness without delirium. The long-term outcome was change in the slope of longitudinal cognitive scores. Primary BPV measure was average real variability (ARV) of systolic blood pressure. Associations were assessed with multivariable multinominal logistic regression and linear mixed effects models. RESULTS Of 794 patients (1130 admissions) 185 developed delirium and 274 developed depressed alertness. There was a dose-response association of 24-h systolic ARV with delirium (adjusted OR, 95% CI 2.15 per 5 mm Hg increase, 1.31-3.06, P < 0.017) and with depressed alertness (OR 1.89, 95% CI 1.18-3.03, P < 0.008). For 371 patients with available longitudinal cognitive scores, the decline in cognitive trajectory was accelerated after discharge (annual change OR -0.097, 95% CI -0.122 to -0.073). This acceleration increased with delirium (additional decline -0.132 [-0.233 to 0.030], P = 0.011). We found no significant association between BPV and post-ICU cognitive trajectory. CONCLUSIONS BPV was associated with increased likelihood of delirium in the ICU. Delirium, but not BPV, was associated with long-term cognitive decline.
Collapse
Affiliation(s)
- Nika Zorko Garbajs
- Department of Medicine, Division of Critical Care and Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA; Department of Vascular Neurology and Intensive Therapy, University Medical Centre Ljubljana, 1000, Slovenia
| | - Tarun D Singh
- Department of Medicine, Division of Critical Care and Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Vitaly Herasevich
- Department of Medicine, Division of Critical Care and Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David S Knopman
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Andrew C Hanson
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN 55905, USA
| | - Andrew J Jennissen
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN 55905, USA
| | - Darrell R Schroeder
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN 55905, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Ognjen Gajic
- Department of Medicine, Division of Critical Care and Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| |
Collapse
|
16
|
Liu YX, Yu Y, Liu JP, Liu WJ, Cao Y, Yan RM, Yao YM. Neuroimmune Regulation in Sepsis-Associated Encephalopathy: The Interaction Between the Brain and Peripheral Immunity. Front Neurol 2022; 13:892480. [PMID: 35832175 PMCID: PMC9271799 DOI: 10.3389/fneur.2022.892480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/27/2022] [Indexed: 11/15/2022] Open
Abstract
Sepsis-associated encephalopathy (SAE), the most popular cause of coma in the intensive care unit (ICU), is the diffuse cerebral damage caused by the septic challenge. SAE is closely related to high mortality and extended cognitive impairment in patients in septic shock. At present, many studies have demonstrated that SAE might be mainly associated with blood–brain barrier damage, abnormal neurotransmitter secretion, oxidative stress, and neuroimmune dysfunction. Nevertheless, the precise mechanism which initiates SAE and contributes to the long-term cognitive impairment remains largely unknown. Recently, a growing body of evidence has indicated that there is close crosstalk between SAE and peripheral immunity. The excessive migration of peripheral immune cells to the brain, the activation of glia, and resulting dysfunction of the central immune system are the main causes of septic nerve damage. This study reviews the update on the pathogenesis of septic encephalopathy, focusing on the over-activation of immune cells in the central nervous system (CNS) and the “neurocentral–endocrine–immune” networks in the development of SAE, aiming to further understand the potential mechanism of SAE and provide new targets for diagnosis and management of septic complications.
Collapse
Affiliation(s)
- Yu-xiao Liu
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, The Chinese PLA General Hospital, Beijing, China
| | - Yang Yu
- Department of Traditional Chinese Medical Science, Sixth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Jing-peng Liu
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
- Department of Traditional Chinese Medical Science, Sixth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Wen-jia Liu
- State Key Laboratory of Proteomics, Beijing Proteome Research Center, National Center for Protein Sciences, Beijing Institute of Lifeomics, Beijing, China
| | - Yang Cao
- Department of Neurosurgery, The Chinese PLA General Hospital, Beijing, China
| | - Run-min Yan
- Department of Neurosurgery, The Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yong-ming Yao
| | - Yong-ming Yao
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
- Run-min Yan
| |
Collapse
|
17
|
Clinical features, electroencephalogram, and biomarkers in pediatric sepsis-associated encephalopathy. Sci Rep 2022; 12:10673. [PMID: 35739230 PMCID: PMC9225983 DOI: 10.1038/s41598-022-14853-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 06/14/2022] [Indexed: 11/09/2022] Open
Abstract
To date, no specific diagnostic criteria for sepsis-associated encephalopathy (SAE) have been established. We studied 33 pediatric patients with sepsis prospectively and evaluated the level of consciousness, the presence of delirium, electroencephalographic (EEG) findings, and plasma levels of neuron-specific enolase and S100-calcium-binding protein-B. A presumptive diagnosis of SAE was primarily considered in the presence of a decreased level of consciousness and/or delirium (clinical criteria), but specific EEG abnormalities were also considered (EEG criteria). The time course of the biomarkers was compared between groups with and without clinical or EEG criteria. The Functional Status Scale (FSS) was assessed at admission, discharge, and 3–6 months post-discharge. Clinical criteria were identified in 75.8% of patients, EEG criteria in 26.9%, both in 23.1%, and none in 23.1%. Biomarkers did not differ between groups. Three patients had an abnormal FSS at discharge, but no one on follow-up. A definitive diagnostic pattern for SAE remained unclear. Clinical criteria should be the basis for diagnosis, but sedation may be a significant confounder, also affecting EEG interpretation. The role of biomarkers requires a better definition. The diagnosis of SAE in pediatric patients remains a major challenge. New consensual diagnostic definitions and mainly prognostic studies are needed.
Collapse
|
18
|
Pohlan J, Nawabi J, Witham D, Schroth L, Krause F, Schulze J, Gelen S, Ahlborn R, Rubarth K, Dewey M. Cerebrovascular Events in Suspected Sepsis: Retrospective Prevalence Study in Critically Ill Patients Undergoing Full-Body Computed Tomography. Front Neurol 2022; 13:811022. [PMID: 35614926 PMCID: PMC9125158 DOI: 10.3389/fneur.2022.811022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/28/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose This study aimed at retrospectively evaluating full-body computed tomography (CT) examinations for the prevalence of cerebrovascular events in patients with suspected sepsis treated in the intensive care unit (ICU). Methods All full-body CT examinations, i.e., both cranial CT (cCT) and body CT including chest, abdomen and pelvis, for focus search in septic patients over a 12-months period were identified from three ICUs, using full-text search. From this retrospective cohort, we fully analyzed 278 cCT examinations for the occurrence of acute cerebral findings. All acute cerebrovascular events were independently reviewed by two blinded readers. Clinical and laboratory findings were extracted. The data were statistically analyzed using contingency tests. Results In our population of patients with suspected sepsis, 10.8% (n = 30/278) were identified to have major cerebral events, including 7.2% (n = 20/278) major cerebrovascular events and 4.3% (n = 12/278) generalized parenchymal damage. 13.4% (n = 22/163) of patients with a severe coma as compared with non-severe coma, 4.4% (n = 3/68), showed a major cerebral event (p = 0.04). Patients referred from the cardiology/nephrology ICU ward showed major cerebral events in 16.3% (n = 22/135), as compared with 4.9% (n = 3/61) in patients from pulmonary ICU and 6.1% (n = 5/82) major cerebral events with surgical referral (p = 0.02). Conclusion Our study provides further evidence that septic patients may suffer from cerebral events with relevance to their prognosis. Severe coma and the referring ward were associated with acute cerebral conditions. Full-body CT has the advantage of both detecting of septic foci and possibly identifying ischemic or hemorrhagic stroke in this vulnerable patient population.
Collapse
Affiliation(s)
- Julian Pohlan
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Charité Medical University of Berlin, Berlin, Germany
- *Correspondence: Julian Pohlan
| | - Jawed Nawabi
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Charité Medical University of Berlin, Berlin, Germany
| | - Denis Witham
- Department of Cardiology With Intensive Care, Charité – Universitätsmedizin Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Luna Schroth
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Finn Krause
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jan Schulze
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Simon Gelen
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Robert Ahlborn
- Department of Information Technology, Charité – Universitätsmedizin Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kerstin Rubarth
- Berlin Institute of Health, Charité Medical University of Berlin, Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marc Dewey
- Department of Radiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| |
Collapse
|
19
|
Lyra E Silva NM, Barros-Aragão FGQ, De Felice FG, Ferreira ST. Inflammation at the crossroads of COVID-19, cognitive deficits and depression. Neuropharmacology 2022; 209:109023. [PMID: 35257690 PMCID: PMC8894741 DOI: 10.1016/j.neuropharm.2022.109023] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/27/2022] [Accepted: 03/02/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Natalia M Lyra E Silva
- Centre for Neuroscience Studies, Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada; Department of Psychiatry, Queen's University, Kingston, ON, Canada.
| | - Fernanda G Q Barros-Aragão
- D'OR Institute for Research & Education, RJ, Brazil; Institute of Medical Biochemistry Leopoldo de Meis, Federal University of Rio de Janeiro, RJ, Brazil.
| | - Fernanda G De Felice
- Centre for Neuroscience Studies, Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada; Department of Psychiatry, Queen's University, Kingston, ON, Canada; D'OR Institute for Research & Education, RJ, Brazil; Institute of Medical Biochemistry Leopoldo de Meis, Federal University of Rio de Janeiro, RJ, Brazil
| | - Sergio T Ferreira
- D'OR Institute for Research & Education, RJ, Brazil; Institute of Medical Biochemistry Leopoldo de Meis, Federal University of Rio de Janeiro, RJ, Brazil; Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, RJ, Brazil
| |
Collapse
|
20
|
Sekino N, Selim M, Shehadah A. Sepsis-associated brain injury: underlying mechanisms and potential therapeutic strategies for acute and long-term cognitive impairments. J Neuroinflammation 2022; 19:101. [PMID: 35488237 PMCID: PMC9051822 DOI: 10.1186/s12974-022-02464-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/14/2022] [Indexed: 12/29/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis causes cerebral dysfunction in the short and long term and induces disruption of the blood–brain barrier (BBB), neuroinflammation, hypoperfusion, and accumulation of amyloid β (Aβ) and tau protein in the brain. White matter changes and brain atrophy can be detected using brain imaging, but unfortunately, there is no specific treatment that directly addresses the underlying mechanisms of cognitive impairments in sepsis. Here, we review the underlying mechanisms of sepsis-associated brain injury, with a focus on BBB dysfunction and Aβ and tau protein accumulation in the brain. We also describe the neurological manifestations and imaging findings of sepsis-associated brain injury, and finally, we propose potential therapeutic strategies for acute and long-term cognitive impairments associated with sepsis. In the acute phase of sepsis, we suggest using antibiotics (such as rifampicin), targeting proinflammatory cytokines, and preventing ischemic injuries and hypoperfusion. In the late phase of sepsis, we suggest targeting neuroinflammation, BBB dysfunction, Aβ and tau protein phosphorylation, glycogen synthase kinase-3 beta (GSK3β), and the receptor for advanced glycation end products (RAGE). These proposed strategies are meant to bring new mechanism-based directions for future basic and clinical research aimed at preventing or ameliorating acute and long-term cognitive impairments in patients with sepsis.
Collapse
Affiliation(s)
- Nobufumi Sekino
- Department of Medicine, Translational Therapeutics Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Magdy Selim
- Department of Neurology, Stroke and Cerebrovascular Diseases Division, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, CLS-641, Boston, MA, 02215, USA
| | - Amjad Shehadah
- Department of Neurology, Stroke and Cerebrovascular Diseases Division, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, CLS-641, Boston, MA, 02215, USA.
| |
Collapse
|
21
|
Barichello T, Generoso JS, Dominguini D, Córneo E, Giridharan VV, Sahrapour TA, Simões LR, Rosa MID, Petronilho F, Ritter C, Sharshar T, Dal-Pizzol F. Postmortem Evidence of Brain Inflammatory Markers and Injury in Septic Patients: A Systematic Review. Crit Care Med 2022; 50:e241-e252. [PMID: 34402457 DOI: 10.1097/ccm.0000000000005307] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Sepsis is a life-threatening organ dysfunction caused by a host's unregulated immune response to eliminate the infection. After hospitalization, sepsis survivors often suffer from long-term impairments in memory, attention, verbal fluency, and executive functioning. To understand the effects of sepsis and the exacerbated peripheral inflammatory response in the brain, we asked the question: What are the findings and inflammatory markers in the brains of deceased sepsis patients? To answer this question, we conducted this systematic review by the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. DATA SOURCES Relevant studies were identified by searching the PubMed/National Library of Medicine, PsycINFO, EMBASE, Bibliographical Index in Spanish in Health Sciences, Latin American and Caribbean Health Sciences Literature, and Web of Science databases for peer-reviewed journal articles published on April 05, 2021. STUDY SELECTION A total of 3,745 articles were included in the primary screening; after omitting duplicate articles, animal models, and reviews, 2,896 articles were selected for the study. These studies were selected based on the title and abstract, and 2,772 articles were still omitted based on the exclusion criteria. DATA EXTRACTION The complete texts of the remaining 124 articles were obtained and thoroughly evaluated for the final screening, and 104 articles were included. DATA SYNTHESIS The postmortem brain had edema, abscess, hemorrhagic and ischemic injuries, infarction, hypoxia, atrophy, hypoplasia, neuronal loss, axonal injuries, demyelination, and necrosis. CONCLUSIONS The mechanisms by which sepsis induces brain dysfunction are likely to include vascular and neuronal lesions, followed by the activation of glial cells and the presence of peripheral immune cells in the brain.
Collapse
Affiliation(s)
- Tatiana Barichello
- Translational Psychiatry Program, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Santa Catarina, Brazil
| | - Jaqueline S Generoso
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Santa Catarina, Brazil
| | - Diogo Dominguini
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Santa Catarina, Brazil
| | - Emily Córneo
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Santa Catarina, Brazil
| | - Vijayasree V Giridharan
- Translational Psychiatry Program, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Taha A Sahrapour
- Translational Psychiatry Program, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Lutiana R Simões
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Santa Catarina, Brazil
| | - Maria Inês da Rosa
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Santa Catarina, Brazil
| | - Fabricia Petronilho
- Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Santa Catarina, Brazil
| | - Cristiane Ritter
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Santa Catarina, Brazil
| | - Tarek Sharshar
- Department of Neurointensive Care and Neuroanesthesia, GHU Paris Psychiatrie et Neuroscience, Paris, France
- Université de Paris, Paris, France
| | - Felipe Dal-Pizzol
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Santa Catarina, Brazil
| |
Collapse
|
22
|
Becker AE, Teixeira SR, Lunig NA, Mondal A, Fitzgerald JC, Topjian AA, Weiss SL, Griffis H, Schramm SE, Traynor DM, Vossough A, Kirschen MP. Sepsis-Related Brain MRI Abnormalities Are Associated With Mortality and Poor Neurological Outcome in Pediatric Sepsis. Pediatr Neurol 2022; 128:1-8. [PMID: 34992035 PMCID: PMC9685598 DOI: 10.1016/j.pediatrneurol.2021.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/28/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND It is not known whether brain magnetic resonance imaging (MRI) abnormalities in pediatric sepsis are associated with clinical outcomes. Study objectives were to (1) determine the prevalence and type of sepsis-related neuroimaging abnormalities evident on clinically indicated brain MRI in children with sepsis and (2) test the association of these abnormalities with mortality, new disability, length of stay (LOS), and MRI indication. METHODS Retrospective cohort study of 140 pediatric patients with sepsis and a clinically indicated brain MRI obtained within 60 days of sepsis onset at a single, large academic pediatric intensive care unit (PICU). Two radiologists systematically reviewed the first post-sepsis brain MRI and determined which abnormalities were sepsis-related. Outcomes compared in patients with versus without sepsis-related MRI abnormalities. RESULTS PICU mortality was 7%. Thirty patients had one or more sepsis-related MRI abnormality, yielding a prevalence of 21% (95% confidence interval 15%, 28%). Among those, 53% (16 of 30) had sepsis-related white matter signal abnormalities; 53% (16 of 30) sepsis-related ischemia, infarction, or thrombosis; and 27% (eight of 30) sepsis-related posterior reversible encephalopathy. Patients with one or more sepsis-related MRI abnormality had increased mortality (17% vs 5%; P = 0.04), new neurological disability at PICU discharge (32% vs 11%; P = 0.03), and longer PICU LOS (median 18 vs 11 days; P = 0.04) compared with patients without. CONCLUSIONS In children with sepsis and a clinically indicated brain MRI, 21% had a sepsis-related MRI abnormality. Sepsis-related MRI abnormalities were associated with increased mortality, new neurological disability, and longer PICU LOS.
Collapse
Affiliation(s)
- Andrew E. Becker
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sara R. Teixeira
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Nicholas A. Lunig
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Antara Mondal
- Department of Biomedical & Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Julie C. Fitzgerald
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,CHOP Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alexis A. Topjian
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Scott L. Weiss
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,CHOP Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Heather Griffis
- Department of Biomedical & Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Stephanie E. Schramm
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Danielle M. Traynor
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Arastoo Vossough
- Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Matthew P. Kirschen
- Department of Anesthesiology & Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
23
|
Pu Y, Zhao L, Xi Y, Xia Y, Qian Y. The protective effects of Mirtazapine against lipopolysaccharide (LPS)-induced brain vascular hyperpermeability. Bioengineered 2022; 13:3680-3693. [PMID: 35081868 PMCID: PMC8973832 DOI: 10.1080/21655979.2021.2024962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Sepsis is mainly characterized by severe inflammation triggered by infection, and sepsis-associated encephalopathy (SAE) is defined as brain damage caused by sepsis. Disruption of the blood-brain barrier (BBB) triggered by injured brain microvascular endothelial cells (BMECs) and damaged tight junction (TJ) structure is closely associated with the pathogenesis of SAE. The present research proposed to evaluate the potential therapeutic effects of Mirtazapine, a central presynaptic α2 receptor antagonist, on LPS-induced BBB disruption. The mice were administered with normal saline and 10 mg/kg Mirtazapine for 8 consecutive days, and from day 6, the experiment group of mice received LPS for 2 days to induce SAE. We found that the increased BBB permeability, elevated concentrations of inflammatory factors in brain tissues, and downregulated zonula occludens -1 (ZO-1) were observed in LPS-stimulated mice, all of which were reversed by 10 mg/kg Mirtazapine. In the in vitro assay, bEnd.3 brain endothelial cells were treated with 1 μM LPS in the absence or presence of Mirtazapine (25, 50 μM). We found that LPS-treated cells had significantly declined transendothelial electrical resistance (TEER), increased monolayer permeability, elevated production of inflammatory factors, and downregulated ZO-1. However, 25 and 50 μM Mirtazapine ameliorated all these LPS- induced aberrations. Mirtazapine also mitigated the decreased level of NF-E2-related factor 2 (Nrf2) in LPS-challenged endothelial cells. The protective effect of Mirtazapine on endothelial permeability against LPS was significantly abolished by the knockdown of Nrf2. Collectively, we concluded that Mirtazapine exerted protective effects on LPS-induced endothelial cells hyperpermeability by upregulating Nrf2.
Collapse
Affiliation(s)
- Yuehong Pu
- Department of Emergency Medicine, Yueyang Hospital of Intergrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lei Zhao
- Department of Emergency Medicine, Yueyang Hospital of Intergrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yao Xi
- Department of Emergency Medicine, Yueyang Hospital of Intergrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yichun Xia
- Department of Emergency Medicine, Yueyang Hospital of Intergrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yiming Qian
- Department of Emergency Medicine, Yueyang Hospital of Intergrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| |
Collapse
|
24
|
Lin J, Tan B, Li Y, Feng H, Chen Y. Sepsis-Exacerbated Brain Dysfunction After Intracerebral Hemorrhage. Front Cell Neurosci 2022; 15:819182. [PMID: 35126060 PMCID: PMC8814659 DOI: 10.3389/fncel.2021.819182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/27/2021] [Indexed: 12/28/2022] Open
Abstract
Sepsis susceptibility is significantly increased in patients with intracerebral hemorrhage (ICH), owing to immunosuppression and intestinal microbiota dysbiosis. To date, ICH with sepsis occurrence is still difficult for clinicians to deal with, and the mortality, as well as long-term cognitive disability, is still increasing. Actually, intracerebral hemorrhage and sepsis are mutually exacerbated via similar pathophysiological mechanisms, mainly consisting of systemic inflammation and circulatory dysfunction. The main consequence of these two processes is neural dysfunction and multiple organ damages, notably, via oxidative stress and neurotoxic mediation under the mediation of central nervous system activation and blood-brain barrier disruption. Besides, the comorbidity-induced multiple organ damages will produce numerous damage-associated molecular patterns and consequently exacerbate the severity of the disease. At present, the prospective views are about operating artificial restriction for the peripheral immune system and achieving cross-tolerance among organs via altering immune cell composition to reduce inflammatory damage.
Collapse
Affiliation(s)
- Jie Lin
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
| | - Binbin Tan
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
| | - Yuhong Li
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
| | - Hua Feng
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Hua Feng, ;
| | - Yujie Chen
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University, Army Medical University, Chongqing, China
- *Correspondence: Yujie Chen, ;
| |
Collapse
|
25
|
Peng X, Luo Z, He S, Zhang L, Li Y. Blood-Brain Barrier Disruption by Lipopolysaccharide and Sepsis-Associated Encephalopathy. Front Cell Infect Microbiol 2021; 11:768108. [PMID: 34804998 PMCID: PMC8599158 DOI: 10.3389/fcimb.2021.768108] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/14/2021] [Indexed: 12/29/2022] Open
Abstract
As a complex multicellular structure of the vascular system at the central nervous system (CNS), the blood-brain barrier (BBB) separates the CNS from the system circulation and regulates the influx and efflux of substances to maintain the steady-state environment of the CNS. Lipopolysaccharide (LPS), the cell wall component of Gram-negative bacteria, can damage the barrier function of BBB and further promote the occurrence and development of sepsis-associated encephalopathy (SAE). Here, we conduct a literature review of the direct and indirect damage mechanisms of LPS to BBB and the relationship between these processes and SAE. We believe that after LPS destroys BBB, a large number of inflammatory factors and neurotoxins will enter and damage the brain tissue, which will activate brain immune cells to mediate inflammatory response and in turn further destroys BBB. This vicious circle will ultimately lead to the progression of SAE. Finally, we present a succinct overview of the treatment of SAE by restoring the BBB barrier function and summarize novel opportunities in controlling the progression of SAE by targeting the BBB.
Collapse
Affiliation(s)
- Xiaoyao Peng
- Department of Clinical Medicine, School of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Zhixuan Luo
- Department of Clinical Medicine, School of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Shuang He
- Department of Clinical Medicine, School of Clinical Medicine, Southwest Medical University, Luzhou, China
| | - Luhua Zhang
- Department of Pathogenic Biology, School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| | - Ying Li
- Department of Immunology, School of Basic Medical Sciences, Southwest Medical University, Luzhou, China
| |
Collapse
|
26
|
Abstract
Uremic encephalopathy encompasses a wide range of central nervous system abnormalities associated with poor kidney function occurring with either progressive chronic kidney disease or acute kidney injury. The syndrome is likely caused by retention of uremic solutes, alterations in hormonal metabolism, changes in electrolyte and acid-base homeostasis, as well as changes in vascular reactivity, blood-brain barrier transport, and inflammation. There are no defining clinical, laboratory, or imaging findings, and the diagnosis is often made retrospectively when symptoms improve after dialysis or transplantation. The diagnosis is also made difficult because of the many confounding and overlapping conditions seen in patients with chronic kidney disease and acute kidney injury. Thus, institution of kidney replacement therapy should be considered as a trial to improve symptoms in the right clinical context. Neurological symptoms that do not improve after improvement in clearance should prompt a search for other explanations. Further knowledge linking possible uremic retention solutes with neurological symptoms is needed to better understand this syndrome as well as to develop more tailored treatments that aim to improve cognitive function.
Collapse
|
27
|
You L, Jiang H. Cabergoline possesses a beneficial effect on blood-brain barrier (BBB) integrity against lipopolysaccharide (LPS). Bioengineered 2021; 12:8358-8369. [PMID: 34592907 PMCID: PMC8806944 DOI: 10.1080/21655979.2021.1987066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Sepsis is a disease induced by severe systemic inflammation and contributes to multiple acute organic dysfunctions. It is reported that disrupted blood-brain barrier (BBB) integrity is involved in sepsis-associated encephalopathy (SAE), which can be alleviated by repairing the damaged tight junction structure. Cabergoline is a specific dopamine D2 receptor agonist developed to treat Parkinson’s disease and hyperprolactinemia and is reported to exert promising anti-inflammatory properties. The present study aimed to explore the beneficial effect of Cabergoline for the treatment of sepsis. In the animal experiments, mice were separated into 4 groups: sham, LPS (5 mg/kg), Cabergoline (0.1 mg/kg/day), and Cabergoline+LPS. We found that the increased neurological deficits, disrupted BBB integrity, elevated production of inflammatory factors, and declined expression level of zonula occludens-1 (ZO-1) were observed in lipopolysaccharide (LPS)-treated mice, all of which were significantly reversed by the administration of Cabergoline. In the in vitro model, human brain microvascular endothelial cells (HBMECs) were challenged with 1 µg/mL LPS in the presence or absence of Cabergoline (10, 20 μM) for 24 hours. The elevated cell permeability Papp value of fluorescein disodium across the HBMECs monolayer and declined trans-endothelial electrical resistance (TEER) in the LPS-treated HBMECs were significantly alleviated by Cabergoline, accompanied by the upregulation of ZO-1. In addition, wnt1 and β-catenin were found downregulated, which was reversed by Cabergoline. Importantly, the protective benefits of Cabergoline were all abolished by the overexpression of Dickkopf 3 (DKK3). Taken together, our data reveal that Cabergoline possessed a protective effect on BBB integrity against LPS.
Collapse
Affiliation(s)
- Lina You
- Department of Gerontology, Traditional Chinese medicine hospital of Jiulongpo District in Chongqing, Chongqing, 400080, China
| | - Haidong Jiang
- Chongqing Infectious Disease Medical Center, Chongqing, 400080, China
| |
Collapse
|
28
|
Huang Y, Chen R, Jiang L, Li S, Xue Y. Basic research and clinical progress of sepsis-associated encephalopathy. JOURNAL OF INTENSIVE MEDICINE 2021; 1:90-95. [PMID: 36788800 PMCID: PMC9923961 DOI: 10.1016/j.jointm.2021.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/22/2021] [Accepted: 08/18/2021] [Indexed: 01/02/2023]
Abstract
Sepsis-associated encephalopathy (SAE), a major cerebral complication of sepsis, occurs in 70% of patients admitted to the intensive care unit (ICU). This condition can cause serious impairment of consciousness and is associated with a high mortality rate. Thus far, several experimental screenings and radiological techniques (e.g., electroencephalography) have been used for the non-invasive assessment of the structure and function of the brain in patients with SAE. Nevertheless, the pathogenesis of SAE is complicated and remains unclear. In the present article, we reviewed the currently available literature on the epidemiology, clinical manifestations, pathology, diagnosis, and management of SAE. However, currently, there is no ideal pharmacological treatment for SAE. Treatment targeting mitochondrial dysfunction may be useful in the management of SAE.
Collapse
Affiliation(s)
- Ying Huang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xin-Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China,Corresponding author: Ying Huang, Department of Anesthesiology and Surgical Intensive Care Unit, Xin-Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Shanghai 200092, China.
| | - Ruman Chen
- Department of Blood Purification, Hainan General Hospital Affiliated to Hainan Medical University, Haikou, Hainan 570311, China
| | - Lai Jiang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xin-Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Siyuan Li
- Department of Anesthesiology and Surgical Intensive Care Unit, Xin-Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| | - Yuchen Xue
- Department of Anesthesiology and Surgical Intensive Care Unit, Xin-Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
| |
Collapse
|
29
|
Cui W, Chen J, Yu F, Liu W, He M. GYY4137 protected the integrity of the blood-brain barrier via activation of the Nrf2/ARE pathway in mice with sepsis. FASEB J 2021; 35:e21710. [PMID: 34143548 DOI: 10.1096/fj.202100074r] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/10/2021] [Accepted: 05/17/2021] [Indexed: 12/20/2022]
Abstract
Injury to the blood-brain barrier (BBB) plays a vital role in sepsis-associated encephalopathy (SAE), which is one of the most common complications of sepsis. GYY4137, a new synthetic compound of hydrogen sulfide (H2 S), has extensive biological benefits. In this study, we focused on the protective effects of GYY4137 on the BBB in septic mice and the underlying mechanisms. The results suggested that whether administrated at the same time or 3 hours after LPS injection, GYY4137 both significantly alleviated the clinical symptoms and the long-term prognosis. Besides, GYY4137 improved the pathological abnormalities of septic mice. Moreover, the degradation of tight junctions in the BBB was considerably inhibited by GYY4137. In addition, GYY4137 significantly attenuated inflammation and apoptosis in the brain. Furthermore, GYY4137 activated the Nrf2/ARE pathway through the sulfhydrylation of Keap1 and inhibited oxidative stress. ML385, the specific inhibitor of Nrf2, significantly reversed the protective effects of GYY4137 in sepsis mice. In conclusion, this study indicated that through the sulfhydrylation of Keap1, GYY4137 activated the Nrf2/ARE pathway and exerted anti-inflammatory, anti-apoptotic and antioxidant effects in septic mice that consequently protected the integrity of the BBB and improved the clinical outcome of sepsis. Our findings suggest that GYY4137 might be a promising agent for the treatment of SAE.
Collapse
Affiliation(s)
- Wei Cui
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jing Chen
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Feng Yu
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Wenhong Liu
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Maolin He
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
30
|
Abstract
An aging-related reduction in the brain's functional reserve may explain why delirium is more frequent in the elderly than in younger people insofar as the reserve becomes inadequate to cover the metabolic requirements that are critically increased by stressors. The aim of this paper is to review the normal aging-related changes that theoretically compromise complex mental activities, neuronal and synaptic densities, and the neurocomputational flexibility of the functional reserve. A pivotal factor is diminished connectivity, which is substantially due to the loss of synapses and should specifically affect association systems and cholinergic fibres in delirious patients. However, micro-angiopathy with impaired blood flow autoregulation, increased blood/brain barrier permeability, changes in cerebrospinal fluid dynamics, weakened mitochondrial performance, and a pro-inflammatory involution of the immune system may also jointly affect neurons and their synaptic assets, and even cause the progression of delirium to dementia regardless of the presence of co-existing plaques, tangles, or other pathological markers. On the other hand, the developmental growth in functional reserve during childhood and adolescence makes the brain increasingly resistant to delirium, and residual reserve can allow the elderly to recover. These data support the view that functional reserve is the variable that confronts stressors and governs the risk and intensity of and recovery from delirium. Although people of any age are at risk of delirium, the elderly are at greater risk because aging and age-dependent structural changes inevitably affect the brain's functional reserve.
Collapse
|
31
|
Pensato U, Muccioli L, Cani I, Janigro D, Zinzani PL, Guarino M, Cortelli P, Bisulli F. Brain dysfunction in COVID-19 and CAR-T therapy: cytokine storm-associated encephalopathy. Ann Clin Transl Neurol 2021; 8:968-979. [PMID: 33780166 PMCID: PMC8045903 DOI: 10.1002/acn3.51348] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/03/2021] [Accepted: 03/07/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Many neurological manifestations are associated with COVID-19, including a distinct form of encephalopathy related to cytokine storm, the acute systemic inflammatory syndrome present in a subgroup of COVID-19 patients. Cytokine storm is also associated with immune effector cell-associated neurotoxicity syndrome (ICANS), a complication of chimeric antigen receptor T-cell (CAR-T) therapy, a highly effective treatment for refractory hematological malignancies. We investigated whether COVID-19-related encephalopathy, ICANS, and other encephalopathies associated with cytokine storm, share clinical and investigative findings. METHODS Narrative literature review. RESULTS Comparisons between COVID-19-related encephalopathy and ICANS revealed several overlapping features. Clinically, these included dysexecutive syndrome, language disturbances, akinetic mutism and delirium. EEG showed a prevalence of frontal abnormalities. Brain MRI was often unrevealing. CSF elevated cytokine levels have been reported. A direct correlation between cytokine storm intensity and severity of neurological manifestations has been shown for both conditions. Clinical recovery occurred spontaneously or following immunotherapies in most of the patients. Similar clinical and investigative features were also reported in other encephalopathies associated with cytokine storm, such as hemophagocytic lymphohistiocytosis, sepsis, and febrile infection-associated encephalopathies. INTERPRETATION COVID-19-related encephalopathy and ICANS are characterized by a predominant electro-clinical frontal lobe dysfunction and share several features with other encephalopathies associated with cytokine storm, which may represent the common denominator of a clinical spectrum of neurological disorders. Therefore, we propose a unifying definition of cytokine storm-associated encephalopathy (CySE), and its diagnostic criteria.
Collapse
Affiliation(s)
- Umberto Pensato
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Lorenzo Muccioli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Ilaria Cani
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Damir Janigro
- Department of Physiology, Case Western Reserve University, Cleveland, OH, USA
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Istituto di Ematologia "Seragnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Pietro Cortelli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesca Bisulli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| |
Collapse
|
32
|
Slessarev M, Mahmoud O, McIntyre CW, Ellis CG. Cerebral Blood Flow Deviations in Critically Ill Patients: Potential Insult Contributing to Ischemic and Hyperemic Injury. Front Med (Lausanne) 2021; 7:615318. [PMID: 33553208 PMCID: PMC7854569 DOI: 10.3389/fmed.2020.615318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/14/2020] [Indexed: 11/27/2022] Open
Abstract
Background: Ischemic and hyperemic injury have emerged as biologic mechanisms that contribute to cognitive impairment in critically ill patients. Spontaneous deviations in cerebral blood flow (CBF) beyond ischemic and hyperemic thresholds may represent an insult that contributes to this brain injury, especially if they accumulate over time and coincide with impaired autoregulation. Methods: We used transcranial Doppler to measure the proportion of time that CBF velocity (CBFv) deviated beyond previously reported ischemic and hyperemic thresholds in a cohort of critically ill patients with respiratory failure and/or shock within 48 h of ICU admission. We also assessed whether these CBFv deviations were more common during periods of impaired dynamic autoregulation, and whether they are explained by concurrent variations in mean arterial pressure (MAP) and end-tidal PCO2 (PetCO2). Results: We enrolled 12 consecutive patients (three females) who were monitored for a mean duration of 462.6 ± 39.8 min. Across patients, CBFv deviated by more than 20–30% from its baseline for 17–24% of the analysis time. These CBFv deviations occurred equally during periods of preserved and impaired autoregulation, while concurrent variations in MAP and PetCO2 explained only 13–21% of these CBFv deviations. Conclusion: CBFv deviations beyond ischemic and hyperemic thresholds are common in critically ill patients with respiratory failure or shock. These deviations occur irrespective of the state of dynamic autoregulation and are not explained by changes in MAP and CO2. Future studies should explore mechanisms responsible for these CBFv deviations and establish whether their cumulative burden predicts poor neurocognitive outcomes.
Collapse
Affiliation(s)
- Marat Slessarev
- Department of Medicine, Western University, London, ON, Canada.,Department of Medical Biophysics, Western University, London, ON, Canada.,Brain & Mind Institute, Western University, London, ON, Canada
| | - Ossama Mahmoud
- Department of Computer Science, Western University, London, ON, Canada
| | - Christopher W McIntyre
- Department of Medicine, Western University, London, ON, Canada.,Department of Medical Biophysics, Western University, London, ON, Canada
| | - Christopher G Ellis
- Department of Medical Biophysics, Western University, London, ON, Canada.,Robarts Research Institute, Western University, London, ON, Canada
| |
Collapse
|
33
|
Rapalino O, Pourvaziri A, Maher M, Jaramillo-Cardoso A, Edlow BL, Conklin J, Huang S, Westover B, Romero JM, Halpern E, Gupta R, Pomerantz S, Schaefer P, Gonzalez RG, Mukerji SS, Lev MH. Clinical, Imaging, and Lab Correlates of Severe COVID-19 Leukoencephalopathy. AJNR Am J Neuroradiol 2021; 42:632-638. [PMID: 33414226 DOI: 10.3174/ajnr.a6966] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/28/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Patients infected with the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) can develop a spectrum of neurological disorders, including a leukoencephalopathy of variable severity. Our aim was to characterize imaging, lab, and clinical correlates of severe coronavirus disease 2019 (COVID-19) leukoencephalopathy, which may provide insight into the SARS-CoV-2 pathophysiology. MATERIALS AND METHODS Twenty-seven consecutive patients positive for SARS-CoV-2 who had brain MR imaging following intensive care unit admission were included. Seven (7/27, 26%) developed an unusual pattern of "leukoencephalopathy with reduced diffusivity" on diffusion-weighted MR imaging. The remaining patients did not exhibit this pattern. Clinical and laboratory indices, as well as neuroimaging findings, were compared between groups. RESULTS The reduced-diffusivity group had a significantly higher body mass index (36 versus 28 kg/m2, P < .01). Patients with reduced diffusivity trended toward more frequent acute renal failure (7/7, 100% versus 9/20, 45%; P = .06) and lower estimated glomerular filtration rate values (49 versus 85 mL/min; P = .06) at the time of MRI. Patients with reduced diffusivity also showed lesser mean values of the lowest hemoglobin levels (8.1 versus 10.2 g/dL, P < .05) and higher serum sodium levels (147 versus 139 mmol/L, P = .04) within 24 hours before MR imaging. The reduced-diffusivity group showed a striking and highly reproducible distribution of confluent, predominantly symmetric, supratentorial, and middle cerebellar peduncular white matter lesions (P < .001). CONCLUSIONS Our findings highlight notable correlations between severe COVID-19 leukoencephalopathy with reduced diffusivity and obesity, acute renal failure, mild hypernatremia, anemia, and an unusual brain MR imaging white matter lesion distribution pattern. Together, these observations may shed light on possible SARS-CoV-2 pathophysiologic mechanisms associated with leukoencephalopathy, including borderzone ischemic changes, electrolyte transport disturbances, and silent hypoxia in the setting of the known cytokine storm syndrome that accompanies severe COVID-19.
Collapse
Affiliation(s)
- O Rapalino
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - A Pourvaziri
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - M Maher
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - A Jaramillo-Cardoso
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | | | - J Conklin
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - S Huang
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | | | - J M Romero
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - E Halpern
- Institute for Technology Assessment (E.H.), Massachusetts General Hospital, Boston, Massachusetts
| | - R Gupta
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - S Pomerantz
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - P Schaefer
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | - R G Gonzalez
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| | | | - M H Lev
- From the Department of Radiology (O.R., A.P., M.M., A.J.-C., J.C., S.H., J.M.R., R.G., S.P., P.S., R.G.G., M.H.L.)
| |
Collapse
|
34
|
Barichello T, Generoso JS, Collodel A, Petronilho F, Dal-Pizzol F. The blood-brain barrier dysfunction in sepsis. Tissue Barriers 2021; 9:1840912. [PMID: 33319634 PMCID: PMC7849782 DOI: 10.1080/21688370.2020.1840912] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 12/30/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction triggered by a dysregulated host immune response attempting to eliminate the infection. After hospital discharge, half of the sepsis survivors recover, one-third of the patients die the following year, and one-sixth have a long-term cognitive impairment, including memory dysfunction, anxiety, depression, and post-traumatic stress disorder. The infection triggers the host immune response, and both can cause vascular endothelial damage, interrupting tight junctions proteins; consequently, the blood-brain barrier (BBB) breaks down, allowing and facilitating the entry of peripheral immune cells into the brain, which triggers or exacerbates the activation of glial cells and neuroinflammation. The focus of this review is to identify biochemical abnormalities induced by sepsis, which is associated with BBB dysfunction; provide evidence of biomarkers involved in the tight junction disruption and BBB damage, and draw attention to the role of the BBB as a bridge between systemic infection and brain inflammation.
Collapse
Affiliation(s)
- Tatiana Barichello
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, Brazil
- Translational Psychiatry Program, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jaqueline S. Generoso
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, Brazil
| | - Allan Collodel
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, Brazil
| | - Fabricia Petronilho
- Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Tubarão, Brazil
| | - Felipe Dal-Pizzol
- Laboratory of Experimental Pathophysiology, Graduate Program in Health Sciences, University of Southern Santa Catarina (UNESC), Criciúma, Brazil
| |
Collapse
|
35
|
Abstract
PURPOSE Triphasic waves (TWs) have been associated with a host of medication toxicities, and cefepime has emerged recently as a frequently encountered offending agent. This investigation aims to evaluate cefepime-induced encephalopathy and to report the associated clinical, EEG expression with TWs, and the radiologic findings. METHODS A retrospective multicenter observational study examining adult patients with cefepime-induced encephalopathy with generalized periodic discharges on either routine or continuous EEG between January 2014 and January 2020. Clinical, electrographic, and radiologic data were collected. Patients in whom cefepime was not the sole causative factor for their encephalopathy were excluded. RESULTS Twenty-seven patients with cefepime-induced encephalopathy marked by generalized periodic discharges with triphasic morphology were identified at both centers, whereas no patients were presenting with generalized periodic discharges without TWs. Patients had a median age of 63 years (interquartile range, 56-73). Fifty-six percent of the cohort (15 patients) were <65 years of age. Eighteen patients (67%) had either acute or chronic kidney impairment (either acute kidney injury or chronic kidney disease or both), whereas 81% had preexisting white matter disease on brain imaging. Of these, 14 patients (51%) were classified as either moderate or severe. In the majority of the patients, TWs were either state-dependent or stimulus-sensitive, and in one third of them presented only as stimulus-induced pattern. All patients improved with discontinuation of cefepime. CONCLUSIONS Cefepime toxicity should be considered in the differential diagnosis in encephalopathic patients with TWs. The presence of preexisting white matter disease in these patients should heighten the degree of suspicion, especially in younger patients and patients without renal dysfunction.
Collapse
|
36
|
Chen J, Martin C, Ball IM, McIntyre CW, Slessarev M. Impact of Graded Passive Cycling on Hemodynamics, Cerebral Blood Flow, and Cardiac Function in Septic ICU Patients. Front Med (Lausanne) 2020; 7:569679. [PMID: 33178715 PMCID: PMC7596326 DOI: 10.3389/fmed.2020.569679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/28/2020] [Indexed: 12/19/2022] Open
Abstract
Background: In-bed passive cycling is considered a safe and feasible early mobilization technique in intensive care unit (ICU) patients who are unable to exercise actively. However, the impact of varying intensity of passive cycling on perfusion and function of ischemia-prone organs is unknown. In this study, we assessed the impact of a graded passive cycling protocol on hemodynamics, cerebral blood flow, and cardiac function in a cohort of septic ICU patients. Methods: In consecutive patients presenting with sepsis, we measured global hemodynamic indices, middle cerebral artery velocity (MCAv), and cardiac function in response to a graded increase in passive cycling cadence. Using 5-min stages, we increased cadence from 5 to 55 RPM in increments of 10 RPM, preceded and followed by 5 min baseline and recovery periods at 0 RPM. The mean values obtained during the last 2 min of each stage were compared within and between subjects for all metrics using repeated-measures ANOVA. Results: Ten septic patients (six males) completed the protocol. Across patients, there was a 5.2% reduction in MCAv from baseline at cycling cadences of 25-45 RPM with a dose-dependent decrease of MCAv of > 10% in four of the 10 patients enrolled. There was a 16% increase in total peripheral resistance from baseline at peak cadence of 55 RPMs and no changes in any other measured hemodynamic parameters. Patient responses to passive cycling varied between patients in terms of magnitude, direction of change, and the cycling cadence at which these changes occurred. Conclusions: In septic patients, graded passive cycling is associated with dose-dependent decreases in cerebral blood flow, increases in total peripheral resistance, and either improvement or worsening of left ventricular function. The magnitude and cadence threshold of these responses vary between patients. Future studies should establish whether these changes are associated with clinical outcomes, including cognitive impairment, vasopressor use, and functional outcomes.
Collapse
Affiliation(s)
- Jennifer Chen
- Department of Medical Biophysics, Western University, London, ON, Canada
| | - Claudio Martin
- Department of Medicine, Western University, London, ON, Canada
| | - Ian M Ball
- Department of Medicine, Western University, London, ON, Canada.,Departments of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Christopher W McIntyre
- Department of Medical Biophysics, Western University, London, ON, Canada.,Department of Medicine, Western University, London, ON, Canada
| | - Marat Slessarev
- Department of Medical Biophysics, Western University, London, ON, Canada.,Department of Medicine, Western University, London, ON, Canada.,The Brain and Mind Institute, Western University, London, ON, Canada
| |
Collapse
|
37
|
van der Slikke EC, An AY, Hancock REW, Bouma HR. Exploring the pathophysiology of post-sepsis syndrome to identify therapeutic opportunities. EBioMedicine 2020; 61:103044. [PMID: 33039713 PMCID: PMC7544455 DOI: 10.1016/j.ebiom.2020.103044] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/09/2020] [Accepted: 09/16/2020] [Indexed: 12/14/2022] Open
Abstract
Sepsis is a major health problem worldwide. As the number of sepsis cases increases, so does the number of sepsis survivors who suffer from “post-sepsis syndrome” after hospital discharge. This syndrome involves deficits in multiple systems, including the immune, cognitive, psychiatric, cardiovascular, and renal systems. Combined, these detrimental consequences lead to rehospitalizations, poorer quality of life, and increased mortality. Understanding the pathophysiology of these issues is crucial to develop new therapeutic opportunities to improve survival rate and quality of life of sepsis survivors. Such novel strategies include modulating the immune system and addressing mitochondrial dysfunction. A sepsis follow-up clinic may be useful to identify long-term health issues associated with post-sepsis syndrome and evaluate existing and novel strategies to improve the lives of sepsis survivors.
Collapse
Affiliation(s)
- Elisabeth C van der Slikke
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, , P.O. Box 30.001, EB70, 9700 RB, Groningen, The Netherlands
| | - Andy Y An
- Centre for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, BC, Canada
| | - Robert E W Hancock
- Centre for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, BC, Canada
| | - Hjalmar R Bouma
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, , P.O. Box 30.001, EB70, 9700 RB, Groningen, The Netherlands; Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| |
Collapse
|
38
|
[Sepsis-associated encephalopathy : A nationwide survey on diagnostic procedures and neuromonitoring in German intensive care units]. Anaesthesist 2020; 70:112-120. [PMID: 32970160 PMCID: PMC7851101 DOI: 10.1007/s00101-020-00853-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/09/2020] [Accepted: 08/23/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Sepsis-associated encephalopathy (SAE) is one of the most frequent causes of neurocognitive impairment in intensive care patients. It is associated with increased hospital mortality and poor long-term neurocognitive outcome. To date there are no evidence-based recommendations for the diagnostics and neuromonitoring of SAE. OBJECTIVE The aim of the study was to evaluate the current clinical practice of diagnostics and neuromonitoring of SAE on intensive care units (ICU) in Germany. MATERIAL AND METHODS Based on available literature focusing on SAE, a questionnaire consisting of 26 items was designed and forwarded to 438 members of the Scientific Working Group for Intensive Care Medicine (WAKI) and the Scientific Working Group for Neuroanesthesia (WAKNA) as an online survey. RESULTS The total participation rate in the survey was 12.6% (55/438). A standardized diagnostic procedure of SAE was reported by 21.8% (12/55) of the participants. The majority of participants preferred delirium screening tools (50/55; 90.9%) and the clinical examination (49/55; 89.1%) to detect SAE. Brain imaging (26/55; 47.3%), laboratory/biomarker determination (15/55; 27.3%), electrophysiological techniques (14/55; 25.5%) and cerebrospinal fluid examination (12/55; 21.8%) are less frequently performed. The follow-up examination of SAE is most frequently performed by a clinical examination (45/55; 81.8%). Neuromonitoring techniques, such as continuous electroencephalography (31/55; 56.4%), transcranial doppler sonography (31/55; 56.4%) and near-infrared spectroscopy (18/55, 32.7%) are not frequently used. We observed statistically significant differences between the theoretically attributed importance and clinical practice. The great majority of respondents (48/55; 87.3%) endorse the development of guidelines containing recommendations for diagnostics and neuromonitoring in SAE. DISCUSSION This explorative survey demonstrated a great heterogeneity in diagnostics and neuromonitoring of SAE in German ICUs. Uniform concepts have not yet been established but are desired by the majority of study participants. Innovative biomarkers of neuroaxonal injury in blood and cerebrospinal fluid as well as electrophysiological and brain imaging techniques could provide valuable prognostic information on the neurocognitive outcome of patients and would thus be a useful addition to the clinical assessment of ICU patients with SAE.
Collapse
|
39
|
Paouri E, Georgopoulos S. Systemic and CNS Inflammation Crosstalk: Implications for Alzheimer's Disease. Curr Alzheimer Res 2020; 16:559-574. [PMID: 30907316 DOI: 10.2174/1567205016666190321154618] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 02/26/2019] [Accepted: 03/19/2019] [Indexed: 12/14/2022]
Abstract
After years of failed therapeutic attempts targeting beta-amyloid (Aβ) in AD, there is now increasing evidence suggesting that inflammation holds a pivotal role in AD pathogenesis and immune pathways can possibly comprise primary therapeutic targets. Inflammation is a key characteristic of numerous diseases including neurodegenerative disorders and thus not surprisingly suppression of inflammation frequently constitutes a major therapeutic strategy for a wide spectrum of disorders. Several brain-resident and peripherally-derived immune populations and inflammatory mediators are involved in AD pathophysiology, with microglia comprising central cellular player in the disease process. Systemic inflammation, mostly in the form of infections, has long been observed to induce behavioral alterations and cognitive dysfunction, suggesting for a close interaction of the peripheral immune system with the brain. Systemic inflammation can result in neuroinflammation, mainly exhibited as microglial activation, production of inflammatory molecules, as well as recruitment of peripheral immune cells in the brain, thus shaping a cerebral inflammatory milieu that may seriously impact neuronal function. Increasing clinical and experimental studies have provided significant evidence that acute (e.g. infections) or chronic (e.g. autoimmune diseases like rheumatoid arthritis) systemic inflammatory conditions may be associated with increased AD risk and accelerate AD progression. Here we review the current literature that links systemic with CNS inflammation and the implications of this interaction for AD in the context of acute and chronic systemic pathologies as acute infection and rheumatoid arthritis. Elucidating the mechanisms that govern the crosstalk between the peripheral and the local brain immune system may provide the ground for new therapeutic approaches that target the immune-brain interface and shed light on the understanding of AD.
Collapse
Affiliation(s)
- Evi Paouri
- Laboratory of Cellular Neurobiology, Center of Basic Research, Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Spiros Georgopoulos
- Laboratory of Cellular Neurobiology, Center of Basic Research, Biomedical Research Foundation, Academy of Athens, Athens, Greece
| |
Collapse
|
40
|
Sepsis-Associated Brain Dysfunction: A Review of Current Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165852. [PMID: 32806705 PMCID: PMC7460246 DOI: 10.3390/ijerph17165852] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 12/18/2022]
Abstract
Sepsis-associated brain dysfunction (SABD) may be the most common type of encephalopathy in critically ill patients. SABD develops in up to 70% of septic patients and represents the most frequent organ insufficiency associated with sepsis. It presents with a plethora of acute neurological features and may have several serious long-term psychiatric consequences. SABD might cause various pathological changes in the brain through numerous mechanisms. Clinical neurological examination is the basic screening method for SABD, although it may be challenging in subjects receiving with opioids and sedative agents. As electrographic seizures and periodic discharges might be present in 20% of septic patients, screening with electroencephalography (EEG) might be useful. Several imaging techniques have been suggested for non-invasive assessment of structure and function of the brain in SABD patients; however, their usefulness is rather limited. Although several experimental therapies have been postulated, at the moment, no specific treatment exists. Clinicians should focus on preventive measures and optimal management of sepsis. This review discusses epidemiology, clinical presentation, pathology, pathophysiology, diagnosis, management, and prevention of SABD.
Collapse
|
41
|
Agarwal S, Jain R, Dogra S, Krieger P, Lewis A, Nguyen V, Melmed K, Galetta S. Cerebral Microbleeds and Leukoencephalopathy in Critically Ill Patients With COVID-19. Stroke 2020; 51:2649-2655. [PMID: 32755456 PMCID: PMC7434006 DOI: 10.1161/strokeaha.120.030940] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: We conducted this study to investigate the prevalence and distribution of cerebral microbleeds and leukoencephalopathy in hospitalized patients with coronavirus disease 2019 (COVID-19) and correlate with clinical, laboratory, and functional outcomes. Methods: We performed a retrospective chart review of 4131 COVID-19 positive adult patients who were admitted to 3 tertiary care hospitals of an academic medical center at the epicenter of the COVID-19 pandemic in New York City from March 1, 2020, to May 10, 2020, to identify patients who had magnetic resonance imaging (MRI) of the brain. We evaluated the MRIs in detail, and identified a subset of patients with leukoencephalopathy and/or cerebral microbleeds. We compared clinical, laboratory, and functional outcomes for these patients to patients who had a brain MRI that did not show these findings. Results: Of 115 patients who had an MRI of the brain performed, 35 (30.4%) patients had leukoencephalopathy and/or cerebral microbleeds. Patients with leukoencephalopathy and/or cerebral microbleeds had neuroimaging performed later during the hospitalization course (27 versus 10.6 days; P<0.001), were clinically sicker at the time of brain MRI (median GCS 6 versus 14; P<0.001), and had higher peak D-dimer levels (8018±6677 versus 3183±3482; P<0.001), lower nadir platelet count (116.9±62.2 versus 158.3±76.2; P=0.03), higher peak international normalized ratio (2.2 versus 1.57; P<0.001) values when compared with patients who had a brain MRI that did not show these findings. They required longer ventilator support (34.6 versus 9.1 days; P<0.001) and were more likely to have moderate and severe acute respiratory distress syndrome score (88.6% versus 23.8%, P<0.001). These patients had longer hospitalizations (42.1 versus 20.9 days; P<0.001), overall worse functional status on discharge (mRS 5 versus 4; P=0.001), and higher mortality (20% versus 9%; P=0.144). Conclusions: The presence of leukoencephalopathy and/or cerebral microbleeds is associated with a critical illness, increased mortality, and worse functional outcome in patients with COVID-19.
Collapse
Affiliation(s)
- Shashank Agarwal
- Department of Neurology (S.A., A.L., K.M., S.G.), NYU Langone Health, New York, NY
| | - Rajan Jain
- Department of Radiology (R.J., S.D., P.K., V.N.), NYU Langone Health, New York, NY.,Department of Neurosurgery (R.J., A.L., K.M.), NYU Langone Health, New York, NY
| | - Siddhant Dogra
- Department of Radiology (R.J., S.D., P.K., V.N.), NYU Langone Health, New York, NY
| | - Penina Krieger
- Department of Radiology (R.J., S.D., P.K., V.N.), NYU Langone Health, New York, NY
| | - Ariane Lewis
- Department of Neurology (S.A., A.L., K.M., S.G.), NYU Langone Health, New York, NY.,Department of Neurosurgery (R.J., A.L., K.M.), NYU Langone Health, New York, NY
| | - Vinh Nguyen
- Department of Radiology (R.J., S.D., P.K., V.N.), NYU Langone Health, New York, NY
| | - Kara Melmed
- Department of Neurology (S.A., A.L., K.M., S.G.), NYU Langone Health, New York, NY.,Department of Neurosurgery (R.J., A.L., K.M.), NYU Langone Health, New York, NY
| | - Steven Galetta
- Department of Neurology (S.A., A.L., K.M., S.G.), NYU Langone Health, New York, NY
| |
Collapse
|
42
|
Ismail Hassan F, Didari T, Baeeri M, Gholami M, Haghi-Aminjan H, Khalid M, Navaei-Nigjeh M, Rahimifard M, Solgi S, Abdollahi M, Mojtahedzadeh M. Metformin Attenuates Brain Injury by Inhibiting Inflammation and Regulating Tight Junction Proteins in Septic Rats. CELL JOURNAL 2020; 22:29-37. [PMID: 32779431 PMCID: PMC7481907 DOI: 10.22074/cellj.2020.7046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 10/01/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Metformin has a potent inhibitory activity against inflammation and oxidative stress, which inevitably occur in sepsis-associated encephalopathy (SAE). The precise mechanisms underlying neuroprotective effects of metformin in SAE, are still unclear. In the present work, the protective effect of metformin on SAE using cecal ligation and puncture (CLP) model of sepsis, was assessed. MATERIALS AND METHODS In this experimental study, CLP procedure was performed in Wistar rats and 50 mg/kg metformin was administered immediately. Specific markers of sepsis severity, inflammation, blood brain barrier (BBB) dysfunction, and brain injury, were investigated. Specific assay kits and real-time polymerase chain reaction (RT-PCR) were used. Histopathological assessment was also carried out. RESULTS Treatment with metformin decreased murine sepsis score (MSS), lactate, platelet lymphocyte ratio (PLR), and high mobility group box (HMGB1) levels. The expression levels of claudin 3 (Cldn3) and claudin 5 (Cldn5) were increased following treatment with metformin. Metformin decreased the expression of S100b, neuron specific enolase (Nse), and glial fibrillary acidic protein (Gfap). CONCLUSION Our study suggests that metformin may inhibit inflammation and increase tight junction protein expressions which may improve BBB function and attenuate CLP-induced brain injury. Hence, the potential beneficial effects of metformin in sepsis, should be considered in future.
Collapse
Affiliation(s)
- Fatima Ismail Hassan
- Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Tina Didari
- Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Baeeri
- Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Gholami
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Haghi-Aminjan
- Pharmaceutical Sciences Research Center, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Madiha Khalid
- Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Mona Navaei-Nigjeh
- Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Mahban Rahimifard
- Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Solgi
- Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Abdollahi
- Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran. Electronic Address:
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Mojtahedzadeh
- Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran. Electronic Address:
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
43
|
Abstract
OBJECTIVES Many survivors of sepsis suffer long-term cognitive impairment, but the mechanisms of this association remain unknown. The objective of this study was to determine whether sepsis is associated with cerebral microinfarcts on brain autopsy. DESIGN Retrospective cohort study. SETTING AND SUBJECTS Five-hundred twenty-nine participants of the Adult Changes in Thought, a population-based prospective cohort study of older adults carried out in Kaiser Permanente Washington greater than or equal to 65 years old without dementia at study entry and who underwent brain autopsy. MEASUREMENTS AND MAIN RESULTS Late-life sepsis hospitalization was identified using administrative data. We identified 89 individuals with greater than or equal to 1 sepsis hospitalization during study participation, 80 of whom survived hospitalization and died a median of 169 days after discharge. Thirty percent of participants with one or more sepsis hospitalization had greater than two microinfarcts, compared with 19% participants without (χ p = 0.02); 20% of those with sepsis hospitalization had greater than two microinfarcts in the cerebral cortex, compared with 10% of those without (χ p = 0.01). The adjusted relative risk of greater than two microinfarcts was 1.61 (95% CI, 1.01-2.57; p = 0.04); the relative risk for having greater than two microinfarcts in the cerebral cortex was 2.12 (95% CI, 1.12-4.02; p = 0.02). There was no difference in Braak stage for neurofibrillary tangles or consortium to establish a registry for Alzheimer's disease score for neuritic plaques between, but Lewy bodies were less significantly common in those with sepsis. CONCLUSIONS Sepsis was specifically associated with moderate to severe vascular brain injury as assessed by microvascular infarcts. This association was stronger for microinfarcts within the cerebral cortex, with those who experienced severe sepsis hospitalization being more than twice as likely to have evidence of moderate to severe cerebral cortical injury in adjusted analyses. Further study to identify mechanisms for the association of sepsis and microinfarcts is needed.
Collapse
|
44
|
|
45
|
Huang L, Peng S, Li R, Xie D, Huang D. Fulminant encephalopathy in a child with hyperferritinemic sepsis: a case report. BMC Neurol 2020; 20:73. [PMID: 32122316 PMCID: PMC7053145 DOI: 10.1186/s12883-020-01661-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/26/2020] [Indexed: 02/06/2023] Open
Abstract
Background Sepsis-associated encephalopathy (SAE) is epidemic in intensive care units and recognized as a fatal complication of sepsis. SAE is characterized by diffuse brain dysfunction and the correct diagnosis of SAE requires ruling out direct central nervous system (CNS) infection or other types of encephalopathy, such as hepatic encephalopathy, pulmonary encephalopathy, and other encephalopathy. Case presentation We reported a rare case of a 5-year-old girl who presented with abdominal pain, vomiting, recurrent seizures, and coma. Brain magnetic resonance imaging (MRI) showed diffuse white matter abnormalities in the brain on day 1. Cerebrospinal fluid (CSF) tests revealed that protein levels and glucose levels were normal without pleocytosis. CSF PCRs for pathogens were all negative. The electroencephalography examination demonstrated diffuse, generalized and slow background activity. The patient showed the symptom of hyperferritinemic sepsis with multiple organ dysfunction syndrome (MODS). SAE was also diagnosed by ruling out other encephalitis or encephalopathy. The patient made marked improvements of clinical symptoms and the lesions on brain imaging disappeared completely within two months after appropriate treatment including antibiotic treatments, methylprednisolone, intravenous immunoglobulin, membrane-based therapeutic plasma exchange (TPE), and continuous renal replacement therapy (CRRT). Conclusions SAE can be a fatal complication of sepsis which asks for immediate diagnosis and treatment. Few reports have focus on MRI imaging findings on the early onset of hyperferritinemic sepsis with MODS since these children were too ill to undergo an MRI scan. However, SAE might appear before other systemic features of sepsis are obvious, and MRI could show abnormal lesion in the brain during the early course. Therefore, MRI should be performed early to diagnose this fatal complication which would play important roles in improving the clinical outcomes by early initiation with appropriate treatments.
Collapse
Affiliation(s)
- Lilin Huang
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China.
| | - Shumei Peng
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Ronghan Li
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Danyu Xie
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Dongping Huang
- Department of Pediatrics, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| |
Collapse
|
46
|
Heming N, Mazeraud A, Azabou E, Moine P, Annane D. Vasopressor Therapy and the Brain: Dark Side of the Moon. Front Med (Lausanne) 2020; 6:317. [PMID: 31998736 PMCID: PMC6966606 DOI: 10.3389/fmed.2019.00317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/13/2019] [Indexed: 12/14/2022] Open
Abstract
Sepsis, a leading cause of morbidity and mortality, is caused by a deregulated host response to pathogens, and subsequent life-threatening organ dysfunctions. All major systems, including the cardiovascular, respiratory, renal, hepatic, hematological, and the neurological system may be affected by sepsis. Sepsis associated neurological dysfunction is triggered by multiple factors including neuro-inflammation, excitotoxicity, and ischemia. Ischemia results from reduced cerebral blood flow, caused by extreme variations of blood pressure, occlusion of cerebral vessels, or more subtle defects of the microcirculation. International guidelines comprehensively describe the initial hemodynamic management of sepsis, revolving around the normalization of systemic hemodynamics and of arterial lactate. By contrast, the management of sepsis patients suffering from brain dysfunction is poorly detailed, the only salient point being mentioned is that sedation and analgesia should be optimized. However, sepsis and the hemodynamic consequences thereof as well as vasopressors may have severe untoward neurological consequences. The current review describes the general neurological complications, as well as the consequences of vasopressor therapy on the brain and its circulation and addresses methods for cerebral monitoring during sepsis.
Collapse
Affiliation(s)
- Nicholas Heming
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
| | - Aurélien Mazeraud
- Department of Neuro-Anesthesiology and Intensive Care Medicine, Sainte-Anne Teaching Hospital, Paris-Descartes University, Paris, France
| | - Eric Azabou
- U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France.,Department of Physiology, Assistance Publique-Hôpitaux de Paris, Raymond-Poincaré Hospital, Garches, France
| | - Pierre Moine
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital, Garches, France.,U1173 Lab Inflammation and Infection, University of Versailles SQY-Paris Saclay - INSERM, Montigny-le-Bretonneux, France
| |
Collapse
|
47
|
Griton M, Dhaya I, Nicolas R, Raffard G, Periot O, Hiba B, Konsman JP. Experimental sepsis-associated encephalopathy is accompanied by altered cerebral blood perfusion and water diffusion and related to changes in cyclooxygenase-2 expression and glial cell morphology but not to blood-brain barrier breakdown. Brain Behav Immun 2020; 83:200-213. [PMID: 31622656 DOI: 10.1016/j.bbi.2019.10.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/02/2019] [Accepted: 10/10/2019] [Indexed: 12/21/2022] Open
Abstract
Sepsis-associated encephalopathy (SAE) refers to brain dysfunction, including delirium, occurs during severe infection and is associated with development of post-traumatic stress disorder. SAE has been proposed to be related to reduced cerebral blood flow (CBF), blood-brain barrier breakdown (BBB), white matter edema and disruption and glia cell activation, but their exact relationships remain to be determined. In the present work, we set out to study CBF using Arterial Spin Labeling (ASL) and grey and white matter structure with T2- and diffusion magnetic resonance imaging (dMRI) in rats with cecal ligation and puncture (CLP)-induced encephalopathy. Using immunohistochemistry, the distribution of the vasoactive prostaglandin-synthesizing enzyme cyclooxygenase-2 (COX-2), perivascular immunoglobulins G (IgG), aquaporin-4 (AQP4) and the morphology of glial cell were subsequently assessed in brains of the same animals. CLP induced deficits in the righting reflex and resulted in higher T2-weighted contrast intensities in the cortex, striatum and at the base of the brain, decreased blood perfusion distribution to the cortex and increased water diffusion parallel to the fibers of the corpus callosum compared to sham surgery. In addition, CLP reduced staining for microglia- and astrocytic-specific proteins in the corpus callosum, decreased neuronal COX-2 and AQP4 expression in the cortex while inducing perivascular COX-2 expression, but did not induce widespread perivascular IgG diffusion. In conclusion, our findings indicate that experimental SAE can occur in the absence of BBB breakdown and is accompanied by increased water diffusion anisotropy and altered glia cell morphology in brain white matter.
Collapse
Affiliation(s)
- Marion Griton
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France; Service de Réanimation Anesthésie Neurochirurgicale, Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Ibtihel Dhaya
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France; Laboratoire de Neurophysiologie Fonctionnelle et Pathologies, UR/11ES09, Faculté des Sciences Mathématiques, Physiques et Naturelles, Université de Tunis El Manar, Tunis, Tunisia
| | - Renaud Nicolas
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France
| | - Gérard Raffard
- CNRS, Résonance Magnétique des Systèmes Biologiques, UMR 5536, Bordeaux, France; Univ. Bordeaux, RMSB, UMR 5536, Bordeaux, France
| | - Olivier Periot
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France; Service de Médecine Nucléaire, Centre Hospitalier Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Bassem Hiba
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France; CNRS UMR 5229, Centre de Neurosciences Cognitives Marc Jeannerod, Bron, France
| | - Jan Pieter Konsman
- INCIA, Institut de Neurosciences Cognitive et Intégrative d'Aquitaine, UMR 5287, Bordeaux, France; Univ. Bordeaux, INCIA, UMR 5287, Bordeaux, France.
| |
Collapse
|
48
|
Kikuchi DS, Campos ACP, Qu H, Forrester SJ, Pagano RL, Lassègue B, Sadikot RT, Griendling KK, Hernandes MS. Poldip2 mediates blood-brain barrier disruption in a model of sepsis-associated encephalopathy. J Neuroinflammation 2019; 16:241. [PMID: 31779628 PMCID: PMC6883676 DOI: 10.1186/s12974-019-1575-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/29/2019] [Indexed: 11/10/2022] Open
Abstract
Background Sepsis-associated encephalopathy (SAE), a diffuse cerebral dysfunction in the absence of direct CNS infection, is associated with increased rates of mortality and morbidity in patients with sepsis. Increased cytokine production and disruption of the blood-brain barrier (BBB) are implicated in the pathogenesis of SAE. The induction of pro-inflammatory mediators is driven, in part, by activation of NF-κΒ. Lipopolysaccharide (LPS), an endotoxin produced by gram-negative bacteria, potently activates NF-κΒ and its downstream targets, including cyclooxygenase-2 (Cox-2). Cox-2 catalyzes prostaglandin synthesis and in the brain prostaglandin, E2 is capable of inducing endothelial permeability. Depletion of polymerase δ-interacting protein 2 (Poldip2) has previously been reported to attenuate BBB disruption, possibly via regulation of NF-κΒ, in response to ischemic stroke. Here we investigated Poldip2 as a novel regulator of NF-κΒ/cyclooxygenase-2 signaling in an LPS model of SAE. Methods Intraperitoneal injections of LPS (18 mg/kg) were used to induce BBB disruption in Poldip2+/+ and Poldip2+/− mice. Changes in cerebral vascular permeability and the effect of meloxicam, a selective Cox-2 inhibitor, were assessed by Evans blue dye extravasation. Cerebral cortices of Poldip2+/+ and Poldip2+/− mice were further evaluated by immunoblotting and ELISA. To investigate the role of endothelial Poldip2, immunofluorescence microscopy and immunoblotting were performed to study the effect of siPoldip2 on LPS-mediated NF-κΒ subunit p65 translocation and Cox-2 induction in rat brain microvascular endothelial cells. Finally, FITC-dextran transwell assay was used to assess the effect of siPoldip2 on LPS-induced endothelial permeability. Results Heterozygous deletion of Poldip2 conferred protection against LPS-induced BBB permeability. Alterations in Poldip2+/+ BBB integrity were preceded by induction of Poldip2, p65, and Cox-2, which was not observed in Poldip2+/− mice. Consistent with these findings, prostaglandin E2 levels were significantly elevated in Poldip2+/+ cerebral cortices compared to Poldip2+/− cortices. Treatment with meloxicam attenuated LPS-induced BBB permeability in Poldip2+/+ mice, while having no significant effect in Poldip2+/− mice. Moreover, silencing of Poldip2 in vitro blocked LPS-induced p65 nuclear translocation, Cox-2 expression, and endothelial permeability. Conclusions These data suggest Poldip2 mediates LPS-induced BBB disruption by regulating NF-κΒ subunit p65 activation and Cox-2 and prostaglandin E2 induction. Consequently, targeted inhibition of Poldip2 may provide clinical benefit in the prevention of sepsis-induced BBB disruption. Electronic supplementary material The online version of this article (10.1186/s12974-019-1575-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Daniel S Kikuchi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, 308 WMB, Atlanta, GA, 30322, USA
| | | | - Hongyan Qu
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, 308 WMB, Atlanta, GA, 30322, USA
| | - Steven J Forrester
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, 308 WMB, Atlanta, GA, 30322, USA
| | - Rosana L Pagano
- Division of Neuroscience, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Bernard Lassègue
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, 308 WMB, Atlanta, GA, 30322, USA
| | - Ruxana T Sadikot
- Division of Pulmonary and Critical Care, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathy K Griendling
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, 308 WMB, Atlanta, GA, 30322, USA
| | - Marina S Hernandes
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, 308 WMB, Atlanta, GA, 30322, USA.
| |
Collapse
|
49
|
Tian J, Tai Y, Shi M, Zhao C, Xu W, Ge X, Zhu G. Atorvastatin Relieves Cognitive Disorder After Sepsis Through Reverting Inflammatory Cytokines, Oxidative Stress, and Neuronal Apoptosis in Hippocampus. Cell Mol Neurobiol 2019; 40:521-530. [PMID: 31696375 DOI: 10.1007/s10571-019-00750-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/25/2019] [Indexed: 02/07/2023]
Abstract
This present research work reports the possible effects and the underlying mechanism of atorvastatin on survival rate and cognitive disorders after sepsis. Sepsis is a life-threatening dysfunction that arises when the body's response to infection causes injury to its own tissues and organs. Diffuse sepsis was induced by cecal ligation and puncture surgery (CLP) in ICR mice. 0.2 mg/kg body weight of atorvastatin was administrated intraperitoneally at 12 h before surgery. The survival of mice was calculated 24 h, 48 h, 72 h, and 96 h after CLP surgery. Two weeks later, open-field test and Morris water maze test were conducted to evaluate the protective effect of atorvastatin. Inflammatory cytokines in plasma, oxidative stress parameters, number of astrocytes, and neuronal cell deaths in the CA3 region of the hippocampus were examined using enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry. The results indicate that pretreatment with atorvastatin can increase survival percentage and improve cognitive function. Atorvastatin reversed all these alterations in parallel with a decrease in circulating levels of cytokines (IL-1β, IL-4, IL-6, and TNF-α) in plasma, inhibited the activities of oxidative stress parameters (lower TBARS levels, ratio of GSH/GSSH, and activities of SOD and CAT), enhanced the activity of citrate synthase in brain, and reduced the number of astrocytes and neuronal cell deaths in CA3 region of hippocampus. Overall, our results indicated that atorvastatin exhibited protective effects on survival rate and cognitive disorders after sepsis by inhibiting the release of inflammatory cytokines, oxidative stress, and neuronal apoptosis in brain tissue.
Collapse
Affiliation(s)
- Jianmei Tian
- Neonate Department, Soochow University Affiliated Children's Hospital, Suzhou, People's Republic of China
| | - Yongjie Tai
- Neonate Department, Soochow University Affiliated Children's Hospital, Suzhou, People's Republic of China
| | - Mengrao Shi
- Neonate Department, Soochow University Affiliated Children's Hospital, Suzhou, People's Republic of China
| | - Chunxiu Zhao
- Neonate Department, Soochow University Affiliated Children's Hospital, Suzhou, People's Republic of China
| | - Wenwen Xu
- Neonate Department, Soochow University Affiliated Children's Hospital, Suzhou, People's Republic of China
| | - Xuhua Ge
- Department of General Medicine, Department of General Practice of Tongji University, Yangpu Hospital Tongji University School of Medicine, 450 Tenyue Road, Shanghai, 200090, People's Republic of China.
| | - Guoji Zhu
- Neonate Department, Soochow University Affiliated Children's Hospital, Suzhou, People's Republic of China. .,Department of Internal Medicine, Soochow University Affiliated Children's Hospital, 303 Jingde Road, Suzhou, 215003, Jiangsu, People's Republic of China.
| |
Collapse
|
50
|
Abstract
Developments in the management of critically ill patients suffering organ dysfunctions have demonstrated that brain is the prominent organ to be effected during critical illness. Acute brain dysfunction due to pathologic neuroinflammatory processes associated with sepsis is commonly seen and related to morbidity and mortality in the ICU treatment. Studies reported that survivors of sepsis may suffer long-term cognitive dysfunction that affects quality of life. However, there are no specific approaches to diagnose acute brain dysfunction in the early phase to target protective measures. In recent years, imaging methods and biomarkers are the most important issues of studies. This review will address the current diagnostic approaches to acute brain dysfunction related to sepsis.
Collapse
|