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Han Y, Han Z, Huang X, Li S, Jin G, Feng J, Wu D, Liu H. An injectable refrigerated hydrogel for inducing local hypothermia and neuroprotection against traumatic brain injury in mice. J Nanobiotechnology 2024; 22:251. [PMID: 38750597 PMCID: PMC11095020 DOI: 10.1186/s12951-024-02454-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/01/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Hypothermia is a promising therapy for traumatic brain injury (TBI) in the clinic. However, the neuroprotective outcomes of hypothermia-treated TBI patients in clinical studies are inconsistent due to several severe side effects. Here, an injectable refrigerated hydrogel was designed to deliver 3-iodothyronamine (T1AM) to achieve a longer period of local hypothermia for TBI treatment. Hydrogel has four advantages: (1) It can be injected into injured sites after TBI, where it forms a hydrogel and avoids the side effects of whole-body cooling. (2) Hydrogels can biodegrade and be used for controlled drug release. (3) Released T1AM can induce hypothermia. (4) This hydrogel has increased medical value given its simple operation and ability to achieve timely treatment. METHODS Pol/T hydrogels were prepared by a low-temperature mixing method and characterized. The effect of the Pol/T hydrogel on traumatic brain injury in mice was studied. The degradation of the hydrogel at the body level was observed with a small animal imager. Brain temperature and body temperature were measured by brain thermometer and body thermometer, respectively. The apoptosis of peripheral nerve cells was detected by immunohistochemical staining. The protective effect of the hydrogels on the blood-brain barrier (BBB) after TBI was evaluated by the Evans blue penetration test. The protective effect of hydrogel on brain edema after injury in mice was detected by Magnetic resonance (MR) in small animals. The enzyme linked immunosorbent assay (ELISA) method was used to measure the levels of inflammatory factors. The effects of behavioral tests on the learning ability and exercise ability of mice after injury were evaluated. RESULTS This hydrogel was able to cool the brain to hypothermia for 12 h while maintaining body temperature within the normal range after TBI in mice. More importantly, hypothermia induced by this hydrogel leads to the maintenance of BBB integrity, the prevention of cell death, the reduction of the inflammatory response and brain edema, and the promotion of functional recovery after TBI in mice. This cooling method could be developed as a new approach for hypothermia treatment in TBI patients. CONCLUSION Our study showed that injectable and biodegradable frozen Pol/T hydrogels to induce local hypothermia in TBI mice can be used for the treatment of traumatic brain injury.
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Affiliation(s)
- Yuhan Han
- Department of Biomedical Engineering, Southern University of Science and Technology, Shenzhen, 518055, Guangdong, China
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Institute of Head Trauma, Shanghai, 200127, China
| | - Zhengzhong Han
- Department of Neurosurgery, Xuzhou Children's Hospital, Xuzhou, 221000, Jiangsu, China
| | - Xuyang Huang
- Institute of Nervous System Diseases, Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
- Department of Intensive Care Medicine, The Second Hospital of Jiaxing, Jiaxing, 314000, Zhejiang, China
| | - Shanshan Li
- Department of Forensic Medicine, Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Guoliang Jin
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Junfeng Feng
- Brain Injury Center, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Institute of Head Trauma, Shanghai, 200127, China.
| | - Decheng Wu
- Department of Biomedical Engineering, Southern University of Science and Technology, Shenzhen, 518055, Guangdong, China.
| | - Hongmei Liu
- Department of Biomedical Engineering, Southern University of Science and Technology, Shenzhen, 518055, Guangdong, China.
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Li J, Tang S, Liu J, He W, Yan J, Huang Z, Li X. A Preliminary Discussion on the Safety of Mild Therapeutic Hypothermia in Target Vessels after Endovascular Intervention in Acute Large Vessel Occlusion Cerebral Infarction. J Vasc Res 2023; 60:227-233. [PMID: 37640011 PMCID: PMC10614551 DOI: 10.1159/000532030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/05/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION The aim of this study was to discuss the safety of rapid administration of 4°C hypothermic normal saline into the occluded vessels using an intra-arterial catheter to induce mild hypothermia following endovascular thrombectomy in patients with acute large vessel occlusion cerebral infarction. METHODS We selected 78 patients with acute large vessel occlusion cerebral infarction who underwent endovascular thrombectomy in the Department of Neurology of our hospital from January 2020 to July 2022 and achieved TICI 2b recanalization. RESULT Twenty-five patients were administered 500 mL of 4°C hypothermic normal saline in the occluded vessels at a rate of 25 mL/min to induce mild hypothermia. Twenty pairs of subjects conformed to strict matching and were finally included in the statistical analysis. The two groups of patients differed significantly in white blood cell count and percentage of neutrophils (p < 0.05); however, there were no significant differences in D-dimer, procalcitonin, and BNP levels. The two groups of patients did not differ significantly with respect to the incidence of the following indicators: upper gastrointestinal bleeding; pulmonary infection; venous thrombosis; vasospasms; seizures; and chills (p > 0.05). CONCLUSION Mild therapeutic hypothermia in target vessels plus endovascular thrombectomy was shown to be safe in patients with acute large vessel occlusion cerebral infarction.
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Affiliation(s)
- Jiang Li
- Neuromedical Center, Huizhou Hospital Affiliated to Guangzhou Medical University, The Third People's Hospital of Huizhou, Huizhou, China
| | - Shaonian Tang
- Neuromedical Center, Huizhou Hospital Affiliated to Guangzhou Medical University, The Third People's Hospital of Huizhou, Huizhou, China
| | - Juanli Liu
- Neuromedical Center, Huizhou Hospital Affiliated to Guangzhou Medical University, The Third People's Hospital of Huizhou, Huizhou, China
| | - Wenlin He
- Neuromedical Center, Huizhou Hospital Affiliated to Guangzhou Medical University, The Third People's Hospital of Huizhou, Huizhou, China
| | - Jinjin Yan
- Neuromedical Center, Huizhou Hospital Affiliated to Guangzhou Medical University, The Third People's Hospital of Huizhou, Huizhou, China
| | - Zhiyong Huang
- Neuromedical Center, Huizhou Hospital Affiliated to Guangzhou Medical University, The Third People's Hospital of Huizhou, Huizhou, China
| | - Xuesong Li
- Neuromedical Center, Huizhou Hospital Affiliated to Guangzhou Medical University, The Third People's Hospital of Huizhou, Huizhou, China
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Li M, Gao Y, Jiang M, Zhang H, Zhang Y, Wu Y, Zhou W, Wu D, Wu C, Wu L, Bao L, Ge X, Qi Z, Wei M, Li A, Ding Y, Zhang J, Pan G, Wu Y, Cheng Y, Zheng Y, Ji X. Dual-sized hollow particle incorporated fibroin thermal insulating coatings on catheter for cerebral therapeutic hypothermia. Bioact Mater 2023; 26:116-127. [PMID: 36879558 PMCID: PMC9984786 DOI: 10.1016/j.bioactmat.2023.02.022] [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: 02/11/2023] [Revised: 02/19/2023] [Accepted: 02/19/2023] [Indexed: 02/27/2023] Open
Abstract
Selective endovascular hypothermia has been used to provide cooling-induced cerebral neuroprotection, but current catheters do not support thermally-insulated transfer of cold infusate, which results in an increased exit temperature, causes hemodilution, and limits its cooling efficiency. Herein, air-sprayed fibroin/silica-based coatings combined with chemical vapor deposited parylene-C capping film was prepared on catheter. This coating features in dual-sized-hollow-microparticle incorporated structures with low thermal conductivity. The infusate exit temperature is tunable by adjusting the coating thickness and infusion rate. No peeling or cracking was observed on the coatings under bending and rotational scenarios in the vascular models. Its efficiency was verified in a swine model, and the outlet temperature of coated catheter (75 μm thickness) was 1.8-2.0 °C lower than that of the uncoated one. This pioneering work on catheter thermal insulation coatings may facilitate the clinical translation of selective endovascular hypothermia for neuroprotection in patients with acute ischemic stroke.
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Affiliation(s)
- Ming Li
- China-America Institute of Neuroscience and Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yuan Gao
- School of Instrumentation and Optoelectronic Engineering, Beihang University, Beijing, 100191, China
| | - Miaowen Jiang
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, 100069, China
| | - Hongkang Zhang
- School of Materials Science and Engineering, Peking University, Beijing, 100871, China
| | - Yang Zhang
- China-America Institute of Neuroscience and Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yan Wu
- China-America Institute of Neuroscience and Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Wenhao Zhou
- Shaanxi Key Laboratory of Biomedical Metallic Materials, Northwest Institute for Nonferrous Metal Research, Xi'an, 710016, China
| | - Di Wu
- China-America Institute of Neuroscience and Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Chuanjie Wu
- China-America Institute of Neuroscience and Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Longfei Wu
- China-America Institute of Neuroscience and Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Luzi Bao
- China-America Institute of Neuroscience and Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Xiaoxiao Ge
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, 100069, China
| | - Zhengfei Qi
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, 100069, China
| | - Ming Wei
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, 100069, China
| | - Ang Li
- Department of Biomedical Engineering, Columbia University, New York City, NY, 10027, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Jicheng Zhang
- Gong Yi Van-research Innovation Composite Material Co. Ltd, Zheng Zhou, 451299, China
| | - Guangzhen Pan
- Gong Yi Van-research Innovation Composite Material Co. Ltd, Zheng Zhou, 451299, China
| | - Yu Wu
- Gong Yi Van-research Innovation Composite Material Co. Ltd, Zheng Zhou, 451299, China
| | - Yan Cheng
- School of Materials Science and Engineering, Peking University, Beijing, 100871, China
| | - Yufeng Zheng
- School of Materials Science and Engineering, Peking University, Beijing, 100871, China
| | - Xunming Ji
- China-America Institute of Neuroscience and Beijing Institute of Geriatrics, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,School of Instrumentation and Optoelectronic Engineering, Beihang University, Beijing, 100191, China.,Beijing Institute for Brain Disorders, Capital Medical University, Beijing, 100069, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
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Horn M, Diprose WK, Pichardo S, Demchuk A, Almekhlafi M. Non-invasive Brain Temperature Measurement in Acute Ischemic Stroke. Front Neurol 2022; 13:889214. [PMID: 35989905 PMCID: PMC9388770 DOI: 10.3389/fneur.2022.889214] [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: 03/03/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Selective therapeutic hypothermia in the setting of mechanical thrombectomy (MT) is promising to further improve the outcomes of large vessel occlusion stroke. A significant limitation in applying hypothermia in this setting is the lack of real-time non-invasive brain temperature monitoring mechanism. Non-invasive brain temperature monitoring would provide important information regarding the brain temperature changes during cooling, and the factors that might influence any fluctuations. This review aims to provide appraisal of brain temperature changes during stroke, and the currently available non-invasive modalities of brain temperature measurement that have been developed and tested over the past 20 years. We cover modalities including magnetic resonance spectroscopy imaging (MRSI), radiometric thermometry, and microwave radiometry, and the evidence for their accuracy from human and animal studies. We also evaluate the feasibility of using these modalities in the acute stroke setting and potential ways for incorporating brain temperature monitoring in the stroke workflow.
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Affiliation(s)
- MacKenzie Horn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- *Correspondence: MacKenzie Horn
| | - William K Diprose
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Samuel Pichardo
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Hong JM, Choi ES, Park SY. Selective Brain Cooling: A New Horizon of Neuroprotection. Front Neurol 2022; 13:873165. [PMID: 35795804 PMCID: PMC9251464 DOI: 10.3389/fneur.2022.873165] [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: 02/10/2022] [Accepted: 05/23/2022] [Indexed: 11/17/2022] Open
Abstract
Therapeutic hypothermia (TH), which prevents irreversible neuronal necrosis and ischemic brain damage, has been proven effective for preventing ischemia-reperfusion injury in post-cardiac arrest syndrome and neonatal encephalopathy in both animal studies and clinical trials. However, lowering the whole-body temperature below 34°C can lead to severe systemic complications such as cardiac, hematologic, immunologic, and metabolic side effects. Although the brain accounts for only 2% of the total body weight, it consumes 20% of the body's total energy at rest and requires a continuous supply of glucose and oxygen to maintain function and structural integrity. As such, theoretically, temperature-controlled selective brain cooling (SBC) may be more beneficial for brain ischemia than systemic pan-ischemia. Various SBC methods have been introduced to selectively cool the brain while minimizing systemic TH-related complications. However, technical setbacks of conventional SBCs, such as insufficient cooling power and relatively expensive coolant and/or irritating effects on skin or mucosal interfaces, limit its application to various clinical settings. This review aimed to integrate current literature on SBC modalities with promising therapeutic potential. Further, future directions were discussed by exploring studies on interesting coping skills in response to environmental or stress-induced hyperthermia among wild animals, including mammals and birds.
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Affiliation(s)
- Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
- *Correspondence: Ji Man Hong
| | - Eun Sil Choi
- Department of Biomedical Science, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - So Young Park
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
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Wu D, Chen J, Zhang X, Ilagan R, Ding Y, Ji X. Selective therapeutic cooling: To maximize benefits and minimize side effects related to hypothermia. J Cereb Blood Flow Metab 2022; 42:213-215. [PMID: 34670442 PMCID: PMC8721772 DOI: 10.1177/0271678x211055959] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Selective therapeutic cooling is a promising technique for reducing final infarct volume and improving outcomes in ischemic stroke, especially as research regarding brain reperfusion continues to be explored. A recent study provided promising results on the safety and feasibility of selective therapeutic hypothermia via a closed-loop cooling catheter system for intra-carotid blood cooling in an ovine stroke model, but they failed to find efficacy of this method in this model. It is a major step forward from bench to bed side, but enhancing benefits of selective therapeutic cooling may need to take into account a more targeted induction of brain hypothermia and should mitigate potential side effects related to inducing hypothermia.
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Affiliation(s)
- Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Xuxiang Zhang
- Department of Ophthalmology, Capital Medical University, Beijing, China
| | - Roxanne Ilagan
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
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7
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Cattaneo GF, Herrmann AM, Eiden SA, Wieser M, Kellner E, Doostkam S, Süß P, Kiefer S, Fauth L, Maurer CJ, Wolfertz J, Nitzsche B, Büchert M, Jost T, Ihorst G, Haberstroh J, Mülling C, Strecker C, Niesen WD, Shah MJ, Urbach H, Boltze J, Meckel S. Selective intra-carotid blood cooling in acute ischemic stroke: A safety and feasibility study in an ovine stroke model. J Cereb Blood Flow Metab 2021; 41:3097-3110. [PMID: 34159825 PMCID: PMC8756475 DOI: 10.1177/0271678x211024952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Selective therapeutic hypothermia (TH) showed promising preclinical results as a neuroprotective strategy in acute ischemic stroke. We aimed to assess safety and feasibility of an intracarotid cooling catheter conceived for fast and selective brain cooling during endovascular thrombectomy in an ovine stroke model.Transient middle cerebral artery occlusion (MCAO, 3 h) was performed in 20 sheep. In the hypothermia group (n = 10), selective TH was initiated 20 minutes before recanalization, and was maintained for another 3 h. In the normothermia control group (n = 10), a standard 8 French catheter was used instead. Primary endpoints were intranasal cooling performance (feasibility) plus vessel patency assessed by digital subtraction angiography and carotid artery wall integrity (histopathology, both safety). Secondary endpoints were neurological outcome and infarct volumes.Computed tomography perfusion demonstrated MCA territory hypoperfusion during MCAO in both groups. Intranasal temperature decreased by 1.1 °C/3.1 °C after 10/60 minutes in the TH group and 0.3 °C/0.4 °C in the normothermia group (p < 0.001). Carotid artery and branching vessel patency as well as carotid wall integrity was indifferent between groups. Infarct volumes (p = 0.74) and neurological outcome (p = 0.82) were similar in both groups.Selective TH was feasible and safe. However, a larger number of subjects might be required to demonstrate efficacy.
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Affiliation(s)
- Giorgio Fm Cattaneo
- Institute for Biomedical Engineering, University of Stuttgart, Stuttgart, Germany
| | - Andrea M Herrmann
- Faculty of Veterinary Medicine, Institute of Veterinary Anatomy, Histology and Embryology, Leipzig University, Leipzig, Germany.,Department of Neuroradiology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian A Eiden
- Department of Neuroradiology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manuela Wieser
- Department of Neuroradiology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Elias Kellner
- Department of MR Physics, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Soroush Doostkam
- Department of Neuropathology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Patrick Süß
- Department of Neuropathology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Selina Kiefer
- Department of Pathology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lisa Fauth
- Department of Pathology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph J Maurer
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Björn Nitzsche
- Faculty of Veterinary Medicine, Institute of Veterinary Anatomy, Histology and Embryology, Leipzig University, Leipzig, Germany
| | | | | | - Gabriele Ihorst
- Department of Clinical Trials, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jörg Haberstroh
- Center for Experimental Models and Transgenic Service (CEMT), Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Mülling
- Faculty of Veterinary Medicine, Institute of Veterinary Anatomy, Histology and Embryology, Leipzig University, Leipzig, Germany
| | - Christoph Strecker
- Department of Neurology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mukesch J Shah
- Department of Neurosurgery, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Boltze
- School of Live Sciences, University of Warwick, Coventry, UK
| | - Stephan Meckel
- Department of Neuroradiology, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Institute of Neuroradiology, Kepler University Hospital, Johannes Kepler University Linz, Austria
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Chao CM, Hsu CC, Huang CC, Wang CH, Lin MT, Chang CP, Lin HJ, Chio CC. Selective brain cooling achieves peripheral organs protection in hemorrhagic shock resuscitation via preserving the integrity of the brain-gut axis. Int J Med Sci 2021; 18:2920-2929. [PMID: 34220319 PMCID: PMC8241763 DOI: 10.7150/ijms.61191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/23/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Although whole-body cooling has been reported to improve the ischemic/reperfusion injury in hemorrhagic shock (HS) resuscitation, it is limited by its adverse reactions following therapeutic hypothermia. HS affects the experimental and clinical bowel disorders via activation of the brain-gut axis. It is unknown whether selective brain cooling achieves beneficial effects in HS resuscitation via preserving the integrity of the brain-gut axis. Methods: Male Sprague-Dawley rats were bled to hypovolemic HS and resuscitated with blood transfusion followed by retrograde jugular vein flush (RJVF) with 4 °C or 36 °C normal saline. The mean arterial blood pressure, cerebral blood flow, and brain and core temperature were measured. The integrity of intestinal tight junction proteins and permeability, blood pro-inflammatory cytokines, and multiple organs damage score were determined. Results: Following blood transfusion resuscitation, HS rats displayed gut barrier disruption, increased blood levels of pro-inflammatory cytokines, and peripheral vital organ injuries. Intrajugular-based infusion cooled the brain robustly with a minimal effect on body temperature. This brain cooling significantly reduced the HS resuscitation-induced gut disruption, systemic inflammation, and peripheral vital organ injuries in rats. Conclusion: Resuscitation with selective brain cooling achieves peripheral vital organs protection in hemorrhagic shock resuscitation via preserving the integrity of the brain-gut axis.
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Affiliation(s)
- Chien-Ming Chao
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan.,Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Senior Services, Southern Taiwan University of Science and Technology, Tainan, Taiwan.,Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Han Wang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Mao-Tsun Lin
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Ping Chang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Hung-Jung Lin
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chung-Ching Chio
- Division of Neurosurgery, Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan
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Wu L, Huber M, Wu D, Chen J, Li M, Ding Y, Ji X. Intra-arterial Cold Saline Infusion in Stroke: Historical Evolution and Future Prospects. Aging Dis 2020; 11:1527-1536. [PMID: 33269105 PMCID: PMC7673854 DOI: 10.14336/ad.2020.0325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 03/25/2020] [Indexed: 01/04/2023] Open
Abstract
Acute ischemic stroke (AIS) is a perpetual threat to life and functionality due to its high morbidity and mortality. In the past several decades, therapeutic hypothermia has garnered interest as an effective neuroprotective method in the setting of AIS. However, traditional hypothermic methods have been criticized for their low cooling efficiency and side effects. Intra-arterial cold saline infusion (IA-CSI), as a novel hypothermic method, not only minimizes these side effects, but is also perfectly integrated with widely accepted recanalization modalities in AIS, thereby serving as a promising prospect for clinical translation. In this article, we review the historical development of IA-CSI, summarize major studies of IA-CSI in rodents, large animals, and humans to date, and suggest insight into future development prospects in the field of AIS. We hope that this article will provide inspiration for the future application of hypothermia in AIS patients.
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Affiliation(s)
- Longfei Wu
- 1Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mitchell Huber
- 2Department of Emergency Medicine, Ascension St. John Hospital, Detroit, MI, USA
| | - Di Wu
- 1Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Chen
- 3Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ming Li
- 1Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- 4Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- 3Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Skok K, Duh M, Stožer A, Markota A, Gosak M. Thermoregulation: A journey from physiology to computational models and the intensive care unit. WILEY INTERDISCIPLINARY REVIEWS. SYSTEMS BIOLOGY AND MEDICINE 2020; 13:e1513. [PMID: 33251759 DOI: 10.1002/wsbm.1513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/24/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
Abstract
Thermoregulation plays a vital role in homeostasis. Many species of animals as well as humans have evolved various physiological mechanisms for body temperature control, which are characteristically flexible and enable a fine-tuned spatial and temporal regulation of body temperature in different environmental conditions and circumstances. Human beings normally maintain a core body temperature at around 37°C, and maintenance of this relatively high temperature is critical for survival. Therefore, principles of thermoregulatory control have also important clinical implications. Infections can cause the body temperature to rise internally and several diseases can cause a dysfunction of thermoregulatory mechanisms. Moreover, the utilization of thermotherapies in treating various diseases has been known for thousands of years with a recent resurgence of interest. An increasing amount of research suggests that targeted temperature management is of paramount importance to patient outcomes in certain clinical scenarios. We provide a concise summary of the basic concepts of thermoregulation. Emphasis is given to the principles of thermoregulation in humans in basic pathological states and to targeted temperature management strategies in the clinical environment, with special attention on therapeutic hypothermia in postcardiac arrest patients. Finally, the discussion is focused on the potential offered by computational thermophysiological models for predicting thermal responses of patients in various clinical circumstances, for proposing new perspectives in the design of novel thermal therapies, and to optimize targeted temperature management strategies. This article is categorized under: Cardiovascular Diseases > Cardiovascular Diseases>Computational Models Cardiovascular Diseases > Cardiovascular Diseases>Environmental Factors Cardiovascular Diseases > Cardiovascular Diseases>Biomedical Engineering.
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Affiliation(s)
- Kristijan Skok
- Department of Pathology, General Hospital Graz II, Location West, Graz, Austria
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Maja Duh
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koros̆ka cesta, Maribor, Slovenia
| | - Andraž Stožer
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Andrej Markota
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Medical Intensive Care Unit, University Medical Centre Maribor, Maribor, Slovenia
| | - Marko Gosak
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
- Faculty of Natural Sciences and Mathematics, University of Maribor, Koros̆ka cesta, Maribor, Slovenia
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11
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Choi JH, Poli S, Chen M, Nguyen TN, Saver JL, Matouk C, Pile-Spellman J. Selective Brain Hypothermia in Acute Ischemic Stroke: Reperfusion Without Reperfusion Injury. Front Neurol 2020; 11:594289. [PMID: 33281733 PMCID: PMC7691595 DOI: 10.3389/fneur.2020.594289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/15/2020] [Indexed: 01/19/2023] Open
Abstract
In acute ischemic stroke, early recanalization of the occluded artery is crucial for best outcome to be achieved. Recanalization aims at restoring blood flow to the ischemic tissue (reperfusion) and is achieved with pharmacological thrombolytic drugs, endovascular thrombectomy (EVT) devices, or both. The introduction of modern endovascular devices has led to tremendous anatomical and clinical success with rates of substantial reperfusion exceeding 80% and proven clinical benefit in patients with anterior circulation large vessel occlusions (LVOs). However, not every successful reperfusion procedure leads to the desired clinical outcome. In fact, the rate of non-disabled outcome at 3 months with current EVT treatment is ~1 out of 4. A constraint upon better outcomes is that reperfusion, though resolving ischemic stress, may not restore the anatomic structures and metabolic functions of ischemic tissue to their baseline states. In fact, ischemia triggers a complex cascade of destructive mechanisms that can sometimes be exacerbated rather than alleviated by reperfusion therapy. Such reperfusion injury may cause infarct progression, intracranial hemorrhage, and unfavorable outcome. Therapeutic hypothermia has been shown to have a favorable impact on the molecular elaboration of ischemic injury, but systemic hypothermia is limited by slow speed of attaining target temperatures and clinical complications. A novel approach is endovascular delivery of hypothermia to cool the affected brain tissue selectively and rapidly with tight local temperature control, features not available with systemic hypothermia devices. In this perspective article, we discuss the possible benefits of adjunctive selective endovascular brain hypothermia during interventional stroke treatment.
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Affiliation(s)
- Jae H. Choi
- Neurovascular Center, Neurological Surgery, P.C., Lake Success, NY, United States
- Hybernia Medical, LLC, New Rochelle, NY, United States
| | - Sven Poli
- Department of Neurology & Stroke, Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Michael Chen
- Stroke Center, Department of Neurosurgery, Rush University Medical Center, Chicago, IL, United States
| | - Thanh N. Nguyen
- Interventional Neurology/Neuroradiology, Boston University School of Medicine, Boston, MA, United States
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Charles Matouk
- Neurovascular Surgery, Department of Neurosurgery, Yale University-New Haven Hospital, New Haven, CT, United States
| | - John Pile-Spellman
- Neurovascular Center, Neurological Surgery, P.C., Lake Success, NY, United States
- Hybernia Medical, LLC, New Rochelle, NY, United States
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12
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Wang Y, Choi JH, Almekhlafi MA, Ziemann U, Poli S. A System for Continuous Pre- to Post-reperfusion Intra-carotid Cold Infusion for Selective Brain Hypothermia in Rodent StrokeModels. Transl Stroke Res 2020; 12:676-687. [PMID: 32910341 PMCID: PMC8213555 DOI: 10.1007/s12975-020-00848-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/12/2020] [Accepted: 09/03/2020] [Indexed: 11/26/2022]
Abstract
Intra-carotid cold infusion (ICCI) appears as a promising method for hypothermia-mediated brain protection from ischemic stroke. Recent clinical pilot studies indicate easy implementation of ICCI into endovascular acute ischemic stroke treatment. Current rodent ICCI-in-stroke models limit ICCI to the post-reperfusion phase. To establish a method for continuous ICCI over the duration of intra-ischemia to post-reperfusion in rodent stroke models, a novel system was developed. Eighteen male Sprague-Dawley rats were included. Intraluminal filament method was used for transient middle cerebral artery occlusion (MCAO). Normal saline (~ 0 °C) was delivered (≤ 2.0 mL/min) into the internal carotid artery via a customized infusion system without interruption during MCAO (intra-ischemia) to after filament withdrawal (post-reperfusion). Bilateral cortical and striatal temperatures were monitored. Hypothermia goals were a temperature reduction in the ischemic hemisphere by 2 °C prior to reperfusion and thereafter maintenance of regional brain hypothermia at ~ 32 °C limiting the administered ICCI volume to ½ of each rat's total blood volume. During ischemia, maximum brain cooling rate was achieved with ICCI at 0.5 mL/min. It took 2 min to reduce ischemic striatal temperature by 2.3 ± 0.3 °C. After reperfusion, brain cooling was continued at 2 mL/min ICCI first (over 42 s) and maintained at 32.1 ± 0.3 °C at 0.7 mL/min ICCI over a duration of 15 ± 0.8 min. ICCI (total 12.6 ± 0.6 mL) was uninterrupted over the duration of the studied phases. First system that allows continuous ICCI during the phases of intra-ischemia to post-reperfusion in small animals for selective brain cooling and for investigations of other neuroprotective infusions.
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Affiliation(s)
- Yi Wang
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Graduate Training Center of Neuroscience, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Jae H Choi
- Neurological Surgery PC, Lake Success, NY, USA
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences and Radiology, Calgary Stroke Program, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany
- Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.
- Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany.
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13
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Lutz Y, Meiner T, Krames L, Cattaneo G, Meckel S, Dossel O, Loewe A. Selective Brain Hypothermia for Ischemic MCA-M1 Stroke: Influence of Cerebral Arterial Circulation in a 3D Brain Temperature Model. IEEE Trans Biomed Eng 2020; 68:404-415. [PMID: 32746020 DOI: 10.1109/tbme.2020.3000521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Acute ischemic stroke is a major health problem with a high mortality rate and a high risk for permanent disabilities. Selective brain hypothermia has the neuroprotective potential to possibly lower cerebral harm. A recently developed catheter system enables to combine endovascular blood cooling and thrombectomy using the same endovascular access. By using the penumbral perfusion via leptomeningeal collaterals, the catheter aims at enabling a cold reperfusion, which mitigates the risk of a reperfusion injury. However, cerebral circulation is highly patient-specific and can vary greatly. Since direct measurement of remaining perfusion and temperature decrease induced by the catheter is not possible without additional harm to the patient, computational modeling provides an alternative to gain knowledge about resulting cerebral temperature decrease. In this work, we present a brain temperature model with a realistic division into gray and white matter and consideration of spatially resolved perfusion. Furthermore, it includes detailed anatomy of cerebral circulation with possibility of personalizing on base of real patient anatomy. For evaluation of catheter performance in terms of cold reperfusion and to analyze its general performance, we calculated the decrease in brain temperature in case of a large vessel occlusion in the middle cerebral artery (MCA) for different scenarios of cerebral arterial anatomy. Congenital arterial variations in the circle of Willis had a distinct influence on the cooling effect and the resulting spatial temperature distribution before vessel recanalization. Independent of the branching configurations, the model predicted a cold reperfusion due to a strong temperature decrease after recanalization (1.4-2.2 °C after 25 min of cooling, recanalization after 20 min of cooling). Our model illustrates the effectiveness of endovascular cooling in combination with mechanical thrombectomy and its results serve as an adequate substitute for temperature measurement in a clinical setting in the absence of direct intraparenchymal temperature probes.
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14
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Ageing as a risk factor for cerebral ischemia: Underlying mechanisms and therapy in animal models and in the clinic. Mech Ageing Dev 2020; 190:111312. [PMID: 32663480 DOI: 10.1016/j.mad.2020.111312] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/24/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
Abstract
Age is the only one non-modifiable risk of cerebral ischemia. Advances in stroke medicine and behavioral adaptation to stroke risk factors and comorbidities was successful in decreasing stroke incidence and increasing the number of stroke survivors in western societies. Comorbidities aggravates the outcome after cerebral ischemia. However, due to the increased in number of elderly, the incidence of stroke has increased again paralleled by an increase in the number of stroke survivors, many with severe disabilities, that has led to an increased economic and social burden in society. Animal models of stroke often ignore age and comorbidities frequently associated with senescence. This might explain why drugs working nicely in animal models fail to show efficacy in stroke survivors. Since stroke afflicts mostly the elderly comorbid patients, it is highly desirable to test the efficacy of stroke therapies in an appropriate animal stroke model. Therefore, in this review, we make parallels between animal models of stroke und clinical data and summarize the impact of ageing and age-related comorbidities on stroke outcome.
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15
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Kuczynski AM, Marzoughi S, Al Sultan AS, Colbourne F, Menon BK, van Es ACGM, Berez AL, Goyal M, Demchuk AM, Almekhlafi MA. Therapeutic Hypothermia in Acute Ischemic Stroke-a Systematic Review and Meta-Analysis. Curr Neurol Neurosci Rep 2020; 20:13. [PMID: 32372297 DOI: 10.1007/s11910-020-01029-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Therapeutic hypothermia (TH) in stroke demonstrates robust neuroprotection in animals but clinical applications remain controversial. We assessed current literature on the efficacy of TH in ischemic stroke. RECENT FINDINGS We conducted a meta-analysis comparing TH versus controls in studies published until June 2019. Controlled studies reporting on ≥ 10 adults with acute ischemic stroke were included. Primary outcome was functional independence (modified Rankin Scale [mRS] ≤ 2). Twelve studies (n = 351 TH, n = 427 controls) were included. Functional independence did not differ between groups (RR 1.17, 95% CI 0.93-1.46, random-effects p = 0.2). Five studies reported individual mRS outcomes and demonstrated a shift toward better outcome with TH (unadjusted cOR 1.57, 95% CI 1.01-2.44, p = 0.05). Overall complications were higher with TH (RR 1.18, 95% CI 1.06-1.32, p < 0.01). We did not observe an overall beneficial effect of TH in this analysis although some studies showed a shift toward better outcome. TH was associated with increased complications.
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Affiliation(s)
| | - Sina Marzoughi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | - Bijoy K Menon
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | - Mayank Goyal
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada
| | - Mohammed A Almekhlafi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada.
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16
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Wu L, Wu D, Yang T, Xu J, Chen J, Wang L, Xu S, Zhao W, Wu C, Ji X. Hypothermic neuroprotection against acute ischemic stroke: The 2019 update. J Cereb Blood Flow Metab 2020; 40:461-481. [PMID: 31856639 PMCID: PMC7026854 DOI: 10.1177/0271678x19894869] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023]
Abstract
Acute ischemic stroke is a leading cause of death and disability worldwide. Therapeutic hypothermia has long been considered as one of the most robust neuroprotective strategies. Although the neuroprotective effects of hypothermia have only been confirmed in patients with global cerebral ischemia after cardiac arrest and in neonatal hypoxic ischemic encephalopathy, establishing standardized protocols and strictly controlling the key parameters may extend its application in other brain injuries, such as acute ischemic stroke. In this review, we discuss the potential neuroprotective effects of hypothermia, its drawbacks evidenced in previous studies, and its potential clinical application for acute ischemic stroke especially in the era of reperfusion. Based on the different conditions between bench and bedside settings, we demonstrate the importance of vascular recanalization for neuroprotection of hypothermia by analyzing numerous literatures regarding hypothermia in focal cerebral ischemia. Then, we make a thorough analysis of key parameters of hypothermia and introduce novel hypothermic therapies. We advocate in favor of the process of clinical translation of intra-arterial selective cooling infusion in the era of reperfusion and provide insights into the prospects of hypothermia in acute ischemic stroke.
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Affiliation(s)
- Longfei Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tuo Yang
- Department of Neurology, Pittsburgh Institute of Brain Disorders and Recovery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jin Xu
- Department of Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Luling Wang
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shuaili Xu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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17
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Tang YN, Zhang GF, Chen HL, Sun XP, Qin WW, Shi F, Sun LX, Xu XN, Wang MS. Selective brain hypothermia-induced neuroprotection against focal cerebral ischemia/reperfusion injury is associated with Fis1 inhibition. Neural Regen Res 2020; 15:903-911. [PMID: 31719256 PMCID: PMC6990783 DOI: 10.4103/1673-5374.268973] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Selective brain hypothermia is considered an effective treatment for neuronal injury after stroke, and avoids the complications of general hypothermia. However, the mechanisms by which selective brain hypothermia affects mitochondrial fission remain unknown. In this study, we investigated the effect of selective brain hypothermia on the expression of fission 1 (Fis1) protein, a key factor in the mitochondrial fission system, during focal cerebral ischemia/reperfusion injury. Sprague-Dawley rats were divided into four groups. In the sham group, the carotid arteries were exposed only. In the other three groups, middle cerebral artery occlusion was performed using the intraluminal filament technique. After 2 hours of occlusion, the filament was slowly removed to allow blood reperfusion in the ischemia/reperfusion group. Saline, at 4°C and 37°C, were perfused through the carotid artery in the hypothermia and normothermia groups, respectively, followed by restoration of blood flow. Neurological function was assessed with the Zea Longa 5-point scoring method. Cerebral infarct volume was assessed by 2,3,5-triphenyltetrazolium chloride staining, and apoptosis was assessed by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling staining. Fis1 and cytosolic cytochrome c levels were assessed by western blot assay. Fis1 mRNA expression was assessed by quantitative reverse transcription-polymerase chain reaction. Mitochondrial ultrastructure was evaluated by transmission electron microscopy. Compared with the sham group, apoptosis, Fis1 protein and mRNA expression and cytosolic cytochrome c levels in the cortical ischemic penumbra and cerebral infarct volume were increased after reperfusion in the other three groups. These changes caused by cerebral ischemia/reperfusion were inhibited in the hypothermia group compared with the normothermia group. These findings show that selective brain hypothermia inhibits Fis1 expression and reduces apoptosis, thereby ameliorating focal cerebral ischemia/reperfusion injury in rats. Experiments were authorized by the Ethics Committee of Qingdao Municipal Hospital of China (approval No. 2019008).
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Affiliation(s)
- Ya-Nan Tang
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Gao-Feng Zhang
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Huai-Long Chen
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xiao-Peng Sun
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Wei-Wei Qin
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Fei Shi
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Li-Xin Sun
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xiao-Na Xu
- Department of Central Laboratory, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Ming-Shan Wang
- Department of Anesthesiology, Affiliated Qingdao Municipal Hospital of Qingdao University, Qingdao, Shandong Province, China
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18
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Cattaneo G, Meckel S. Review of selective brain hypothermia in acute ischemic stroke therapy using an intracarotid, closed-loop cooling catheter. Brain Circ 2019; 5:211-217. [PMID: 31950097 PMCID: PMC6950513 DOI: 10.4103/bc.bc_54_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 11/25/2019] [Accepted: 12/05/2019] [Indexed: 02/01/2023] Open
Abstract
In acute ischemic stroke patients, selective brain hypothermia is a promising concept aiming at a fast decrease of brain temperature and thus neuroprotection in the acute phase of ischemia. At the same time, the emergence of mechanical thrombectomy (MT) as an effective treatment in large-vessel occlusion opens the door for a combination of neuroprotective approaches in the frame of a neurovascular, catheter-based intervention. In this regard, intracarotid cooling is a very effective energetic approach, using the blood supply to the penumbra as a fast transport vector for heat exchange in affected brain regions. We review the state of development of a novel closed-loop cooling catheter, describing design-related as well as procedural aspects and presenting results from different theoretical and experimental studies. Finally, we compare the concept with two alternative methods: cold saline infusion and extracorporeal blood cooling. We focus on the combination with MT, considering the effect of different and variable perfusion rates on the final goal of a “cold reperfusion” at the time of blood flow restoration.
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Affiliation(s)
- Giorgio Cattaneo
- Institute for Biomedical Engineering, University of Stuttgart, Stuttgart, Germany
| | - Stephan Meckel
- Department of Neuroradiology, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
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19
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Merrill TL, Smith BF, Mitchell JE, Merrill DR, Pukenas BA, Konstas AA. Infusion warm during selective hypothermia in acute ischemic stroke. Brain Circ 2019; 5:218-224. [PMID: 31950098 PMCID: PMC6950505 DOI: 10.4103/bc.bc_48_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 10/28/2019] [Accepted: 11/14/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Mechanical thrombectomy (MT) has dramatically improved the prognosis for acute ischemic stroke (AIS) patients. Despite high recanalization rates, up to half of the patients will not present a good neurological outcome after MT. Therapeutic hypothermia is perhaps the most robust neuroprotectant studied preclinically. MATERIALS AND METHODS We explored various warming effects that can reduce the effectiveness or potency of selective hypothermia during AIS under conditions similar to actual clinical care. Four different selective hypothermia layouts were chosen. Layouts 1 and 2 used a single catheter without and with an insulated IV bag. Layouts 3 and 4 used two catheters arrange coaxially, without and with an insulated IV bag. Independent variables measured were IV bag exit temperature, catheter inlet temperature, and catheter outlet temperature at four different flow rates ranging from 8 to 25 ml/min over an infusion duration of 20 min. RESULTS Dominant warming occurs along the catheter pathway compared to warming along the infusion line pathway, ranging from 66% to 72%. Coaxial configurations provided an approximate 4°C cooler temperature benefit on delivered infusate over a single catheter. Brain tissue temperature predictions show that the maximum cooling layout, Layout 4 at maximum flow provides a 1°C within 5 min. CONCLUSION Significant rewarming effects occur along the infusate flow path from IV bag to site of injury in the brain. Previous selective hypothermia clinical work, using flow rates and equipment at conditions similar to our study, likely produced rapid but not deep tissue cooling in the brain (~ 1°C).
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Affiliation(s)
- Thomas L Merrill
- Department of Mechanical and Biomedical Engineering, Rowan University, Glassboro, USA.,FocalCool, LLC, Mullica Hill, New Jersey, USA
| | - Bradley F Smith
- Department of Mechanical and Biomedical Engineering, Rowan University, Glassboro, USA
| | | | | | - Bryan A Pukenas
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angelos A Konstas
- Department of Radiology, Huntington Hospital, Pasadena, California, USA
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20
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Mattingly TK, Lownie SP. Cold blood perfusion for selective hypothermia in acute ischemic stroke. Brain Circ 2019; 5:187-194. [PMID: 31950094 PMCID: PMC6950509 DOI: 10.4103/bc.bc_17_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/28/2019] [Accepted: 11/25/2019] [Indexed: 11/04/2022] Open
Abstract
Hypothermia is the most reliably effective neuroprotectant, and yet systemic complications limit application. A large body of animal data suggests that hypothermia is effective for focal cerebral ischemia, namely acute ischemic stroke. In order to apply hypothermia effectively, a selective approach is required to maximize the effect on the brain while minimizing systemic side effects. Due to poor transferability of promising findings in rodent models to human clinical trials for neuroprotection, the focus of this review is large animal gyrencephalic models. Unlike rodent data which favor mild hypothermia, the majority of large animal studies on selective hypothermia support moderate-to-deep hypothermia (<30°C). Cold blood perfusion produces the rapid rate of temperature reduction and depth of hypothermia required to produce meaningful neuroprotection. Further studies of selective hypothermia in acute ischemic stroke require attention to duration and rate of cooling to optimize the neuroprotection offered by this technique.
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Affiliation(s)
- Thomas K Mattingly
- Department of Neurosurgery, Division of Cerebrovascular Surgery, University of Rochester, Rochester, NY, USA
| | - Stephen P Lownie
- Department of Neurosurgery, Otolaryngology and Imaging Sciences, London Health Sciences Centre, Western University, London, ON, Canada
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21
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Almekhlafi MA, Poli S, Goyal M, Demchuk AM. Therapeutic hypothermia in stroke: Quo Vadis? Brain Circ 2019; 5:157-159. [PMID: 31950090 PMCID: PMC6950514 DOI: 10.4103/bc.bc_62_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 12/08/2019] [Accepted: 12/09/2019] [Indexed: 12/24/2022] Open
Affiliation(s)
- Mohammed A. Almekhlafi
- Department of Clinical Neurosciences and Radiology, Calgary Stroke Program, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Sven Poli
- Department of Neurology and Stroke, Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Mayank Goyal
- Department of Clinical Neurosciences and Radiology, Calgary Stroke Program, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences and Radiology, Calgary Stroke Program, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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22
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Baron JC. Protecting the ischaemic penumbra as an adjunct to thrombectomy for acute stroke. Nat Rev Neurol 2019; 14:325-337. [PMID: 29674752 DOI: 10.1038/s41582-018-0002-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
After ischaemic stroke, brain damage can be curtailed by rescuing the 'ischaemic penumbra' - that is, the severely hypoperfused, at-risk but not yet infarcted tissue. Current evidence-based treatments involve restoration of blood flow so as to salvage the penumbra before it evolves into irreversibly damaged tissue, termed the 'core'. Intravenous thrombolysis (IVT) can salvage the penumbra if given within 4.5 h after stroke onset; however, the early recanalization rate is only ~30%. Direct removal of the occluding clot by mechanical thrombectomy considerably improves outcomes over IVT alone, but despite early recanalization in > 80% of cases, ~50% of patients who receive this treatment do not enjoy functional independence, usually because the core is already too large at the time of recanalization. Novel therapies aiming to 'freeze' the penumbra - that is, prevent core growth until recanalization is complete - hold potential as adjuncts to mechanical thrombectomy. This Review focuses on nonpharmacological approaches that aim to restore the physiological balance between oxygen delivery to and oxygen demand of the penumbra. Particular emphasis is placed on normobaric oxygen therapy, hypothermia and sensory stimulation. Preclinical evidence and early pilot clinical trials are critically reviewed, and future directions, including clinical translation and trial design issues, are discussed.
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Affiliation(s)
- Jean-Claude Baron
- Department of Neurology, Hôpital Sainte-Anne, Université Paris 5, INSERM U894, Paris, France.
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Corey S, Abraham DI, Kaneko Y, Lee JY, Borlongan CV. Selective endovascular cooling for stroke entails brain-derived neurotrophic factor and splenic IL-10 modulation. Brain Res 2019; 1722:146380. [PMID: 31415765 DOI: 10.1016/j.brainres.2019.146380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/08/2019] [Accepted: 08/12/2019] [Indexed: 12/27/2022]
Abstract
Stroke poses a serious health and economic burden, and the lack of treatment options necessitates a viable therapy. Hypothermia represents a promising stroke therapy, yet side effects of full-body cooling, such as pneumonia, limit its clinical application. Selective endovascular cooling (SEC), via infusion of cold saline through the intraarterial artery, represents an attractive alternative by locally cooling the brain while preserving body temperature. However, the mechanisms underlying SEC are poorly understood. Brain-derived neurotrophic factor (BDNF) is a widely recognized promotor of neuroplasticity and biomarker of stroke outcomes, as well as its association with inflammation, such as IL-10. Stroke-induced neuroinflammation exacerbates damage and stems from peripheral organs, namely the spleen. The spleen has emerged as a therapeutic target for stroke, yet the effect of SEC on the splenic inflammatory response is unknown. Here, we aimed to elucidate the local and peripheral mechanisms driving SEC as a neuroprotective stroke therapy by examining brain BDNF and splenic IL-10 expression. Animals that received SEC prior to stroke displayed elevated brain BDNF expression ipsilaterally and contralaterally across the cortex, striatum, and hippocampus. SEC also upregulated splenic IL-10, suggesting alteration of the peripheral inflammatory response. The oxygen-glucose deprivation in vitro model of stroke further demonstrated that "cold" rat splenocytes protected rat primary neurons by upregulating BDNF and IL-10. Altogether these data support BDNF- and IL-10-based mechanisms underlying the neuroprotective potential of SEC therapy for stroke, and further advance the concept of exploiting the pathological link between brain and spleen as therapeutic targets.
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Affiliation(s)
- Sydney Corey
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd., Tampa, FL 33612, USA
| | - Diego Incontri Abraham
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd., Tampa, FL 33612, USA
| | - Yuji Kaneko
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd., Tampa, FL 33612, USA
| | - Jea-Young Lee
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd., Tampa, FL 33612, USA
| | - Cesar V Borlongan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd., Tampa, FL 33612, USA.
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24
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Caroff J, King RM, Mitchell JE, Marosfoi M, Licwinko JR, Gray-Edwards HL, Puri AS, Merrill TL, Gounis MJ. Focal cooling of brain parenchyma in a transient large vessel occlusion model: proof-of-concept. J Neurointerv Surg 2019; 12:209-213. [PMID: 31363042 DOI: 10.1136/neurintsurg-2019-015179] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The neuroprotective benefit of therapeutic hypothermia (TH) has been demonstrated, but systemic side effects and time required to achieve effective TH in acute ischemic stroke (AIS) care limits clinical use. We investigate rapid and localized cooling using a novel insulated catheter in an ischemia-reperfusion model. METHODS In phase I (n=4), cold saline was delivered to the canine internal carotid artery via an insulated catheter. Temperature was measured using intracerebral thermocouples. The coolant flow rate was varied to meet a target temperature of 31-32°C in the hemisphere infused. In phase II (n=8), a temporary middle cerebral artery occlusion was created. Five dogs underwent localized TH at the optimal flow rate from phase I, and the remaining animals were untreated controls. Cooling was initiated 5 min before recanalization and continued for an additional 20 min following 45 min of occlusion duration. The outcome was infarct volume and neurological function. RESULTS Ipsilateral tissue cooling rates were 2.2±2.5°C/min at a flow rate of 20-40 mL/min with an observed minimum of 23.8°C. Tissue cooling was localized to the ipsilateral side of the infusion with little impact on temperatures of the core or contralateral hemisphere of the brain. In phase II, animals tolerated TH with minimal systemic impact. Infarct volume in treated animals was 0.2±0.2 cm3, which was smaller than in sham animals (3.8±1.0 cm3) as well as six untreated historical control animals (4.0±2.8 cm3) (p=0.013). CONCLUSIONS Proof-of-concept data show that localised brain TH can be quickly and safely achieved through a novel insulated catheter. The small infarct volumes suggest potential benefit for this approach.
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Affiliation(s)
- Jildaz Caroff
- Interventional Neuroradiology, NEURI Center, Bicêtre Hospital, Le Kremlin- Bicêtre, France
| | - Robert M King
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | | | - Miklos Marosfoi
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | | | - Heather L Gray-Edwards
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ajit S Puri
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Thomas L Merrill
- FocalCool, Mullica Hill, New Jersey, USA.,Department of Mechanical Engineering, Rowan University, Glassboro, NJ, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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25
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Lutz Y, Loewe A, Meckel S, Dössel O, Cattaneo G. Combined local hypothermia and recanalization therapy for acute ischemic stroke: Estimation of brain and systemic temperature using an energetic numerical model. J Therm Biol 2019; 84:316-322. [PMID: 31466769 DOI: 10.1016/j.jtherbio.2019.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 10/26/2022]
Abstract
Local brain hypothermia is an attractive method for providing cerebral neuroprotection for ischemic stroke patients and at the same time reducing systemic side effects of cooling. In acute ischemic stroke patients with large vessel occlusion, combination with endovascular mechanical recanalization treatment could potentially allow for an alleviation of inflammatory and apoptotic pathways in the critical phase of reperfusion. The direct cooling of arterial blood by means of an intra-carotid heat exchange catheter compatible with recanalization systems is a novel promising approach. Focusing on the concept of "cold reperfusion", we developed an energetic model to calculate the rate of temperature decrease during intra-carotid cooling in case of physiological as well as decreased perfusion. Additionally, we discussed and considered the effect and biological significance of temperature decrease on resulting brain perfusion. Our model predicted a 2 °C brain temperature decrease in 8.3, 11.8 and 26.2 min at perfusion rates of 50, 30 and 10ml100g⋅min, respectively. The systemic temperature decrease - caused by the venous blood return to the main circulation - was limited to 0.5 °C in 60 min. Our results underline the potential of catheter-assisted, intracarotid blood cooling to provide a fast and selective brain temperature decrease in the phase of vessel recanalization. This method can potentially allow for a tissue hypothermia during the restoration of the physiological flow and thus a "cold reperfusion" in the setting of mechanical recanalization.
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Affiliation(s)
- Yannick Lutz
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany.
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Stephan Meckel
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Olaf Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
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26
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Duan H, Huber M, Ding JN, Huber C, Geng X. Local endovascular infusion and hypothermia in stroke therapy: A systematic review. Brain Circ 2019; 5:68-73. [PMID: 31334359 PMCID: PMC6611196 DOI: 10.4103/bc.bc_9_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/03/2019] [Accepted: 05/16/2019] [Indexed: 01/01/2023] Open
Abstract
Ischemic stroke is a leading cause of death and disability worldwide, but there are no effective, widely applicable stroke therapies. Systemic hypothermia is an international mainstay of postcardiac arrest care, and the neuroprotective benefits of systemic hypothermia following cerebral ischemia have been proven in clinical trials, but logistical issues hinder clinical acceptance. As a novel solution to these logistical issues, the application of local endovascular infusion of cold saline directly to the infarct site using a microcatheter has been put forth. In small animal models, the procedure has shown incredible neuroprotective promise on the biochemical, structural, and functional levels, and preliminary trials in large animals and humans have been similarly encouraging. In addition, the procedure would be relatively cost-effective and widely applicable. The administration of local endovascular hypothermia in humans is relatively simple, as this is a normal part of endovascular intervention for neuroendovascular surgeons. Therefore, it is expected that this new therapy could easily be added to an angiography suite. However, the neuroprotective efficacy in humans has yet to be determined, which is an end goal of researchers in the field. Given the potentially massive benefits, ease of induction, and cost-effective nature, it is likely that local endovascular hypothermia will become an integral part of endovascular treatment following ischemic stroke. This review outlines relevant research, discusses neuroprotective mechanisms, and discusses possibilities for future directions.
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Affiliation(s)
- Honglian Duan
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Mitchell Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Jessie N Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Christian Huber
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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27
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Kuczynski AM, Demchuk AM, Almekhlafi MA. Therapeutic hypothermia: Applications in adults with acute ischemic stroke. Brain Circ 2019; 5:43-54. [PMID: 31334356 PMCID: PMC6611191 DOI: 10.4103/bc.bc_5_19] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/05/2019] [Accepted: 04/09/2019] [Indexed: 12/13/2022] Open
Abstract
The advent of mechanical thrombectomy and increasing alteplase use have transformed the care of patients with acute ischemic stroke. Patients with major arterial occlusions with poor outcomes now have a chance of returning to independent living in more than half of the cases. However, many patients with these severe strokes suffer major disability despite these therapies. The search is ongoing for agents that can be combined with thrombectomy to achieve better recovery through halting infarct growth and mitigating injury after ischemic stroke. Several studies in animals and humans have demonstrated that therapeutic hypothermia (TH) offers potential to interrupt the ischemic cascade, reduce infarct volume, and improve functional independence. We performed a literature search to look up recent advances in the use of TH surrounding the science, efficacy, and feasibility of inducing TH in modern stroke treatments. While protocols remain controversial, there is a real opportunity to combine TH with the existing therapies to improve outcome in adults with acute ischemic stroke.
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Affiliation(s)
| | - Andrew M Demchuk
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada
| | - Mohammed A Almekhlafi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, Hotchkiss Brain Institute, Calgary, AB, Canada.,O'Brien Institute for Public Health, Calgary, AB, Canada
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Almekhlafi MA, Colbourne F, Al Sultan AS, Goyal M, Demchuk AM. Selective brain cooling: Let us have a moment of science. J Cereb Blood Flow Metab 2019; 39:182-183. [PMID: 30215541 PMCID: PMC6311662 DOI: 10.1177/0271678x18800274] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Selective brain cooling is a promising advent for reducing final infarct volume and improving outcomes in ischemic stroke victims. Despite the robust body of evidence from animal studies, evidence supporting the use of selective hypothermia in stroke patients is lacking. A recent study provided promising results on the safety and possible efficacy of selective brain hypothermia via intraarterial infusion of cooled saline. Better understanding of the patients' population that may attain benefit from this approach will be informative. Details of infarct progression using perfusion imaging will also help understand the mechanism of effect of selective hypothermia to inform future trials.
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Affiliation(s)
- Mohammed A Almekhlafi
- 1 Department of Clinical Neurosciences, at Cumming school of Medicine, University of Calgary, Alberta, Canada.,2 Department of Radiology at Cumming school of Medicine, University of Calgary, Alberta, Canada.,3 Hotchkiss Brain Institute at Cumming school of Medicine, University of Calgary, Alberta, Canada
| | - Fred Colbourne
- 4 Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada.,5 Department of Psychology, University of Alberta, Edmonton, Canada
| | - Abdulaziz S Al Sultan
- 1 Department of Clinical Neurosciences, at Cumming school of Medicine, University of Calgary, Alberta, Canada.,3 Hotchkiss Brain Institute at Cumming school of Medicine, University of Calgary, Alberta, Canada
| | - Mayank Goyal
- 2 Department of Radiology at Cumming school of Medicine, University of Calgary, Alberta, Canada.,3 Hotchkiss Brain Institute at Cumming school of Medicine, University of Calgary, Alberta, Canada
| | - Andrew M Demchuk
- 1 Department of Clinical Neurosciences, at Cumming school of Medicine, University of Calgary, Alberta, Canada.,3 Hotchkiss Brain Institute at Cumming school of Medicine, University of Calgary, Alberta, Canada
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29
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Cold Blooded: Evaluating Brain Temperature by MRI During Surface Cooling of Human Subjects. Neurocrit Care 2018; 27:214-219. [PMID: 28352966 DOI: 10.1007/s12028-017-0389-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Targeted temperature management (TTM) confers neurological and survival benefits for post-cardiac arrest patients with return of spontaneous circulation (ROSC) who remain comatose. Specialized equipment for induction of hypothermia is not available in the prehospital setting, and there are no reliable methods for emergency medical services personnel to initiate TTM. We hypothesized that the application of surface cooling elements to the neck will decrease brain temperature and act as initiators of TTM. METHODS Magnetic resonance (MR) spectroscopy was used to evaluate the effect of a carotid surface cooling element on brain temperature in healthy adults. RESULTS Six individuals completed this study. We measured a temperature drop of 0.69 ± 0.38 °C (95% CI) in the cortex of the brain following the application of the cooling element. Application of a room temperature element also caused a measurable decrease in brain temperature of 0.66 ± 0.41 °C (95% CI) which may be attributable to baroreceptor activation. CONCLUSION The application of surface cooling elements to the neck decreased brain temperature and may serve as a method to initiate TTM in the prehospital setting.
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30
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Abstract
Selective brain hypothermia is a powerful concept for neuroprotection that has been successfully investigated in a variety of animal models of global and focal ischemia. Its major advantages over systemic hypothermia include rapid induction of cooling, ability to achieve profound target brain temperatures, organ-selective cooling, and temperature control. Clinical systems and devices are available or are currently under development that utilize conductive (surface-cooling pads, closed-loop catheters), convective (transnasal coolant delivery), or mass and energy transport (cold intra-arterial infusion) methods to achieve and maintain selective brain hypothermia. The "ideal" brain-cooling system that is characterized by rapid cooling to profound hypothermia, its ability to maintain selective cooling over several days, and is noninvasive in nature, remains unrealistic. Instead, systems may be identified by their distinct advantages to meet a specific need in the care of a patient. This involves the consideration of the timing of ischemic injury (preischemic, intraischemic, postischemic), extent of ischemic damage (excitotoxicity, inflammation, necrosis, edema), and type and setting of therapeutic intervention (intensive care, interventional therapy, surgery). The successful translation of these systems into clinical practice will depend on smart engineering, safety and efficacy, and usability in current clinical work flow.
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Affiliation(s)
- Jae H Choi
- Neurological Surgery PC, Lake Success, NY, United States.
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31
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Zhu L. Hypothermia Used in Medical Applications for Brain and Spinal Cord Injury Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1097:295-319. [PMID: 30315552 DOI: 10.1007/978-3-319-96445-4_16] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite more than 80 years of animal experiments and clinical practice, efficacy of hypothermia in improving treatment outcomes in patients suffering from cell and tissue damage caused by ischemia is still ongoing. This review will first describe the history of utilizing cooling in medical treatment, followed by chemical and biochemical mechanisms of cooling that can lead to neuroprotection often observed in animal studies and some clinical studies. The next sections will be focused on current cooling approaches/devices, as well as cooling parameters recommended by researchers and clinicians. Animal and clinical studies of implementing hypothermia to spinal cord and brain tissue injury patients are presented next. This section will review the latest outcomes of hypothermia in treating patients suffering from traumatic brain injury (TBI), spinal cord injury (SCI), stroke, cardiopulmonary surgery, and cardiac arrest, followed by a summary of available evidence regarding both demonstrated neuroprotection and potential risks of hypothermia. Contributions from bioengineers to the field of hypothermia in medical treatment will be discussed in the last section of this review. Overall, an accumulating body of clinical evidence along with several decades of animal research and mathematical simulations has documented that the efficacy of hypothermia is dependent on achieving a reduced temperature in the target tissue before or soon after the injury-precipitating event. Mild hypothermia with temperature reduction of several degrees Celsius is as effective as modest or deep hypothermia in providing therapeutic benefit without introducing collateral/systemic complications. It is widely demonstrated that the rewarming rate must be controlled to be lower than 0.5 °C/h to avoid mismatch between local blood perfusion and metabolism. In the past several decades, many different cooling methods and devices have been designed, tested, and used in medical treatments with mixed results. Accurately designing treatment protocols to achieve specific cooling outcomes requires collaboration among engineers, researchers, and clinicians. Although this problem is quite challenging, it presents a major opportunity for bioengineers to create methods and devices that quickly and safely produce hypothermia in targeted tissue regions without interfering with routine medical treatment.
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Affiliation(s)
- Liang Zhu
- Department of Mechanical Engineering, University of Maryland Baltimore County, Baltimore, MD, USA.
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32
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Sandu RE, Dumbrava D, Surugiu R, Glavan DG, Gresita A, Petcu EB. Cellular and Molecular Mechanisms Underlying Non-Pharmaceutical Ischemic Stroke Therapy in Aged Subjects. Int J Mol Sci 2017; 19:ijms19010099. [PMID: 29286319 PMCID: PMC5796049 DOI: 10.3390/ijms19010099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/22/2017] [Accepted: 12/24/2017] [Indexed: 12/12/2022] Open
Abstract
The incidence of ischemic stroke in humans increases exponentially above 70 years both in men and women. Comorbidities like diabetes, arterial hypertension or co-morbidity factors such as hypercholesterolemia, obesity and body fat distribution as well as fat-rich diet and physical inactivity are common in elderly persons and are associated with higher risk of stroke, increased mortality and disability. Obesity could represent a state of chronic inflammation that can be prevented to some extent by non-pharmaceutical interventions such as calorie restriction and hypothermia. Indeed, recent results suggest that H₂S-induced hypothermia in aged, overweight rats could have a higher probability of success in treating stroke as compared to other monotherapies, by reducing post-stroke brain inflammation. Likewise, it was recently reported that weight reduction prior to stroke, in aged, overweight rats induced by caloric restriction, led to an early re-gain of weight and a significant improvement in recovery of complex sensorimotor skills, cutaneous sensitivity, or spatial memory. CONCLUSION animal models of stroke done in young animals ignore age-associated comorbidities and may explain, at least in part, the unsuccessful bench-to-bedside translation of neuroprotective strategies for ischemic stroke in aged subjects.
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Affiliation(s)
- Raluca Elena Sandu
- Department of Functional Sciences, Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania.
| | - Danut Dumbrava
- Department of Functional Sciences, Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania.
| | - Roxana Surugiu
- Department of Functional Sciences, Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania.
| | - Daniela-Gabriela Glavan
- Department of Functional Sciences, Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania.
| | - Andrei Gresita
- Department of Functional Sciences, Center of Clinical and Experimental Medicine, University of Medicine and Pharmacy of Craiova, Craiova 200349, Romania.
| | - Eugen Bogdan Petcu
- Gold Coast Campus, School of Medicine, Griffith University, Southport 4222, Australia.
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Li H, Chen RK, Tang Y, Meurer W, Shih AJ. An experimental study and finite element modeling of head and neck cooling for brain hypothermia. J Therm Biol 2017; 71:99-111. [PMID: 29301706 DOI: 10.1016/j.jtherbio.2017.10.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 10/31/2017] [Accepted: 10/31/2017] [Indexed: 11/28/2022]
Abstract
Reducing brain temperature by head and neck cooling is likely to be the protective treatment for humans when subjects to sudden cardiac arrest. This study develops the experimental validation model and finite element modeling (FEM) to study the head and neck cooling separately, which can induce therapeutic hypothermia focused on the brain. Anatomically accurate geometries based on CT images of the skull and carotid artery are utilized to find the 3D geometry for FEM to analyze the temperature distributions and 3D-printing to build the physical model for experiment. The results show that FEM predicted and experimentally measured temperatures have good agreement, which can be used to predict the temporal and spatial temperature distributions of the tissue and blood during the head and neck cooling process. Effects of boundary condition, perfusion, blood flow rate, and size of cooling area are studied. For head cooling, the cooling penetration depth is greatly depending on the blood perfusion in the brain. In the normal blood flow condition, the neck internal carotid artery temperature is decreased only by about 0.13°C after 60min of hypothermia. In an ischemic (low blood flow rate) condition, such temperature can be decreased by about 1.0°C. In conclusion, decreasing the blood perfusion and metabolic reduction factor could be more beneficial to cool the core zone. The results also suggest that more SBC researches should be explored, such as the optimization of simulation and experimental models, and to perform the experiment on human subjects.
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Affiliation(s)
- Hui Li
- Mechanical Engineering, University of Michigan, Ann Arbor, MI 48109, USA; Mechanical and Automotive Engineering, South China University of Technology, Guangzhou 510640, China; Electronic Paper Display Institute, South China Normal University, Guangzhou 510006, China.
| | - Roland K Chen
- Mechanical and Materials Engineering, Washington State University, Pullman, WA 99164-2920, USA
| | - Yong Tang
- Mechanical and Automotive Engineering, South China University of Technology, Guangzhou 510640, China
| | - William Meurer
- Department of Emergency Medicine, Department of Neurology, Michigan Center for Integrative Research in Critical Care, University of Michigan Health System, Ann Arbor, MI 48109-5303, USA
| | - Albert J Shih
- Mechanical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
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34
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Kurisu K, Yenari MA. Therapeutic hypothermia for ischemic stroke; pathophysiology and future promise. Neuropharmacology 2017; 134:302-309. [PMID: 28830757 DOI: 10.1016/j.neuropharm.2017.08.025] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/12/2017] [Accepted: 08/17/2017] [Indexed: 01/08/2023]
Abstract
Therapeutic hypothermia, or cooling of the body or brain for the purposes of preserving organ viability, is one of the most robust neuroprotectants at both the preclinical and clinical levels. Although therapeutic hypothermia has been shown to improve outcome from related clinical conditions, the significance in ischemic stroke is still under investigation. Numerous pre-clinical studies of therapeutic hypothermia has suggested optimal cooling conditions, such as depth, duration, and temporal therapeutic window for effective neuroprotection. Several studies have also explored mechanisms underlying the mechanisms of neuroprotection by therapeutic hypothermia. As such, it appears that cooling affects multiple aspects of brain pathophysiology, and regulates almost every pathway involved in the evolution of ischemic stroke. This multifaceted mechanism is thought to contribute to its strong neuroprotective effect. In order to carry out this therapy in optimal clinical settings, methodological and pathophysiological understanding is crucial. However, more investigation is still needed to better understand the underlying mechanisms of this intervention, and to overcome clinical barriers which seem to preclude the routine use therapeutic hypothermia in stroke. This article is part of the Special Issue entitled 'Cerebral Ischemia'.
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Affiliation(s)
- Kota Kurisu
- Department of Neurology, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, CA 94121, USA
| | - Midori A Yenari
- Department of Neurology, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, CA 94121, USA.
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35
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Wu D, Shi J, Elmadhoun O, Duan Y, An H, Zhang J, He X, Meng R, Liu X, Ji X, Ding Y. Dihydrocapsaicin (DHC) enhances the hypothermia-induced neuroprotection following ischemic stroke via PI3K/Akt regulation in rat. Brain Res 2017; 1671:18-25. [PMID: 28684048 DOI: 10.1016/j.brainres.2017.06.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 06/27/2017] [Accepted: 06/28/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Hypothermia has demonstrated neuroprotection following ischemia in preclinical studies while its clinical application is still very limited. The aim of this study was to explore whether combining local hypothermia in ischemic territory achieved by intra-arterial cold infusions (IACIs) with pharmacologically induced hypothermia enhances therapeutic outcomes, as well as the underlying mechanism. METHODS Sprague-Dawley rats were subjected to right middle cerebral artery occlusion (MCAO) for 2h using intraluminal hollow filament. The ischemic rats were randomized to receive: 1) pharmacological hypothermia by intraperitoneal (i.p.) injection of dihydrocapsaicin (DHC); 2) physical hypothermia by IACIs for 10min; or 3) the combined treatments. Extent of brain injury was determined by neurological deficit, infarct volume, and apoptotic cell death at 24h and/or 7d following reperfusion. ATP and ROS levels were measured. Expression of p-Akt, cleaved Caspase-3, pro-apoptotic (AIF, Bax) and anti-apoptotic proteins (Bcl-2, Bcl-xL) was evaluated at 24h. Finally, PI3K inhibitor was used to determine the effect of p-Akt. RESULTS DHC or IACIs each exhibited hypothermic effect and neuroprotection in rat MCAO models. The combination of pharmacological and physical approaches led to a faster and sustained reduction in brain temperatures and improved ischemia-induced injury than either alone (P<0.01). Furthermore, the combination treatment favorably increased the expression of anti-apoptotic proteins and decreased pro-apoptotic protein levels (P<0.01 or 0.05). This neuroprotective effect was largely blocked by p-Akt inhibition, indicating a potential role of Akt pathway in this mechanism (P<0.01 or 0.05). CONCLUSIONS The combination approach is able to enhance the efficiency of hypothermia and efficacy of hypothermia-induced neuroprotection following ischemic stroke. The findings here move us a step closer towards translating this long recognized TH from bench to bedside.
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Affiliation(s)
- Di Wu
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Jingfei Shi
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing, China
| | - Omar Elmadhoun
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yunxia Duan
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hong An
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jun Zhang
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaoduo He
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Meng
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiangrong Liu
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.
| | - Yuchuan Ding
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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Kurisu K, Abumiya T, Ito M, Gekka M, Osanai T, Shichinohe H, Nakayama N, Kazumata K, Houkin K. Transarterial regional hypothermia provides robust neuroprotection in a rat model of permanent middle cerebral artery occlusion with transient collateral hypoperfusion. Brain Res 2016; 1651:95-103. [PMID: 27663968 DOI: 10.1016/j.brainres.2016.09.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/31/2016] [Accepted: 09/12/2016] [Indexed: 11/20/2022]
Abstract
The robust neuroprotective effects of transarterial regional hypothermia have been demonstrated in the typical transient middle cerebral artery occlusion (tMCAO) model, but have not yet been tested in other ischemic stroke models, even though clinical ischemic conditions are diverse. In order to clarify these effects in a different ischemic stroke model, we employed a rat model of permanent MCAO (pMCAO) with transient collateral hypoperfusion (tCHP), which was achieved by direct MCA ligation through craniotomy and 1-h bilateral common carotid artery occlusion at the beginning of pMCAO. The infusion of 20ml/kg of 4°C cold saline (CS) or 37°C warm saline (WS) into the ipsilateral internal carotid artery (ICA) was performed for 15min in intra- or post-tCHP. Neurological scores, infarct/edema volumes, and neuronal apoptosis and reactive gliosis were compared between the CS and WS groups and a non-infusion control group after 48h of reperfusion. Although brain temperatures were only reduced by 2-3°C for 15min, the CS group had significantly better neurological scores, smaller infarct/edema volumes, and less penumbral neuronal apoptosis and reactive gliosis than the control and WS groups. The post-tCHP CS group exhibited prominent neuroprotective effects, even though infarct volumes and neuronal apoptosis were reduced less than those in the intra-tCHP CS group. In conclusion, we demonstrated the neuroprotective effects of transarterial regional hypothermia in an ischemic model of pMCAO with tCHP. Even though MCAO is persistent, cold infusion via the ICA is neuroprotective for the penumbra, suggesting the wider therapeutic application of this therapy.
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Affiliation(s)
- Kota Kurisu
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Takeo Abumiya
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan.
| | - Masaki Ito
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Masayuki Gekka
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Toshiya Osanai
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Hideo Shichinohe
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Naoki Nakayama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Ken Kazumata
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Kiyohiro Houkin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
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Ren X, Orlova EV, Maevsky EI, Bonicalzi V, Canavero S. Brain protection during cephalosomatic anastomosis. Surgery 2016; 160:5-10. [DOI: 10.1016/j.surg.2016.01.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 12/23/2015] [Accepted: 01/12/2016] [Indexed: 01/09/2023]
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Kurisu K, Abumiya T, Nakamura H, Shimbo D, Shichinohe H, Nakayama N, Kazumata K, Shimizu H, Houkin K. Transarterial Regional Brain Hypothermia Inhibits Acute Aquaporin-4 Surge and Sequential Microvascular Events in Ischemia/Reperfusion Injury. Neurosurgery 2016; 79:125-34. [DOI: 10.1227/neu.0000000000001088] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Lamb JA, Rajput PS, Lyden PD. Novel method for inducing rapid, controllable therapeutic hypothermia in rats using a perivascular implanted closed-loop cooling circuit. J Neurosci Methods 2016; 267:55-61. [PMID: 27090948 DOI: 10.1016/j.jneumeth.2016.04.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/05/2016] [Accepted: 04/12/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Hypothermia is the most potent protective therapy available for cerebral ischemia. In experimental models, cooling the brain even a single degree Celsius alters outcome after global and focal ischemia. Difficulties translating therapeutic hypothermia to patients with stroke or after cardiac arrest include: uncertainty as to the optimal treatment duration; best target-depth temperature; and longest time delay after which therapeutic hypothermia won't benefit. Recent results from human clinical trials suggest that cooling with surface methods provides insufficient cooling speed or control over target temperature. COMPARISON WITH EXISTING METHODS Available animal models incorporate surface cooling methods that are slow, and do not allow for precise control of the target temperature. NEW METHOD To address this need, we developed a rapid, simple, inexpensive model for inducing hypothermia using a perivascular implanted closed-loop cooling circuit. The method allows precise control of the target temperature. RESULTS Using this method, target temperature for therapeutic hypothermia was reached within 13±1.07min (Mean±SE). Once at target, the temperature was maintained within 0.09°C for 4h. CONCLUSIONS This method will allow future experiments to determine under what conditions therapeutic hypothermia is effective, determine the optimal relationship among delay, duration, and depth, and provide the research community with a new model for conducting further research into mechanistic questions underlying the efficacy of therapeutic hypothermia.
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Affiliation(s)
- Jessica A Lamb
- Department of Neurology, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, Los Angeles, CA 90048, United States.
| | - Padmesh S Rajput
- Department of Neurology, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, Los Angeles, CA 90048, United States
| | - Patrick D Lyden
- Department of Neurology, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, Los Angeles, CA 90048, United States
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40
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Giuliani E, Magnoni S, Fei M, Addis A, Zanasi R, Stocchetti N, Barbieri A. A Novel Cooling Device for Targeted Brain Temperature Control and Therapeutic Hypothermia: Feasibility Study in an Animal Model. Neurocrit Care 2016; 25:464-472. [PMID: 26927280 PMCID: PMC5138276 DOI: 10.1007/s12028-016-0257-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Therapeutic hypothermia (i.e., temperature management) is an effective option for improving survival and neurological outcome after cardiac arrest and is potentially useful for the care of the critically ill neurological patient. We analyzed the feasibility of a device to control the temperature of the brain by controlling the temperature of the blood flowing through the neck. Methods A lumped parameter dynamic model, with one-dimensional heat transfer, was used to predict cooling effects and to test experimental hypotheses. The cooling system consisted of a flexible collar and was tested on 4 adult sheep, in which brain and body temperatures were invasively monitored for the duration of the experiment. Results Model-based simulations predicted a lowering of the temperature of the brain and the body following the onset of cooling, with a rate of 0.4 °C/h for the brain and 0.2 °C/h for the body. The experimental findings showed comparable cooling rates in the two body compartments, with temperature reductions of 0.6 (0.2) °C/h for the brain and 0.6 (0.2) °C/h for the body. For a 70 kg adult human subject, we predict a temperature reduction of 0.64 °C/h for the brain and 0.43 °C/h for the body. Conclusions This work demonstrates the feasibility of using a non-invasive method to induce brain hypothermia using a portable collar. This device demonstrated an optimal safety profile and represents a potentially useful method for the administration of mild hypothermia and temperature control (i.e., treatment of hyperpyrexia) in cardiac arrest and critically ill neurologic patients. Electronic supplementary material The online version of this article (doi:10.1007/s12028-016-0257-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- E Giuliani
- Neuron Guard S.r.l., Via L. Castelvetro 15, 41124, Modena, Italy.
| | - S Magnoni
- Department of Anesthesiology and Intensive Care, Ospedale Fondazione IRCCS, Ca' Granda, Milan, Italy
| | - M Fei
- Neuron Guard S.r.l., Via L. Castelvetro 15, 41124, Modena, Italy
| | - A Addis
- CRABCC, Biotechnology Research Center for Cardiothoracic Applications, Rivolta d'Adda, CR, Italy
| | - R Zanasi
- Department of Engineering, University of Modena and Reggio Emilia, Modena, Italy
| | - N Stocchetti
- Department of Anesthesiology and Intensive Care, Ospedale Fondazione IRCCS, Ca' Granda, Milan, Italy.,Milan University, Milan, Italy
| | - A Barbieri
- Department of Anesthesiology and Intensive Care, University of Modena and Reggio Emilia, Modena, Italy
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Twenty-four hours hypothermia has temporary efficacy in reducing brain infarction and inflammation in aged rats. Neurobiol Aging 2015; 38:127-140. [PMID: 26827651 DOI: 10.1016/j.neurobiolaging.2015.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/19/2015] [Accepted: 11/11/2015] [Indexed: 11/23/2022]
Abstract
Stroke is a major cause of disability for which no neuroprotective measures are available. Age is the principal nonmodifiable risk factor for this disease. Previously, we reported that exposure to hydrogen sulfide for 48 hours after stroke lowers whole body temperature and confers neuroprotection in aged animals. Because the duration of hypothermia in most clinical trials is between 24 and 48 hours, we questioned whether 24 hours exposure to gaseous hypothermia confers the same neuroprotective efficacy as 48 hours exposure. We found that a shorter exposure to hypothermia transiently reduced both inflammation and infarct size. However, after 1 week, the infarct size became even larger than in controls and after 2 weeks there was no beneficial effect on regenerative processes such as neurogenesis. Behaviorally, hypothermia also had a limited beneficial effect. Finally, after hydrogen sulfide-induced hypothermia, the poststroke aged rats experienced a persistent sleep impairment during their active nocturnal period. Our data suggest that cellular events that are delayed by hypothermia in aged rats may, in the long term, rebound, and diminish the beneficial effects.
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Khan IS, Odom M, Ehtesham M, Colvin D, Quarles CC, McLaughlin B, Singer RJ. Intraarterial administration of norcantharidin attenuates ischemic stroke damage in rodents when given at the time of reperfusion: novel uses of endovascular capabilities. J Neurosurg 2015; 125:152-9. [PMID: 26544777 DOI: 10.3171/2015.4.jns142400] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Matrix metalloprotease-9 (MMP-9) plays a critical role in infarct progression, blood-brain barrier (BBB) disruption, and vasogenic edema. While systemic administration of MMP-9 inhibitors has shown neuroprotective promise in ischemic stroke, there has been little effort to incorporate these drugs into endovascular modalities. By modifying the rodent middle cerebral artery occlusion (MCAO) model to allow local intraarterial delivery of drugs, one has the ability to mimic endovascular delivery of therapeutics. Using this model, the authors sought to maximize the protective potential of MMP-9 inhibition by intraarterial administration of an MMP-9 inhibitor, norcantharidin (NCTD). METHODS Spontaneously hypertensive rats were subjected to 90-minute MCAO followed immediately by local intraarterial administration of NCTD. The rats' neurobehavioral performances were scored according to the ladder rung walking test results and the Garcia neurological test for as long as 7 days after stroke. MRI was also conducted 24 hours after the stroke to assess infarct volume and BBB disruption. At the end of the experimental protocol, rat brains were used for active MMP-9 immunohistochemical analysis to assess the degree of MMP-9 inhibition. RESULTS NCTD-treated rats showed significantly better neurobehavioral scores for all days tested. MR images also depicted significantly decreased infarct volumes and BBB disruption 24 hours after stroke. Inhibition of MMP-9 expression in the ischemic region was depicted on immunohistochemical analysis, wherein treated rats showed decreased active MMP-9 staining compared with controls. CONCLUSIONS Intraarterial NCTD significantly improved outcome when administered at the time of reperfusion in a spontaneously hypertensive rat stroke model. This study suggests that supplementing endovascular revascularization with local neuroprotective drug therapy may be a viable therapeutic strategy.
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Affiliation(s)
- Imad S Khan
- J.B. Marshall Laboratory for Neurovascular Therapeutics at Dartmouth;,Division of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Mitchell Odom
- Department of Neurosurgery, Vanderbilt University Medical Center
| | - Moneeb Ehtesham
- Department of Neurosurgery, Vanderbilt University Medical Center
| | - Daniel Colvin
- Vanderbilt University Institute of Imaging Sciences; and
| | - C Chad Quarles
- Vanderbilt University Institute of Imaging Sciences; and
| | - BethAnn McLaughlin
- Department of Neurology and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert J Singer
- J.B. Marshall Laboratory for Neurovascular Therapeutics at Dartmouth;,Division of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Han Z, Liu X, Luo Y, Ji X. Therapeutic hypothermia for stroke: Where to go? Exp Neurol 2015; 272:67-77. [PMID: 26057949 DOI: 10.1016/j.expneurol.2015.06.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/16/2015] [Accepted: 06/04/2015] [Indexed: 01/08/2023]
Abstract
Ischemic stroke is a major cause of death and long-term disability worldwide. Thrombolysis with recombinant tissue plasminogen activator is the only proven and effective treatment for acute ischemic stroke; however, therapeutic hypothermia is increasingly recognized as having a tissue-protective function and positively influencing neurological outcome, especially in cases of ischemia caused by cardiac arrest or hypoxic-ischemic encephalopathy in newborns. Yet, many aspects of hypothermia as a treatment for ischemic stroke remain unknown. Large-scale studies examining the effects of hypothermia on stroke are currently underway. This review discusses the mechanisms underlying the effect of hypothermia, as well as trends in hypothermia induction methods, methods for achieving optimal protection, side effects, and therapeutic strategies combining hypothermia with other neuroprotective treatments. Finally, outstanding issues that must be addressed before hypothermia treatment is implemented at a clinical level are also presented.
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Affiliation(s)
- Ziping Han
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Xiangrong Liu
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Yumin Luo
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China
| | - Xunming Ji
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital of Capital Medical University, Beijing 100053, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing 100053, China; Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing 100053, China.
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Hutchens MP, Fujiyoshi T, Koerner IP, Herson PS. Extracranial hypothermia during cardiac arrest and cardiopulmonary resuscitation is neuroprotective in vivo. Ther Hypothermia Temp Manag 2014; 4:79-87. [PMID: 24865403 DOI: 10.1089/ther.2014.0003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is increasing evidence that ischemic brain injury is modulated by peripheral signaling. Peripheral organ ischemia can induce brain inflammation and injury. We therefore hypothesized that brain injury sustained after cardiac arrest (CA) is influenced by peripheral organ ischemia and that peripheral organ protection can reduce brain injury after CA and cardiopulmonary resuscitation (CPR). Male C57Bl/6 mice were subjected to CA/CPR. Brain temperature was maintained at 37.5°C ± 0.0°C in all animals. Body temperature was maintained at 35.1°C ± 0.1°C (normothermia) or 28.8°C ± 1.5°C (extracranial hypothermia [ExHy]) during CA. Body temperature after resuscitation was maintained at 35°C in all animals. Behavioral testing was performed at 1, 3, 5, and 7 days after CA/CPR. Either 3 or 7 days after CA/CPR, blood was analyzed for serum urea nitrogen, creatinine, alanine aminotransferase, aspartate aminotransferase, and interleukin-1β; mice were euthanized; and brains were sectioned. CA/CPR caused peripheral organ and brain injury. ExHy animals experienced transient reduction in brain temperature after resuscitation (2.1°C ± 0.5°C for 4 minutes). Surprisingly, ExHy did not change peripheral organ damage. In contrast, hippocampal injury was reduced at 3 days after CA/CPR in ExHy animals (22.4% ± 6.2% vs. 45.7% ± 9.1%, p=0.04, n=15/group). This study has two main findings. Hypothermia limited to CA does not reduce peripheral organ injury. This unexpected finding suggests that after brief ischemia, such as during CA/CPR, signaling or events after reperfusion may be more injurious than those during the ischemic period. Second, peripheral organ hypothermia during CA reduces hippocampal injury independent of peripheral organ protection. While it is possible that this protection is due to subtle differences in brain temperature during early reperfusion, we speculate that additional mechanisms may be involved. Our findings add to the growing understanding of brain-body cross-talk by suggesting that peripheral interventions can protect the brain even if peripheral organ injury is not altered.
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Affiliation(s)
- Michael P Hutchens
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University , Portland, Oregon
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