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Jahromi HM, Rafati A, Karbalay-Doust S, Keshavarz S, Naseh M. The combination treatment of hypothermia and intranasal insulin ameliorates the structural and functional changes in a rat model of traumatic brain injury. Brain Struct Funct 2024; 229:947-957. [PMID: 38498064 DOI: 10.1007/s00429-024-02769-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 01/26/2024] [Indexed: 03/19/2024]
Abstract
The present study aimed to investigate the combination effects of hypothermia (HT) and intranasal insulin (INS) on structural changes of the hippocampus and cognitive impairments in the traumatic brain injury (TBI) rat model. The rats were divided randomly into the following five groups (n = 10): Sham, TBI, TBI with HT treatment for 3 h (TBI + HT), TBI with INS (ten microliters of insulin) treatment daily for 7 days (TBI + INS), and TBI with combining HT and INS (TBI + HT + INS). At the end of the 7th day, the open field and the Morris water maze tests were done for evaluation of anxiety-like behavior and memory performance. Then, after sacrificing, the brain was removed for stereological study. TBI led to an increase in the total volume of hippocampal subfields CA1 and DG and a decrease in the total number of neurons and non-neuronal cells in both sub-regions, which was associated with anxiety-like behavior and memory impairment. Although, the combination of HT and INS prevented the increased hippocampal volume and cell loss and improved behavioral performances in the TBI group. Our study suggests that the combined treatment of HT and INS could prevent increased hippocampal volume and cell loss in CA1 and DG sub-regions and consequently improve anxiety-like behaviors and memory impairment following TBI.
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Affiliation(s)
- Hadi Moatamed Jahromi
- Histomorphometry and Stereology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Physiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Rafati
- Histomorphometry and Stereology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Physiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saied Karbalay-Doust
- Histomorphometry and Stereology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Anatomy Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Somaye Keshavarz
- Histomorphometry and Stereology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- Department of Physiology, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Maryam Naseh
- Histomorphometry and Stereology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Keeves J, Gadowski A, McKimmie A, Bagg MK, Antonic-Baker A, Hicks AJ, Clarke N, Brown A, McNamara R, Reeder S, Roman C, Jeffcote T, Romero L, Hill R, Ponsford JL, Lannin NA, O'Brien TJ, Cameron PA, Rushworth N, Fitzgerald M, Gabbe BJ, Cooper DJ. The Australian Traumatic Brain Injury Initiative: Systematic Review of the Effect of Acute Interventions on Outcome for People With Moderate-Severe Traumatic Brain Injury. J Neurotrauma 2024. [PMID: 38279797 DOI: 10.1089/neu.2023.0465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024] Open
Abstract
The Australian Traumatic Brain Injury Initiative (AUS-TBI) is developing a data resource to enable improved outcome prediction for people with moderate-severe TBI (msTBI) across Australia. Fundamental to this resource is the collaboratively designed data dictionary. This systematic review and consultation aimed to identify acute interventions with potential to modify clinical outcomes for people after msTBI, for inclusion in a data dictionary. Standardized searches were implemented across bibliographic databases from inception through April 2022. English-language reports of randomized controlled trials (RCTs) evaluating any association between any acute intervention and clinical outcome in at least 100 patients with msTBI, were included. A predefined algorithm was used to assign a value to each observed association. Consultation with AUS-TBI clinicians and researchers formed the consensus process for interventions to be included in a single data dictionary. Searches retrieved 14,455 records, of which 124 full-length RCTs were screened, with 35 studies included. These studies evaluated 26 unique acute interventions across 21 unique clinical outcomes. Only 4 interventions were considered to have medium modifying value for any outcome from the review, with an additional 8 interventions agreed upon through the consensus process. The interventions with medium value were tranexamic acid and phenytoin, which had a positive effect on an outcome; and decompressive craniectomy surgery and hypothermia, which negatively affected outcomes. From the systematic review and consensus process, 12 interventions were identified as potential modifiers to be included in the AUS-TBI national data resource.
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Affiliation(s)
- Jemma Keeves
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adelle Gadowski
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ancelin McKimmie
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Matthew K Bagg
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health Sciences and Physiotherapy, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Ana Antonic-Baker
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nyssa Clarke
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alastair Brown
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Rob McNamara
- School of Medicine, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sandy Reeder
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Toby Jeffcote
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | | | - Regina Hill
- Regina Hill Effective Consulting Pty. Ltd., Melbourne, Victoria, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter A Cameron
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nick Rushworth
- Brain Injury Australia, Sydney, New South Wales, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australlia, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
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3
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Kawakita K, Shishido H, Kuroda Y. Review of Temperature Management in Traumatic Brain Injuries. J Clin Med 2024; 13:2144. [PMID: 38610909 PMCID: PMC11012999 DOI: 10.3390/jcm13072144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 04/14/2024] Open
Abstract
Therapeutic hypothermia (TH) for severe traumatic brain injury has seen restricted application due to the outcomes of randomized controlled trials (RCTs) conducted since 2000. In contrast with earlier RCTs, recent trials have implemented active normothermia management in control groups, ensuring comparable intensities of non-temperature-related therapeutic interventions, such as neurointensive care. This change in approach may be a contributing factor to the inability to establish the efficacy of TH. Currently, an active temperature management method using temperature control devices is termed "targeted temperature management (TTM)". One of the goals of TTM for severe traumatic brain injury is the regulation of increased intracranial pressure, employing TTM as a methodology for intracranial pressure management. Additionally, fever in traumatic brain injury has been acknowledged as contributing to poor prognosis, underscoring the importance of proactively preventing fever. TTM is also employed for the preemptive prevention of fever in severe traumatic brain injury. As an integral component of current neurointensive care, it is crucial to precisely delineate the targets of TTM and to potentially apply them in the treatment of severe traumatic brain injury.
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Affiliation(s)
- Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Miki 761-0793, Japan;
| | - Hajime Shishido
- Emergency Medical Center, Kagawa University Hospital, Miki 761-0793, Japan;
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, Miki 760-0793, Japan;
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Tejerina Álvarez EE, Lorente Balanza JÁ. Temperature management in acute brain injury: A narrative review. Med Intensiva 2024:S2173-5727(24)00054-7. [PMID: 38493062 DOI: 10.1016/j.medine.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/10/2024] [Indexed: 03/18/2024]
Abstract
Temperature management has been used in patients with acute brain injury resulting from different conditions, such as post-cardiac arrest hypoxic-ischaemic insult, acute ischaemic stroke, and severe traumatic brain injury. However, current evidence offers inconsistent and often contradictory results regarding the clinical benefit of this therapeutic strategy on mortality and functional outcomes. Current guidelines have focused mainly on active prevention and treatment of fever, while therapeutic hypothermia (TH) has fallen into disuse, although doubts persist as to its effectiveness according to the method of application and appropriate patient selection. This narrative review presents the most relevant clinical evidence on the effects of TH in patients with acute neurological damage, and the pathophysiological concepts supporting its use.
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Affiliation(s)
- Eva Esther Tejerina Álvarez
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - José Ángel Lorente Balanza
- Servicio de Medicina Intensiva. Hospital Universitario de Getafe, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Departamento de Bioingeniería, Universidad Carlos III de Madrid, Leganés, Madrid, Spain; Departamento de Medicina, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
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Liddle LJ, Huang YG, Kung TFC, Mergenthaler P, Colbourne F, Buchan AM. An Assessment of Physical and N6-Cyclohexyladenosine-Induced Hypothermia in Rodent Distal Focal Ischemic Stroke. Ther Hypothermia Temp Manag 2024; 14:36-45. [PMID: 37339459 DOI: 10.1089/ther.2023.0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Therapeutic hypothermia (TH) mitigates damage in ischemic stroke models. However, safer and easier TH methods (e.g., pharmacological) are needed to circumvent physical cooling complications. This study evaluated systemic and pharmacologically induced TH using the adenosine A1 receptor agonist, N6-cyclohexyladenosine (CHA), with control groups in male Sprague-Dawley rats. CHA was administered intraperitoneally 10 minutes following a 2-hour intraluminal middle cerebral artery occlusion. We used a 1.5 mg/kg induction dose, followed by three 1.0 mg/kg doses every 6 hours for a total of 4 doses, causing 20-24 hours of hypothermia. Animals assigned to physical hypothermia and CHA-hypothermia had similar induction rates and nadir temperatures, but forced cooling lasted ∼6 hours longer compared with CHA-treated animals. The divergence is likely attributable to individual differences in CHA metabolism, which led to varied durations at nadir, whereas physical hypothermia was better regulated. Physical hypothermia significantly reduced infarction (primary endpoint) on day 7 (mean reduction of 36.8 mm3 or 39% reduction; p = 0.021 vs. normothermic animals; Cohen's d = 0.75), whereas CHA-induced hypothermia did not (p = 0.33). Similarly, physical cooling improved neurological function (physical hypothermia median = 0, physical normothermia median = 2; p = 0.008) and CHA-induced cooling did not (p > 0.99). Our findings demonstrate that forced cooling was neuroprotective compared with controls, but prolonged CHA-induced cooling was not neuroprotective.
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Affiliation(s)
- Lane J Liddle
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
| | - Yi-Ge Huang
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Tiffany F C Kung
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
| | - Philipp Mergenthaler
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Department of Neurology with Experimental Neurology, NeuroCure Clinical Research Center, Berlin, Germany
| | - Frederick Colbourne
- Department of Psychology, University of Alberta, Edmonton, Alberta, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Alastair M Buchan
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Charité-Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
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Cata JP, Sessler DI. Lost in Translation: Failure of Preclinical Studies to Accurately Predict the Effect of Regional Analgesia on Cancer Recurrence. Anesthesiology 2024; 140:361-374. [PMID: 38170786 DOI: 10.1097/aln.0000000000004823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The major goal of translational research is to evaluate the efficacy and effectiveness of treatments and interventions that have emerged from exhaustive preclinical evidence. In 2007, a major clinical trial was started to investigate the impact of paravertebral analgesia on breast cancer recurrence. The trial was based on preclinical evidence demonstrating that spinal anesthesia suppressed metastatic dissemination by inhibiting surgical stress, boosting the immunological response, avoiding volatile anesthetics, and reducing opioid use. However, that trial and three more recent randomized trials with a total of 4,770 patients demonstrate that regional analgesia does not improve survival outcomes after breast, lung, and abdominal cancers. An obvious question is why there was an almost complete disconnect between the copious preclinical investigations suggesting benefit and robust clinical trials showing no benefit? The answer is complex but may result from preclinical research being mechanistically driven and based on reductionist models. Both basic scientists and clinical investigators underestimated the limitations of various preclinical models, leading to the apparently incorrect hypothesis that regional anesthesia reduces cancer recurrence. This article reviews factors that contributed to the discordance between the laboratory science, suggesting that regional analgesia might reduce cancer recurrence and clinical trials showing that it does not-and what can be learned from the disconnect.
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Affiliation(s)
- Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas-MD Anderson Cancer Center, Houston, Texas
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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Hall AD, Kumar JE, Golba CE, Luckett KM, Bryant WK. Primary amebic meningoencephalitis: a review of Naegleria fowleri and analysis of successfully treated cases. Parasitol Res 2024; 123:84. [PMID: 38182931 DOI: 10.1007/s00436-023-08094-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 12/12/2023] [Indexed: 01/07/2024]
Abstract
Primary amebic meningoencephalitis (PAM) is a necrotizing and hemorrhagic inflammation of the brain and meninges caused by Naegleria fowleri, a free-living thermophilic ameba of freshwater systems. PAM remains a neglected disease that disproportionately affects children in tropical and subtropical climates, with an estimated mortality rate of 95-98%. Due to anthropogenic climate change, the average temperature in the USA has increased by 0.72 to 1.06 °C in the last century, promoting the poleward spread of N. fowleri. PAM is often misdiagnosed as bacterial meningitis or viral encephalitis, which shortens the window for potentially life-saving treatment. Diagnosis relies on the patient's history of freshwater exposure and the physician's high index of suspicion, supported by cerebrospinal fluid studies. While no experimental trials have been conducted to assess the relative efficacy of treatment regimens, anti-amebic therapy with adjunctive neuroprotection is standard treatment in the USA. We performed a literature review and identified five patients from North America between 1962 and 2022 who survived PAM with various degrees of sequelae.
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Affiliation(s)
- Ashton D Hall
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Julia E Kumar
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Claire E Golba
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA
| | - Keith M Luckett
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Whitney K Bryant
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45267, USA.
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Cujkevic-Plecko N, Rodriguez A, Anderson T, Rhodes J. Targeted temperature management and P btO 2 in traumatic brain injury. Brain Spine 2023; 3:102704. [PMID: 38105803 PMCID: PMC10724196 DOI: 10.1016/j.bas.2023.102704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/06/2023] [Accepted: 10/29/2023] [Indexed: 12/19/2023]
Abstract
Introduction Targeted Temperature Management (TTM) to normothermia is widely used in traumatic brain injury (TBI). We investigated the effects to of TTM to normothermia patients with TBI (GCS≤12) monitored with multimodality monitoring, to better understand the physiological consequences of this intervention. Research question In TBI patients cooled to normothermia and in which brain oxygenation deteriorates, are there changes in physiological parameters which are pertinent to brain oxygenation? Material and method 102 TBI patients with continuous recordings of intracranial pressure (ICP) and brain oxygen tension (PbtO2) were studied retrospectively. Non-continuous arterial carbon dioxide (PaCO2) and oxygen (PaO2) tensions, and core body temperature (Tc) were added. PaO2 and PaCO2 were also corrected for Tc. Transitions from elevated Tc to normothermia were identified in 39 patients. The 8 h pre and post the transition to normothermia were compared. Data is given as median [IQR] or mean (SD). Results Overall, normothermia reduced ICP (12 [9-18] -11 [8-17] mmHg, p < 0.009) and Tcore (38.3 [0.3]-36.9 [0.4] oC, p < 0.001), but not PbtO2 (23.3 [16.6]-24.4 [17.2-28.7] mmHg, NS). Normothermia was associated with a fall in PbtO2 in 18 patients (24.5 [9.3] -20.8 [7.6] mmHg). Only in those with a fall in PbtO2 with cooling did ICP (15 [10.8-18.5] -12 [7.8-17.3] mmHg, p = 0.002), and temperature corrected PaCO2 (5.3 [0.5]- 4.9 [0.8] kPa, p = 0.001) decrease. Discussion and conclusion A reduction in PbtO2 was only present in the subgroup of patients with a fall in temperature corrected PaCO2 with cooling. This suggests that even modest temperature changes could result in occult hyperventilation in some patients. pH stat correction of ventilation may be an important factor to consider in future TTM protocols.
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Affiliation(s)
| | | | - T. Anderson
- University of Edinburgh Department of Anaesthesia, Critical Care and Pain Medicine & NHS Lothian, UK
| | - J. Rhodes
- University of Edinburgh Department of Anaesthesia, Critical Care and Pain Medicine & NHS Lothian, UK
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Trieu C, Rajagopalan S, Kofke WA, Cruz Navarro J. Overview of Hypothermia, Its Role in Neuroprotection, and the Application of Prophylactic Hypothermia in Traumatic Brain Injury. Anesth Analg 2023; 137:953-962. [PMID: 37115720 DOI: 10.1213/ane.0000000000006503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
The current standard of practice is to maintain normothermia in traumatic brain injury (TBI) patients despite the theoretical benefits of hypothermia and numerous animal studies with promising results. While targeted temperature management or induced hypothermia to support neurological function is recommended for a select patient population postcardiac arrest, similar guidelines have not been instituted for TBI. In this review, we will examine the pathophysiology of TBI and discuss the benefits and risks of induced hypothermia in this patient population. In addition, we provide an overview of the largest randomized controlled trials testing-induced hypothermia. Our literature review on hypothermia returned a myriad of studies and trials, many of which have inconclusive results. The aim of this review was to recognize the effects of hypothermia, summarize the latest trials, address the inconsistencies, and discuss future directions for the study of hypothermia in TBI.
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Affiliation(s)
- Christine Trieu
- From the Department of Anesthesiology, Baylor College of Medicine, Houston, Texas; Departments of
| | - Suman Rajagopalan
- From the Department of Anesthesiology, Baylor College of Medicine, Houston, Texas; Departments of
| | - W Andrew Kofke
- Anesthesiology and Critical Care
- Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and Departments of
| | - Jovany Cruz Navarro
- Anesthesiology and Critical Care
- Neurosurgery, Baylor College of Medicine, Houston, Texas
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Walter AE, Bai X, Wilkes J, Neuberger T, Sebastianelli W, Slobounov SM. Selective head cooling in the acute phase of concussive injury: a neuroimaging study. Front Neurol 2023; 14:1272374. [PMID: 37965166 PMCID: PMC10641407 DOI: 10.3389/fneur.2023.1272374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction Neurovascular decoupling is a common consequence after brain injuries like sports-related concussion. Failure to appropriately match cerebral blood flow (CBF) with increases in metabolic demands of the brain can lead to alterations in neurological function and symptom presentation. Therapeutic hypothermia has been used in medicine for neuroprotection and has been shown to improve outcome. This study aimed to examine the real time effect of selective head cooling on healthy controls and concussed athletes via magnetic resonance spectroscopy (MRS) and arterial spin labeling (ASL) measures. Methods 24 participants (12 controls; 12 concussed) underwent study procedures including the Post-Concussion Symptom Severity (PCSS) Rating Form and an MRI cooling protocol (pre-cooling (T1 MPRAGE, ASL, single volume spectroscopy (SVS)); during cooling (ASL, SVS)). Results Results showed general decreases in brain temperature as a function of time for both groups. Repeated measures ANOVA showed a significant main effect of time (F = 7.94, p < 0.001) and group (F = 22.21, p < 0.001) on temperature, but no significant interaction of group and time (F = 1.36, p = 0.237). CBF assessed via ASL was non-significantly lower in concussed individuals at pre-cooling and generalized linear mixed model analyses demonstrated a significant main effect of time for the occipital left ROI (F = 11.29, p = 0.002) and occipital right ROI (F = 13.39, p = 0.001). There was no relationship between any MRI metric and PCSS symptom burden. Discussion These findings suggest the feasibility of MRS thermometry to monitor alterations of brain temperature in concussed athletes and that metabolic responses in response to cooling after concussion may differ from controls.
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Affiliation(s)
- Alexa E. Walter
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, United States
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Xiaoxiao Bai
- Social, Life, and Engineering Science Imaging Center, The Pennsylvania State University, University Park, PA, United States
| | - James Wilkes
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, United States
| | - Thomas Neuberger
- Department of Biomedical Engineering, and Social, Life, and Engineering Science Imaging Center, Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park, PA, United States
| | - Wayne Sebastianelli
- Department of Athletic Medicine, The Pennsylvania State University, University Park, PA, United States
- Department of Orthopaedics, Penn State Health, State College, PA, United States
| | - Semyon M. Slobounov
- Department of Kinesiology, The Pennsylvania State University, University Park, PA, United States
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Stein KY, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Zeiler FA. Intracranial Pressure Monitoring and Treatment Thresholds in Acute Neural Injury: A Narrative Review of the Historical Achievements, Current State, and Future Perspectives. Neurotrauma Rep 2023; 4:478-494. [PMID: 37636334 PMCID: PMC10457629 DOI: 10.1089/neur.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Since its introduction in the 1960s, intracranial pressure (ICP) monitoring has become an indispensable tool in neurocritical care practice and a key component of the management of moderate/severe traumatic brain injury (TBI). The primary utility of ICP monitoring is to guide therapeutic interventions aimed at maintaining physiological ICP and preventing intracranial hypertension. The rationale for such ICP maintenance is to prevent secondary brain injury arising from brain herniation and inadequate cerebral blood flow. There exists a large body of evidence indicating that elevated ICP is associated with mortality and that aggressive ICP control protocols improve outcomes in severe TBI patients. Therefore, current management guidelines recommend a cerebral perfusion pressure (CPP) target range of 60-70 mm Hg and an ICP threshold of >20 or >22 mm Hg, beyond which therapeutic intervention should be initiated. Though our ability to achieve these thresholds has drastically improved over the past decades, there has been little to no change in the mortality and morbidity associated with moderate-severe TBI. This is a result of the "one treatment fits all" dogma of current guideline-based care that fails to take individual phenotype into account. The way forward in moderate-severe TBI care is through the development of continuously derived individualized ICP thresholds. This narrative review covers the topic of ICP monitoring in TBI care, including historical context/achievements, current monitoring technologies and indications, treatment methods, associations with patient outcome and multi-modal cerebral physiology, present controversies surrounding treatment thresholds, and future perspectives on personalized approaches to ICP-directed therapy.
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Affiliation(s)
- Kevin Y. Stein
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Escamilla-Ocañas CE, Albores-Ibarra N. Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. Neurologia 2023:S2173-5808(23)00008-1. [PMID: 37031799 DOI: 10.1016/j.nrleng.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 08/04/2020] [Indexed: 04/11/2023] Open
Abstract
INTRODUCTION Increased intracranial pressure (ICP) has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury (TBI). Traditionally, ICP-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe TBI in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.
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Affiliation(s)
- César E Escamilla-Ocañas
- Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA.
| | - Nadxielli Albores-Ibarra
- División de Ciencias de la Salud, Universidad de Monterrey, San Pedro Garza García, Nuevo León, México
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Suehiro E, Tanaka T, Kawashima M, Matsuno A. Challenges in the Treatment of Severe Traumatic Brain Injury Based on Data in the Japan Neurotrauma Data Bank. Neurol Med Chir (Tokyo) 2023; 63:43-47. [PMID: 36436980 PMCID: PMC9995150 DOI: 10.2176/jns-nmc.2022-0276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The Japan Neurotrauma Data Bank is a source of epidemiological data for patients with severe traumatic brain injury (TBI) and is sponsored by the Japan Society of Neurotraumatology. In this report, we examined the changes in the treatment of severe TBI in Japan based on data of the Japan Neurotrauma Data Bank. Controlling and decreasing intracranial pressure (ICP) are the primary objective of severe TBI treatment. Brain-oriented whole-body control or neurocritical care, including control of cerebral perfusion pressure, respiration, and infusion, are also increasingly considered important because cerebral tissues require oxygenation to improve the outcomes of patients with severe TBI. The introduction of neurocritical care in Japan was delayed compared with that in Western countries. However, the rate of ICP monitoring increased from 28.0% in 2009 to 36.7% in 2015 and is currently likely to be higher. Neurocritical care has also become more common, but the functional prognosis of patients has not significantly improved in Japan. Changes in the background of patients with severe TBI suggest the need for improvement of acute-phase treatment for elderly patients. Appropriate social rehabilitation from the subacute to chronic phases and introduction of cellular therapeutics are also needed for patients with TBI.
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Affiliation(s)
- Eiichi Suehiro
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
| | - Tatsuya Tanaka
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
| | - Masatou Kawashima
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
| | - Akira Matsuno
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
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Gu W, Bai Y, Cai J, Mi H, Bao Y, Zhao X, Lu C, Zhang F, Li YH, Lu Q. Hypothermia impairs glymphatic drainage in traumatic brain injury as assessed by dynamic contrast-enhanced MRI with intrathecal contrast. Front Neurosci 2023; 17:1061039. [PMID: 36816105 PMCID: PMC9932501 DOI: 10.3389/fnins.2023.1061039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction The impact of hypothermia on the impaired drainage function of the glymphatic system in traumatic brain injury (TBI) is not understood. Methods Male Sprague-Dawley rats undergoing controlled cortical impact injury (CCI) were subjected to hypothermia or normothermia treatment. The rats undergoing sham surgery without CCI were used as the control. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with intrathecal administration of low- and high-molecular-weight contrast agents (Gd-DTPA and hyaluronic acid conjugated Gd-DTPA) was performed after TBI and head temperature management. The semiquantitative kinetic parameters characterizing the contrast infusion and cleanout in the brain, including influx rate, efflux rate, and clearance duration, were calculated from the average time-intensity curves. Results and discussion The qualitative and semiquantitative results of DCE-MRI obtained from all examined perivascular spaces and most brain tissue regions showed a significantly increased influx rate and efflux rate and decreased clearance duration among all TBI animals, demonstrating a significant impairment of glymphatic drainage function. This glymphatic drainage dysfunction was exacerbated when additional hypothermia was applied. The early glymphatic drainage reduction induced by TBI and aggravated by hypothermia was linearly related to the late increased deposition of p-tau and beta-amyloid revealed by histopathologic and biochemical analysis and cognitive impairment assessed by the Barnes maze and novel object recognition test. The glymphatic system dysfunction induced by hypothermia may be an indirect alternative pathophysiological factor indicating injury to the brain after TBI. Longitudinal studies and targeted glymphatic dysfunction management are recommended to explore the potential effect of hypothermia in TBI.
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Affiliation(s)
- Wenquan Gu
- Department of Radiology, Shanghai Punan Hospital of Pudong New Area, Shanghai, China
| | - Yingnan Bai
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianguo Cai
- Department of Radiology, Xinhua Hospital Chongming Branch, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Honglan Mi
- Department of Radiology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yinghui Bao
- Department of Neurology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xinxin Zhao
- Department of Radiology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chen Lu
- Shanghai Weiyu International School, Shanghai, China
| | - Fengchen Zhang
- Department of Neurology, School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yue-hua Li
- Department of Radiology, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China,*Correspondence: Yue-hua Li,
| | - Qing Lu
- School of Medicine, Shanghai East Hospital, Tongji University, Shanghai, China,Qing Lu,
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15
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Contartese DS, Rey-Funes M, Peláez R, Soliño M, Fernández JC, Nakamura R, Ciranna NS, Sarotto A, Dorfman VB, López-Costa JJ, Zapico JM, Ramos A, de Pascual-Teresa B, Larrayoz IM, Loidl CF, Martínez A. A hypothermia mimetic molecule (zr17-2) reduces ganglion cell death and electroretinogram distortion in a rat model of intraorbital optic nerve crush (IONC). Front Pharmacol 2023; 14:1112318. [PMID: 36755945 PMCID: PMC9899795 DOI: 10.3389/fphar.2023.1112318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/10/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction: Ocular and periocular traumatisms may result in loss of vision. Our previous work showed that therapeutic hypothermia prevents retinal damage caused by traumatic neuropathy. We also generated and characterized small molecules that elicit the beneficial effects of hypothermia at normal body temperature. Here we investigate whether one of these mimetic molecules, zr17-2, is able to preserve the function of eyes exposed to trauma. Methods: Intraorbital optic nerve crush (IONC) or sham manipulation was applied to Sprague-Dawley rats. One hour after surgery, 5.0 µl of 330 nmol/L zr17-2 or PBS, as vehicle, were injected in the vitreum of treated animals. Electroretinograms were performed 21 days after surgery and a- and b-wave amplitude, as well as oscillatory potentials (OP), were calculated. Some animals were sacrificed 6 days after surgery for TUNEL analysis. All animal experiments were approved by the local ethics board. Results: Our previous studies showed that zr17-2 does not cross the blood-ocular barrier, thus preventing systemic treatment. Here we show that intravitreal injection of zr17-2 results in a very significant prevention of retinal damage, providing preclinical support for its pharmacological use in ocular conditions. As previously reported, IONC resulted in a drastic reduction in the amplitude of the b-wave (p < 0.0001) and OPs (p < 0.05), a large decrease in the number of RGCs (p < 0.0001), and a large increase in the number of apoptotic cells in the GCL and the INL (p < 0.0001). Interestingly, injection of zr17-2 largely prevented all these parameters, in a very similar pattern to that elicited by therapeutic hypothermia. The small molecule was also able to reduce oxidative stress-induced retinal cell death in vitro. Discussion: In summary, we have shown that intravitreal injection of the hypothermia mimetic, zr17-2, significantly reduces the morphological and electrophysiological consequences of ocular traumatism and may represent a new treatment option for this cause of visual loss.
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Affiliation(s)
- Daniela S. Contartese
- Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), UBA-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Manuel Rey-Funes
- Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), UBA-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Rafael Peláez
- Biomarkers and Molecular Signaling, Neurodegenerative Diseases Area, Center for Biomedical Research of La Rioja (CIBIR), Logroño, Spain
| | - Manuel Soliño
- Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), UBA-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Juan C. Fernández
- Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), UBA-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Ronan Nakamura
- Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), UBA-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Nicolás S. Ciranna
- Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), UBA-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Aníbal Sarotto
- Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), UBA-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Verónica B. Dorfman
- Centro de Estudios Biomédicos Básicos, Aplicados y Desarrollo (CEBBAD), Universidad Maimónides, Buenos Aires, Argentina
| | - Juan J. López-Costa
- Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), UBA-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - José M. Zapico
- Department of Chemistry and Biochemistry, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Madrid, Spain
| | - Ana Ramos
- Department of Chemistry and Biochemistry, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Madrid, Spain
| | - Beatriz de Pascual-Teresa
- Department of Chemistry and Biochemistry, Facultad de Farmacia, Universidad San Pablo-CEU, CEU Universities, Madrid, Spain
| | - Ignacio M. Larrayoz
- Biomarkers and Molecular Signaling, Neurodegenerative Diseases Area, Center for Biomedical Research of La Rioja (CIBIR), Logroño, Spain
| | - César F. Loidl
- Departamento de Biología Celular, Histología, Embriología y Genética, Instituto de Biología Celular y Neurociencia “Prof. E. De Robertis” (IBCN), UBA-CONICET, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Alfredo Martínez
- Angiogenesis Group, Center for Biomedical Research of La Rioja, Logroño, Spain,*Correspondence: Alfredo Martínez,
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Bai Y, Yuan M, Mi H, Zhang F, Liu X, Lu C, Bao Y, Li Y, Lu Q. Hypothermia reduces glymphatic transportation in traumatic edematous brain assessed by intrathecal dynamic contrast-enhanced MRI. Front Neurol 2022; 13:957055. [PMID: 36341130 PMCID: PMC9632734 DOI: 10.3389/fneur.2022.957055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/03/2022] [Indexed: 02/28/2024] Open
Abstract
The glymphatic system has recently been shown to clear brain extracellular solutes and can be extensively impaired after traumatic brain injury (TBI). Despite hypothermia being identified as a protective method for the injured brain via minimizing the formation of edema in the animal study, little is known about how hypothermia affects the glymphatic system following TBI. We use dynamic contrast-enhanced MRI (DCE-MRI) following cisterna magna infusion with a low molecular weight contrast agent to track glymphatic transport in male Sprague-Dawley rats following TBI with hypothermia treatment and use diffusion-weighted imaging (DWI) sequence to identify edema after TBI, and further distinguish between vasogenic and cytotoxic edema. We found that hypothermia could attenuate brain edema, as demonstrated by smaller injured lesions and less vasogenic edema in most brain subregions. However, in contrast to reducing cerebral edema, hypothermia exacerbated the reduction of efficiency of glymphatic transportation after TBI. This deterioration of glymphatic drainage was present brain-wide and showed hemispherical asymmetry and regional heterogeneity across the brain, associated with vasogenic edema. Moreover, our data show that glymphatic transport reduction and vasogenic edema are closely related to reducing perivascular aquaporin-4 (AQP4) expression. The suppression of glymphatic transportation might eliminate the benefits of brain edema reduction induced by hypothermia and provide an alternative pathophysiological factor indicating injury to the brain after TBI. Thus, this study poses a novel emphasis on the potential role of hypothermia in managing severe TBI.
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Affiliation(s)
- Yingnan Bai
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital and Institute of Biomedical Sciences, Fudan University, Shanghai, China
| | - Mingyuan Yuan
- Department of Radiology, Affiliated Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Honglan Mi
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fengchen Zhang
- Department of Neurosurgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiangyu Liu
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chen Lu
- Shanghai Wei Yu International School, Shanghai, China
| | - Yinghui Bao
- Department of Neurosurgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuehua Li
- Department of Radiology, Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qing Lu
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Radiology, Shanghai East Hospital Tongji University, Shanghai, China
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17
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Liu H, Zhou M. The utility of therapeutic hypothermia on cerebral autoregulation. J Intensive Med 2023; 3:27-37. [PMID: 36789361 DOI: 10.1016/j.jointm.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/26/2022] [Accepted: 08/10/2022] [Indexed: 11/07/2022]
Abstract
Cerebral autoregulation (CA) dysfunction is a strong predictor of clinical outcome in patients with acute brain injury (ABI). CA dysfunction is a potential pathologic defect that may lead to secondary injury and worse functional outcomes. Early therapeutic hypothermia (TH) in patients with ABI is controversial. Many factors, including patient selection, timing, treatment depth, duration, and rewarming strategy, impact its clinical efficacy. Therefore, optimizing the benefit of TH is an important issue. This paper reviews the state of current research on the impact of TH on CA function, which may provide the basis and direction for CA-oriented target temperature management.
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18
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Yan C, Mao J, Yao C, Liu Y, Yan H, Jin W. Neuroprotective effects of mild hypothermia against traumatic brain injury by the involvement of the Nrf2/ARE pathway. Brain Behav 2022; 12:e2686. [PMID: 35803901 PMCID: PMC9392531 DOI: 10.1002/brb3.2686] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/01/2022] [Accepted: 06/14/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is the leading cause of death and disability worldwide. Mild hypothermia (32-35°C) has been found to show neuroprotective effects against TBI. However, the specific mechanism is still elusive. In the current study, we explored the relationship between oxidative damage after TBI and treatment with mild hypothermia as well as the underlying molecular mechanisms. METHODS We used the closed cortex injury model to perform the brain injury and a temperature monitoring and control system to regulate the body temperature of mice after injury. Adult male C57BL/6 mice were adopted in this study and divided into four experimental groups. Tissue samples were harvested 24 h after injury. RESULTS First, our results showed that treatment with mild hypothermia significantly improved neurobehavioral dysfunction and alleviated brain edema after TBI. Moreover, treatment with mild hypothermia enhanced the activity of the antioxidant enzymes superoxide dismutase and glutathione peroxidase and reduced the accumulation of lipid peroxidation malondialdehyde. Importantly, the expression and activation of the nuclear factor erythroid 2-related factor 2-antioxidant response element (Nrf2-ARE) pathway were upregulated by mild hypothermia after TBI. Finally, treatment with hypothermia significantly decreased the cell apoptosis induced by TBI. CONCLUSION Our results showed that the protective effects of mild hypothermia after TBI may be achieved by the upregulation of the Nrf2-ARE pathway and revealed Nrf2 as a potentially important target to improve the prognosis of TBI.
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Affiliation(s)
- Chaolong Yan
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Department of Neurosurgery, Zhongshan Hospital, The Affiliated Hospital of Fudan University, Shanghai, China
| | - Jiannan Mao
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Chenbei Yao
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yang Liu
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Huiying Yan
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Wei Jin
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Du Q, Liu Y, Chen X, Li K. Effect of Hypothermia Therapy on Children with Traumatic Brain Injury: A Meta-Analysis of Randomized Controlled Trials. Brain Sci 2022; 12:1009. [PMID: 36009072 PMCID: PMC9406098 DOI: 10.3390/brainsci12081009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/19/2022] [Accepted: 07/27/2022] [Indexed: 02/04/2023] Open
Abstract
Hypothermia therapy is a promising therapeutic strategy for traumatic brain injury (TBI); however, some trials have shown that hypothermia therapy has a negative effect on patients with TBI. The treatment of hypothermia in children with TBI remains controversial. We conducted a search of six online databases to validate the literature on comparing hypothermia with normal therapy for children with TBI. Eight randomized controlled trials (514 patients) were included. The meta-analysis indicated that hypothermia therapy may increase the Glasgow Outcome Scale (GOS) scores. However, in terms of improving the rate of complications, intracranial pressure (ICP), mortality, cerebral perfusion pressure (CPP), and length of stay both in hospital as well as pediatric ICU, the difference was not statistically significant. Hypothermia therapy may have clinical advantages in improving the GOS scores in children with TBI compared with normothermic therapy, but hypothermia therapy may have no benefit in improving the incidence of complications, ICP, mortality, CPP, and length of stay both in pediatric ICU as well as hospital. The decision to implement hypothermia therapy for children with TBI depends on the advantages and disadvantages from many aspects and these must be considered comprehensively.
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Kobata H, Kuroda Y, Suehiro E, Kaneko T, Fujita M, Bunya N, Miyata K, Inoue A, Hifumi T, Oda Y, Dohi K, Yamashita S, Maekawa T. Benefits of Hypothermia for Young Patients with Acute Subdural Hematoma: A Computed Tomography Analysis of the Brain Hypothermia Study. Neurotrauma Rep 2022; 3:250-260. [PMID: 35982984 PMCID: PMC9380885 DOI: 10.1089/neur.2021.0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Therapeutic hypothermia for severe traumatic brain injury (TBI) has been repeatedly studied, but no past studies have assessed the detailed head computed tomography (CT) findings. We sought to investigate individual CT findings of severe TBI patients treated with targeted temperature management utilizing the head CT database obtained from the Brain Hypothermia study. Enrolled patients underwent either mild therapeutic hypothermia (32.0°C−34.0°C) or fever control (35.5°C−37.0°C). We assessed individual head CT images on arrival and after rewarming and investigated the correlations with outcomes. The initial CT data were available for 125 patients (hypothermia group = 80, fever control group = 45). Baseline characteristics and CT findings, such as hematoma thickness and midline shift, were similar in all aspects between the two groups. The favorable outcomes in the hypothermia and fever control groups were 38 (47.5%) and 24 (53.3%; p = 0.53) for all 125 patients, respectively; 21 (46.7%) vs. 10 (38.5%; p = 0.50) for 71 patients with acute subdural hematoma (SDH), respectively; and 12 (75.0%) vs. 4 (36.4%; p = 0.045) in 27 young adults (≤50 years) with acute SDH, respectively. There was a trend toward favorable outcomes for earlier time to reach 35.5°C (190 vs. 377 min, p = 0.052) and surgery (155 vs. 180 min, p = 0.096) in young patients with acute SDH. The second CT image revealed progression of the brain injury. This study demonstrated the potential benefits of early hypothermia in young patients with acute SDH, despite no difference in CT findings between the two groups. However, the small number of cases involved hindered the drawing of definitive conclusions. Future studies are warranted to validate the results.
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Affiliation(s)
- Hitoshi Kobata
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Kagawa University School of Medicine, Takamatsu, Japan
| | - Eiichi Suehiro
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita, Japan
| | - Tadashi Kaneko
- Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Motoki Fujita
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Naofumi Bunya
- Department of Emergency Medicine and Sapporo Medical University, Sapporo, Japan
| | - Kei Miyata
- Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasutaka Oda
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Kenji Dohi
- Department of Emergency, Disaster and Critical Care Medicine, Showa University, Tokyo, Japan
| | - Susumu Yamashita
- Emergency and Critical Care Center, Tokuyama Central Hospital, Tokuyama, Japan
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21
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Esopenko C, de Souza NL, Jia Y, Parrott JS, Merkley TL, Dennis EL, Hillary FG, Velez C, Cooper DB, Kennedy J, Lewis J, York G, Menefee DS, McCauley SR, Bowles AO, Wilde EA, Tate DF. Latent Neuropsychological Profiles to Discriminate Mild Traumatic Brain Injury and Posttraumatic Stress Disorder in Active-Duty Service Members. J Head Trauma Rehabil 2022. [PMID: 35452025 DOI: 10.1097/HTR.0000000000000779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine whether cognitive and psychological symptom profiles differentiate clinical diagnostic classifications (eg, history of mild traumatic brain injury [mTBI] and posttraumatic stress disorder [PTSD]) in military personnel. METHODS US Active-Duty Service Members (N = 209, 89% male) with a history of mTBI (n = 56), current PTSD (n = 23), combined mTBI + PTSD (n = 70), or orthopedic injury controls (n = 60) completed a neuropsychological battery assessing cognitive and psychological functioning. Latent profile analysis was performed to determine how neuropsychological outcomes of individuals clustered together. Diagnostic classifications (ie, mTBI, PTSD, mTBI + PTSD, and orthopedic injury controls) within each symptom profile were examined. RESULTS A 5-profile model had the best fit. The profiles differentiated subgroups with high (34.0%) or normal (21.5%) cognitive and psychological functioning, cognitive symptoms (19.1%), psychological symptoms (15.3%), and combined cognitive and psychological symptoms (10.0%). The symptom profiles differentiated participants as would generally be expected. Participants with PTSD were mainly represented in the psychological symptom subgroup, while orthopedic injury controls were mainly represented in the high-functioning subgroup. Further, approximately 79% of participants with comorbid mTBI and PTSD were represented in a symptomatic group (∼24% = cognitive symptoms, ∼29% = psychological symptoms, and 26% = combined cognitive/psychological symptoms). Our results also showed that approximately 70% of military personnel with a history of mTBI were represented in the high- and normal-functioning groups. CONCLUSIONS These results demonstrate both overlapping and heterogeneous symptom and performance profiles in military personnel with a history of mTBI, PTSD, and/or mTBI + PTSD. The overlapping profiles may underscore why these diagnoses are often difficult to diagnose and treat, but suggest that advanced statistical models may aid in identifying profiles representing symptom and cognitive performance impairments within patient groups and enable identification of more effective treatment targets.
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22
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Dhamanaskar R, Feldman WB, Merz JF. Practicalities of Impracticability: An Interim Review of Randomized Controlled Trials. J Empir Res Hum Res Ethics 2022; 17:329-345. [PMID: 35440213 DOI: 10.1177/15562646221092663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Impracticability is an ethical standard for waiver of informed consent in research. We examine how well the criterion of impracticability appears to have been fulfilled in a set of 36 completed randomized controlled trials (RCTs) that secured consent from some subjects or LARs and employed waivers to enroll others. These trials were identified among 155 RCTs using waivers of consent in a convenience sample drawn from 7 systematic reviews. Recruitment data were available for 19 of the 36 trials, revealing an average of 41.6% of subjects (range 0.2-98.7%, 95% CI: 24.8-58.4%) were enrolled without consent. Six trials enrolled less than 10% of subjects without consent and an overlapping set of 9 trials sought consent from all subjects or LARs at some sites while waiving consent at other sites. We question whether these trials were practicable without waivers and identify issues for consideration by investigators and ethics review boards.
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Affiliation(s)
- Roma Dhamanaskar
- Department of Health Research Methods, Evidence and Impact, 152969McMaster University Medical Centre, 1280 Main Street West, 2C Area, Hamilton, Ontario, Canada L8S 4K1
| | - William B Feldman
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, 1861Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA
| | - Jon F Merz
- Department of Medical Ethics & Health Policy, 14640Perelman School of Medicine at the University of Pennsylvania, Blockley Hall Floor 14, 423 Guardian Drive, Philadelphia, Pennsylvania 19104-4884, USA
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23
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Zhang Y, Li M, Yu B, Lu S, Zhang L, Zhu S, Yu Z, Xia T, Huang H, Jiang W, Zhang S, Sun L, Ye Q, Sun J, Zhu H, Huang P, Hong H, Yu S, Li W, Ai D, Fan J, Li W, Song H, Xu L, Chen X, Chen T, Zhou M, Ou J, Yang J, Li W, Hu Y, Wu W. Cold protection allows local cryotherapy in a clinical-relevant model of traumatic optic neuropathy. eLife 2022; 11:75070. [PMID: 35352678 PMCID: PMC9068221 DOI: 10.7554/elife.75070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/29/2022] [Indexed: 11/24/2022] Open
Abstract
Therapeutic hypothermia (TH) is potentially an important therapy for central nervous system (CNS) trauma. However, its clinical application remains controversial, hampered by two major factors: (1) Many of the CNS injury sites, such as the optic nerve (ON), are deeply buried, preventing access for local TH. The alternative is to apply TH systemically, which significantly limits the applicable temperature range. (2) Even with possible access for 'local refrigeration', cold-induced cellular damage offsets the benefit of TH. Here we present a clinically translatable model of traumatic optic neuropathy (TON) by applying clinical trans-nasal endoscopic surgery to goats and non-human primates. This model faithfully recapitulates clinical features of TON such as the injury site (pre-chiasmatic ON), the spatiotemporal pattern of neural degeneration, and the accessibility of local treatments with large operating space. We also developed a computer program to simplify the endoscopic procedure and expand this model to other large animal species. Moreover, applying a cold-protective treatment, inspired by our previous hibernation research, enables us to deliver deep hypothermia (4 °C) locally to mitigate inflammation and metabolic stress (indicated by the transcriptomic changes after injury) without cold-induced cellular damage, and confers prominent neuroprotection both structurally and functionally. Intriguingly, neither treatment alone was effective, demonstrating that in situ deep hypothermia combined with cold protection constitutes a breakthrough for TH as a therapy for TON and other CNS traumas.
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Affiliation(s)
- Yikui Zhang
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Mengyun Li
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Bo Yu
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Shengjian Lu
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Lujie Zhang
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of TechnologyBeijingChina
| | - Senmiao Zhu
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Zhonghao Yu
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Tian Xia
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Haoliang Huang
- Department of Ophthalmology, Stanford University School of MedicinePalo AltoUnited States
| | - WenHao Jiang
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Si Zhang
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Lanfang Sun
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Qian Ye
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Jiaying Sun
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Hui Zhu
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Pingping Huang
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Huifeng Hong
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Shuaishuai Yu
- School of Laboratory Medicine and Life Sciences, Wenzhou Medical UniversityWenzhouChina
| | - Wenjie Li
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of TechnologyBeijingChina
| | - Danni Ai
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of TechnologyBeijingChina
| | - Jingfan Fan
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of TechnologyBeijingChina
| | - Wentao Li
- School of Computer Science & Technology, Beijing Institute of TechnologyBeijingChina
| | - Hong Song
- School of Computer Science & Technology, Beijing Institute of TechnologyBeijingChina
| | - Lei Xu
- Medical Radiology Department, 2nd Affiliated Hospital, Wenzhou Medical UniversityWenzhouChina
| | - Xiwen Chen
- Animal Facility Center, Wenzhou Medical UniversityWenzhouChina
| | - Tongke Chen
- Animal Facility Center, Wenzhou Medical UniversityWenzhouChina
| | - Meng Zhou
- School of Biomedical Engineering, The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
| | - Jingxing Ou
- Department of Hepatic Surgery and Liver Transplantation Center of the Third Affiliated, Hospital, Guangdong Province Engineering Laboratory for Transplantation MedicineGuangzhouChina,Guangdong Key Laboratory of Liver Disease Research, the Third Affiliated Hospital of Sun Yat-sen UniversityGuangzhouChina
| | - Jian Yang
- Beijing Engineering Research Center of Mixed Reality and Advanced Display, School of Optics and Photonics, Beijing Institute of TechnologyBeijingChina
| | - Wei Li
- Retinal Neurophysiology Section, National Eye Institute, National Institute of Health, NIHBethesdaUnited States
| | - Yang Hu
- Department of Ophthalmology, Stanford University School of MedicinePalo AltoUnited States
| | - Wencan Wu
- The Eye Hospital, School of Ophthalmology & Optometry, Wenzhou Medical UniversityWenzhouChina
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24
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Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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26
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Mao LP, Jiao Y, Xiang JH, Luo XW, He Q, Ran DH, Xu Q, Lang CH, Chen LX. Cold-inducible RNA-binding protein migrates from the nucleus to the cytoplasm under cold stress in normal human bronchial epithelial cells via TRPM8-mediated mechanism. Ann Transl Med 2021; 9:1470. [PMID: 34734022 PMCID: PMC8506723 DOI: 10.21037/atm-21-4447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/16/2021] [Indexed: 11/11/2022]
Abstract
Background Cold-inducible RNA-binding protein (CIRP or hnRNP A18) is a multifunctional stress-responsive protein. Our previous study demonstrated that cold stress increased CIRP expression and migrated from the nucleus to the cytoplasm in airway epithelial cells. However, the mechanism through which CIRP migrates from the nucleus to the cytoplasm upon cold stress remains unknown. Methods The expression of CIRP in the bronchial epithelium was examined using immunofluorescence, real-time polymerase chain reaction (RT-PCR), and Western blotting. The expression of inflammatory factors interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-α (TNF-α) were detected by ELISA and RT-PCR. Transient receptor potential melastatin 8 (TRPM8) receptor function was characterized by Ca2+ imaging. Results Cold stress upregulated the expression of CIRP, inflammatory factors and promoted the translocation of CIRP from the nucleus to the cytoplasm in normal human bronchial epithelial (NHBE) cells. Cold stress activated the TRPM8/(Ca2+)/PKCα/glycogen synthase kinase 3β (GSK3β) signaling cascade, and that inhibition of this signaling pathway attenuated the migration of CIRP from the nucleus to cytoplasm but did not decrease its overexpression induced by cold stress. Knocked down CIRP expression or blocked CIRP migration between the nucleus and cytoplasm significantly decreased inflammatory factor expression. Conclusions These results indicate that cold stress leads to the migration of CIRP from the nucleus to the cytoplasm with alteration of expression, which are involved in the expression of inflammatory factors (IL-1β, IL-6, IL-8 and TNF-α) induced by cold air, through TRPM8/Ca2+/PKCα/GSK3β signaling cascade.
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Affiliation(s)
- Liang-Ping Mao
- Department of Respiratory and Critical Care Medicine, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Yan Jiao
- Department of Respiratory and Critical Care Medicine, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Jian-Hua Xiang
- Department of Respiratory and Critical Care Medicine, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Xin-Wei Luo
- Department of Respiratory and Critical Care Medicine, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Qian He
- Department of Respiratory and Critical Care Medicine, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Dan-Hua Ran
- Department of Respiratory and Geriatrics Medicine, Chongqing Public Health Medical Center, Chongqing, China
| | - Qing Xu
- Department of Respiratory and Critical Care Medicine, Eastern Hospital, Sichuan Provincial Medical Sciences Academy & Sichuan Provincial People's Hospital, Chengdu, China
| | - Chun-Hui Lang
- Department of Clinical Nutrition, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Ling-Xiu Chen
- Department of Respiratory and Critical Care Medicine, Chongqing University Three Gorges Hospital, Chongqing, China
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27
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Abstract
Hypothermia is defined as a core body temperature of < 35°C, and as body temperature is reduced the impact on physiological processes can be beneficial or detrimental. The beneficial effect of hypothermia enables circulation of cooled experimental animals to be interrupted for 1-2 h without creating harmful effects, while tolerance of circulation arrest in normothermia is between 4 and 5 min. This striking difference has attracted so many investigators, experimental as well as clinical, to this field, and this discovery was fundamental for introducing therapeutic hypothermia in modern clinical medicine in the 1950's. Together with the introduction of cardiopulmonary bypass, therapeutic hypothermia has been the cornerstone in the development of modern cardiac surgery. Therapeutic hypothermia also has an undisputed role as a protective agent in organ transplantation and as a therapeutic adjuvant for cerebral protection in neonatal encephalopathy. However, the introduction of therapeutic hypothermia for organ protection during neurosurgical procedures or as a scavenger after brain and spinal trauma has been less successful. In general, the best neuroprotection seems to be obtained by avoiding hyperthermia in injured patients. Accidental hypothermia occurs when endogenous temperature control mechanisms are incapable of maintaining core body temperature within physiologic limits and core temperature becomes dependent on ambient temperature. During hypothermia spontaneous circulation is considerably reduced and with deep and/or prolonged cooling, circulatory failure may occur, which may limit safe survival of the cooled patient. Challenges that limit safe rewarming of accidental hypothermia patients include cardiac arrhythmias, uncontrolled bleeding, and "rewarming shock".
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Affiliation(s)
- Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
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28
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Olah E, Poto L, Rumbus Z, Pakai E, Romanovsky AA, Hegyi P, Garami A. POLAR Study Revisited: Therapeutic Hypothermia in Severe Brain Trauma Should Not Be Abandoned. J Neurotrauma 2021; 38:2772-2776. [PMID: 34002636 DOI: 10.1089/neu.2020.7509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The benefits of therapeutic hypothermia (TH) in severe traumatic brain injury (sTBI) have been long debated. In 2018, the POLAR study, a high-quality international trial, appeared to end the debate by showing that TH did not improve mortality in sTBI. However, the POLAR-based recommendation to abandon TH was challenged by different investigators. In our recent meta-analysis, we introduced the cooling index (COIN) to assess the extent of cooling and showed that TH is beneficial in sTBI, but only when the COIN is sufficiently high. In the present study, we calculated the COIN for the POLAR study and ran a new meta-analysis, which included the POLAR data and accounted for the cooling extent. The POLAR study targeted a high cooling extent (COIN of 276°C × h; calculated for 72 h), but the achieved cooling was much lower (COIN of 193°C × h)-because of deviations from the protocol. When the POLAR data were included in the COIN-based meta-analysis, TH had an overall effect of reducing death (odds rate of 0.686; p = 0.007). Among the subgroups with different COIN levels, the only significantly decreased odds rate (i.e., beneficial effect of TH) was observed in the subgroup with high COIN (0.470; p = 0.013). We conclude that, because of deviations from the targeted cooling protocol, the overall cooling extent was not sufficiently high in the POLAR study, thus masking the beneficial effects of TH. The current analysis shows that TH is beneficial in sTBI, but only when the COIN is high. Abandoning the use of TH in sTBI may be premature.
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Affiliation(s)
- Emoke Olah
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
| | - Laszlo Poto
- Institute of Bioanalysis, Medical School, University of Pecs, Pecs, Hungary
| | - Zoltan Rumbus
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
| | - Eszter Pakai
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
| | | | - Peter Hegyi
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
| | - Andras Garami
- Institute for Translational Medicine, Medical School, University of Pecs, Pecs, Hungary
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29
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Hergenroeder GW, Yokobori S, Choi HA, Schmitt K, Detry MA, Schmitt LH, McGlothlin A, Puccio AM, Jagid J, Kuroda Y, Nakamura Y, Suehiro E, Ahmad F, Viele K, Wilde EA, McCauley SR, Kitagawa RS, Temkin NR, Timmons SD, Diringer MN, Dash PK, Bullock R, Okonkwo DO, Berry DA, Kim DH. Hypothermia for Patients Requiring Evacuation of Subdural Hematoma: A Multicenter Randomized Clinical Trial. Neurocrit Care 2021; 36:560-572. [PMID: 34518968 PMCID: PMC8964656 DOI: 10.1007/s12028-021-01334-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/13/2021] [Indexed: 11/24/2022]
Abstract
Background Hypothermia is neuroprotective in some ischemia–reperfusion injuries. Ischemia–reperfusion injury may occur with traumatic subdural hematoma (SDH). This study aimed to determine whether early induction and maintenance of hypothermia in patients with acute SDH would lead to decreased ischemia–reperfusion injury and improve global neurologic outcome. Methods This international, multicenter randomized controlled trial enrolled adult patients with SDH requiring evacuation of hematoma within 6 h of injury. The intervention was controlled temperature management of hypothermia to 35 °C prior to dura opening followed by 33 °C for 48 h compared with normothermia (37 °C). Investigators randomly assigned patients at a 1:1 ratio between hypothermia and normothermia. Blinded evaluators assessed outcome using a 6-month Glasgow Outcome Scale Extended score. Investigators measured circulating glial fibrillary acidic protein and ubiquitin C-terminal hydrolase L1 levels. Results Independent statisticians performed an interim analysis of 31 patients to assess the predictive probability of success and the Data and Safety Monitoring Board recommended the early termination of the study because of futility. Thirty-two patients, 16 per arm, were analyzed. Favorable 6-month Glasgow Outcome Scale Extended outcomes were not statistically significantly different between hypothermia vs. normothermia groups (6 of 16, 38% vs. 4 of 16, 25%; odds ratio 1.8 [95% confidence interval 0.39 to ∞], p = .35). Plasma levels of glial fibrillary acidic protein (p = .036), but not ubiquitin C-terminal hydrolase L1 (p = .26), were lower in the patients with favorable outcome compared with those with unfavorable outcome, but differences were not identified by temperature group. Adverse events were similar between groups. Conclusions This trial of hypothermia after acute SDH evacuation was terminated because of a low predictive probability of meeting the study objectives. There was no statistically significant difference in functional outcome identified between temperature groups. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01334-w.
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Affiliation(s)
- Georgene W Hergenroeder
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA. .,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA.
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Huimahn Alex Choi
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Karl Schmitt
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Michelle A Detry
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Lisa H Schmitt
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Anna McGlothlin
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan Jagid
- Department of Neurological Surgery, Jackson Memorial Hospital, University of Miami, Miami, FL, USA
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Kagawa University Hospital, Kagawa Prefecture, Japan
| | - Yukihiko Nakamura
- Emergency and Critical Care Medicine, Kurume University Hospital, Fukuoka, Japan
| | - Eiichi Suehiro
- Department of Neurosurgery, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Faiz Ahmad
- Department of Neurological Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Kert Viele
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Elisabeth A Wilde
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Stephen R McCauley
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Ryan S Kitagawa
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
| | - Nancy R Temkin
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle, WA, USA
| | - Shelly D Timmons
- Department of Neurological Surgery, Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael N Diringer
- Departments of Neurology, Neurological Surgery, Anesthesiology, and Occupational Therapy, Washington University School of Medicine, St. Louis, MO, USA
| | - Pramod K Dash
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Department of Neurobiology and Anatomy, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ross Bullock
- Department of Neurological Surgery, Jackson Memorial Hospital, University of Miami, Miami, FL, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Donald A Berry
- Statistical and Software Team, Berry Consultants, Austin, TX, USA
| | - Dong H Kim
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 7.156, Houston, TX, 77030, USA.,Memorial Hermann Hospital, Texas Medical Center, Houston, TX, USA
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30
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Abstract
Refractory intracranial hypertension after traumatic brain injury (TBI) is defined as recurrent increase of intracranial pressure (ICP) above 20-22 mmHg for sustained period of time (10-15 min), despite conventional therapies, such as osmotic therapy, cerebral spinal fluid drainage and mild hyperventilation. As such, more aggressive treatments should be taken into consideration. In particular, therapeutic hypothermia, barbiturates administration and decompressive craniectomy are considered as tier-three or "salvage" interventions, as they have shown to be able to control refractory hypertension, but are also associated with an increased risk of significant side effects. The aim of this review is therefore to describe the evidence supporting the use of these tier-three therapies in the management of refractory intracranial hypertension in TBI patients.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy - .,San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy -
| | - Francesca Iannuzzi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio S Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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31
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Kim JH, Nagy Á, Putzu A, Belletti A, Biondi-Zoccai G, Likhvantsev VV, Yavorovskiy AG, Landoni G. Therapeutic Hypothermia in Critically Ill Patients: A Systematic Review and Meta-Analysis of High Quality Randomized Trials. Crit Care Med 2020; 48:1047-54. [PMID: 32355134 DOI: 10.1097/CCM.0000000000004364] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To investigate the effect of the application of therapeutic hypothermia (32-35°C) on survival and major clinical endpoints in critically ill patients. DATA SOURCES We searched online database and clinical trial registries dated up to April 30, 2019, and references of relevant studies. STUDY SELECTION Low risk of bias randomized trials which compared hypothermia applied for at least 24 hours and conventional therapy in critically ill patients were included. We excluded trials investigating therapeutic hypothermia in indications already supported by international guidelines (adult cardiac arrest and hypoxic-ischemic encephalopathy of newborns) or intraoperative hypothermia. DATA EXTRACTION Titles and abstracts were reviewed independently by two authors. If the articles seemed eligible, full-text articles were reviewed, and data were abstracted using a structured template. DATA SYNTHESIS Our search retained 14 low risk of bias randomized trials (2,670 patients) performed in three different settings: traumatic brain injury, serious infections, and stroke. Therapeutic hypothermia was associated with an increase in mortality at longest follow-up available (432/1,375 [31%] vs 330/1,295 [25%]; risk ratio, 1.24; 95% CI, 1.10-1.39; p = 0.0004; I = 0%). Pooled results showed no difference of good neurologic outcome among survivors between the two treatment arms (493/1,142 [43%] vs 486/1,067 [46%]; risk ratio, 1.04; 95% CI, 0.97-1.12; p = 0.27; I = 1%). Arrhythmias were significantly increased among patients undergoing therapeutic hypothermia. We found no difference between groups in pneumonia, serious infections, any infection, hemorrhage, renal failure, deep vein thrombosis, and uncontrollable intracranial hypertension. CONCLUSIONS High-quality randomized evidence indicates that therapeutic hypothermia is associated with higher mortality and no difference in good neurologic outcome compared with normothermia in critically ill patients. Although there still might be a possibility that therapeutic hypothermia is beneficial in a specific setting, routine application of therapeutic hypothermia would better be avoided outside the settings indicated by international guidelines (adult cardiac arrest and hypoxic-ischemic encephalopathy of newborns).
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Bourgeois-Tardif S, De Beaumont L, Rivera JC, Chemtob S, Weil AG. Role of innate inflammation in traumatic brain injury. Neurol Sci 2021; 42:1287-1299. [PMID: 33464411 DOI: 10.1007/s10072-020-05002-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/14/2020] [Indexed: 12/26/2022]
Abstract
Traumatic brain injury is one of the leading causes of morbidity and mortality throughout the world. Its increasing incidence, in addition to its fundamental role in the development of neurodegenerative disease, proves especially concerning. Despite extensive preclinical and clinical studies, researchers have yet to identify a safe and effective neuroprotective strategy. Following brain trauma, secondary injury from molecular, metabolic, and cellular changes causes progressive cerebral tissue damage. Chronic neuroinflammation following traumatic brain injuries is a key player in the development of secondary injury. Targeting this phenomenon for development of effective neuroprotective therapies holds promise. This strategy warrants a concrete understanding of complex neuroinflammatory mechanisms. In this review, we discuss pathophysiological mechanisms such as the innate immune response, glial activation, blood-brain barrier disruption, activation of immune mediators, as well as biological markers of traumatic brain injury. We then review existing and emerging pharmacological therapies that target neuroinflammation to improve functional outcome.
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Affiliation(s)
- Sandrine Bourgeois-Tardif
- Department of Neuroscience, University of Montreal, Montreal, Canada
- Hopital du Sacre-Coeur de Montreal, Universite de Montreal - Psychology, Montreal, QC, Canada
| | - Louis De Beaumont
- Hopital du Sacre-Coeur de Montreal, Universite de Montreal - Psychology, Montreal, QC, Canada
| | - José Carlos Rivera
- Department of Pediatrics, Ophthalmology and Pharmacology, Centre Hospitalier Universitaire Sainte-Justine Research Center, 3175, Chemin Côte Ste-Catherine, Montreal, Quebec, Canada
- Department of Ophthalmology, Maisonneuve-Rosemont Hospital Research Center, University of Montréal, Montreal, Quebec, Canada
| | - Sylvain Chemtob
- Department of Pediatrics, Ophthalmology and Pharmacology, Centre Hospitalier Universitaire Sainte-Justine Research Center, 3175, Chemin Côte Ste-Catherine, Montreal, Quebec, Canada
- Department of Ophthalmology, Maisonneuve-Rosemont Hospital Research Center, University of Montréal, Montreal, Quebec, Canada
| | - Alexander G Weil
- Neurosurgery Service, Department of Surgery, University of Montreal, Montreal, Canada.
- Centre Hospitalier Universitaire Sainte-Justine, Centre de Recherche, Room 3.17.100_6, 3175, Côte Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada.
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Abstract
Substantial progress has been made over the past two decades in detecting, predicting and promoting recovery of consciousness in patients with disorders of consciousness (DoC) caused by severe brain injuries. Advanced neuroimaging and electrophysiological techniques have revealed new insights into the biological mechanisms underlying recovery of consciousness and have enabled the identification of preserved brain networks in patients who seem unresponsive, thus raising hope for more accurate diagnosis and prognosis. Emerging evidence suggests that covert consciousness, or cognitive motor dissociation (CMD), is present in up to 15-20% of patients with DoC and that detection of CMD in the intensive care unit can predict functional recovery at 1 year post injury. Although fundamental questions remain about which patients with DoC have the potential for recovery, novel pharmacological and electrophysiological therapies have shown the potential to reactivate injured neural networks and promote re-emergence of consciousness. In this Review, we focus on mechanisms of recovery from DoC in the acute and subacute-to-chronic stages, and we discuss recent progress in detecting and predicting recovery of consciousness. We also describe the developments in pharmacological and electrophysiological therapies that are creating new opportunities to improve the lives of patients with DoC.
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Affiliation(s)
- Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicholas D Schiff
- Feil Family Brain Mind Research Institute, Weill Cornell Medical College, New York, NY, USA
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA.
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Yamal JM, Aisiku IP, Hannay HJ, Brito FA, Robertson CS. Disability Rating Scale in the First Few Weeks After a Severe Traumatic Brain Injury as a Predictor of 6-Month Functional Outcome. Neurosurgery 2021; 88:619-626. [PMID: 33369651 PMCID: PMC7884144 DOI: 10.1093/neuros/nyaa474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 08/23/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND An early acute marker of long-term neurological outcome would be useful to help guide clinical decision making and therapeutic effectiveness after severe traumatic brain injury (TBI). We investigated the utility of the Disability Rating Scale (DRS) as early as 1 wk after TBI as a predictor of favorable 6-mo Glasgow Outcome Scale extended (GOS-E). OBJECTIVE To determine the predictability of a favorable 6-mo GOS-E using the DRS measured during weeks 1 to 4 of injury. METHODS The study is a sub analysis of patients enrolled in the Epo Severe TBI Trial (n = 200) to train and validate L1-regularized logistic regression models. DRS was collected at weeks 1 to 4 and GOS-E at 6 mo. RESULTS The average area under the receiver operating characteristic curve was 0.82 for the model with baseline demographic and injury severity variables and week 1 DRS and increased to 0.88 when including weekly DRS until week 4. CONCLUSION This study suggests that week 1 to 4 DRS may be predictors of favorable 6-mo outcome in severe TBI patients and thus useful both for clinical prognostication as well as surrogate endpoints for adaptive clinical trials.
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Affiliation(s)
- Jose-Miguel Yamal
- Department of Biostatistics and Data Science, The University of Texas School of Public Health, Houston, Texas
| | - Imoigele P Aisiku
- Department of Emergency Medicine, Harvard Medical School/Brigham and Women's Hospital, Boston, Massachusetts
| | - H Julia Hannay
- Department of Psychology and Texas Institute for Measurement Evaluation and Statistics (TIMES), University of Houston, Houston Texas
| | - Frances A Brito
- Department of Biostatistics and Data Science, The University of Texas School of Public Health, Houston, Texas
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Abstract
Published epidemiological studies of traumatic brain injury (TBI) of all severities consistently report higher incidence in men. Recent increases in the participation of women in sports and active military service as well as increasing awareness of the very large number of women who sustain but do not report TBI as a result of intimate partner violence (IPV) suggest that the number of women with TBI is significantly larger than previously believed. Women are also grossly under-represented in clinical and natural history studies of TBI, most of which include relatively small numbers of women, ignore the role of sex- and age-related gonadal hormone levels, and report conflicting results. The emerging picture from recent studies powered to detect effects of biological sex as well as age (as a surrogate of hormonal status) suggest young (i.e., premenopausal) women are more likely to die from TBI relative to men of the same age group, but this is reversed in the 6th and 7th decades of life, coinciding with postmenopausal status in women. New data from concussion studies in young male and female athletes extend this finding to mild TBI, since female athletes who sustained mild TBI are significantly more likely to report more symptoms than males. Studies including information on gonadal hormone status at the time of injury are still too scarce and small to draw reliable conclusions, so there is an urgent need to include biological sex and gonadal hormone status in the design and analysis of future studies of TBI.
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Affiliation(s)
- Anat Biegon
- Department of Radiology and Neurology, Stony Brook University School of Medicine, Stony Brook, NY, United States
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36
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Hui J, Feng J, Tu Y, Zhang W, Zhong C, Liu M, Wang Y, Long L, Chen L, Liu J, Mou C, Qiu B, Huang X, Huang Q, Zhang N, Yang X, Yang C, Li L, Ma R, Wu X, Lei J, Jiang Y, Liu L, Gao G, Jiang J. Safety and efficacy of long-term mild hypothermia for severe traumatic brain injury with refractory intracranial hypertension (LTH-1): A multicenter randomized controlled trial. EClinicalMedicine 2021; 32:100732. [PMID: 33681741 PMCID: PMC7910713 DOI: 10.1016/j.eclinm.2021.100732] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia may need prolonged duration for the patients with severe traumatic brain injury (sTBI). METHODS The Long-Term Hypothermia trial was a prospective, multicenter, randomized, controlled clinical trial to examine the safety and efficacy in adults with sTBI. Eligible patients were 18-65, Glasgow Coma Scale score at 4 to 8, and initial intracranial pressure (ICP) ≥ 25 mm Hg, randomly assigned to the long-term mild hypothermia group (34-35 °C for 5 days) or normothermia group at 37 °C. The primary outcome was the Glasgow outcome scale (GOS) at 6 months. Secondary outcomes included ICP control, complications and laboratory findings, the length of ICU and hospital stay, and GOS at 6 months in patients with initial ICP ≥ 30 mm Hg. This trial is registered with ClinicalTrials.gov, NCT01886222. FINDINGS 302 patients were enrolled from June 25, 2013, to December 31, 2018, with 6 months follow-up in 14 hospitals, 156 in hypothermia group and 146 in normothermia group. There was no difference in favorable outcome (OR 1·55, 95%CI 0·91-2·64; P = 0·105) and in mortality (P = 0·111) between groups. In patients with an initial ICP ≥ 30 mm Hg, hypothermic treatment significantly increased favorable outcome over normothermia group (60·82%, 42·71%, respectively; OR 1·861, 95%CI 1·031-3·361; P = 0·039). Long-term mild hypothermia did not increase the incidences of complications. INTERPRETATION Long-term mild hypothermia did not improve the neurological outcomes. However, it may be a potential option in sTBI patients with initial ICP ≥ 30 mm Hg. FUNDING : Shanghai municipal government and Shanghai Jiao Tong University/School of Medicine.
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Affiliation(s)
- Jiyuan Hui
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
| | - Junfeng Feng
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
| | - Yue Tu
- Neurological Intensive Care Unit, Beijing Chaoyang Integrative Medicine Emergency Medical Center, Beijing, China
| | - Weituo Zhang
- Clinical Research Institute, Shanghai Jiao Tong University/School of Medicine, Shanghai, China
| | - Chunlong Zhong
- Department of Neurosurgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Min Liu
- Department of Neurosurgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuhai Wang
- Department of Neurosurgery, Taihu Hospital, Wuxi, China
| | - Liansheng Long
- Department of Neurosurgery, South Taihu Hospital, Huzhou, China
| | - Ligang Chen
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jinfang Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Chaohui Mou
- Department of Neurosurgery, Taizhou First People's Hospital, Zhejiang, China
| | - Binghui Qiu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xianjian Huang
- Department of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen, China
| | - Qibing Huang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, China
| | - Nu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaofeng Yang
- Emergency and Trauma Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chaohua Yang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Lihong Li
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Rong Ma
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
| | - Xiang Wu
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
| | - Jin Lei
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
| | - Yong Jiang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Liang Liu
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiyao Jiang
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
- Department of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen, China
- Emergency and Trauma Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - the LTH-1 Trial collaborators
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Neurological Intensive Care Unit, Beijing Chaoyang Integrative Medicine Emergency Medical Center, Beijing, China
- Clinical Research Institute, Shanghai Jiao Tong University/School of Medicine, Shanghai, China
- Department of Neurosurgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Neurosurgery, Taihu Hospital, Wuxi, China
- Department of Neurosurgery, South Taihu Hospital, Huzhou, China
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurosurgery, Taizhou First People's Hospital, Zhejiang, China
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen, China
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, China
- Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Emergency and Trauma Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
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Idris Z, Ang SY, Wan Hassan WMN, Hassan MH, Mohd Zain KA, Abdul Manaf A. A Clinical Test for a Newly Developed Direct Brain Cooling System for the Injured Brain and Pattern of Cortical Brainwaves in Cooling, Noncooling, and Dead Brain. Ther Hypothermia Temp Manag 2021; 12:103-114. [PMID: 33513054 DOI: 10.1089/ther.2020.0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To ensure the direct delivery of therapeutic hypothermia at a selected constant temperature to the injured brain, a newly innovated direct brain cooling system was constructed. The practicality, effectiveness, and safety of this system were clinically tested in our initial series of 14 patients with severe head injuries. The patients were randomized into two groups: direct brain cooling at 32°C and the control group. All of them received intracranial pressure (ICP), focal brain oxygenation, brain temperature, and direct cortical brainwave monitoring. The direct brain cooling group did better in the Extended Glasgow Outcome Scale at the time of discharge and at 6 months after trauma. This could be owing to a trend in the monitored parameters; reduction in ICP, increment in cerebral perfusion pressure, optimal brain redox regulation, near-normal brain temperature, and lessening of epileptic-like brainwave activities are likely the reasons for better outcomes in the cooling group. Finally, this study depicts interesting cortical brainwaves during a transition time from being alive to dead. It is believed that the demonstrated cortical brainwaves follow the principles of quantum physics.
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Affiliation(s)
- Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia.,Brain and Behaviour Cluster (BBC), School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia.,Hospital Universiti Sains Malaysia (HUSM), Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Song Yee Ang
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia.,Hospital Universiti Sains Malaysia (HUSM), Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Wan Mohd Nazaruddin Wan Hassan
- Hospital Universiti Sains Malaysia (HUSM), Universiti Sains Malaysia, Kubang Kerian, Malaysia.,Department of Anaesthesiology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Mohd Hasyizan Hassan
- Hospital Universiti Sains Malaysia (HUSM), Universiti Sains Malaysia, Kubang Kerian, Malaysia.,Department of Anaesthesiology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Khairu Anuar Mohd Zain
- Collaborative Microelectronic Design Excellence Center (CEDEC), Universiti Sains Malaysia, Bayan Lepas, Malaysia
| | - Asrulnizam Abdul Manaf
- Collaborative Microelectronic Design Excellence Center (CEDEC), Universiti Sains Malaysia, Bayan Lepas, Malaysia
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Danladi J, Sabir H. Perinatal Infection: A Major Contributor to Efficacy of Cooling in Newborns Following Birth Asphyxia. Int J Mol Sci 2021; 22:ijms22020707. [PMID: 33445791 PMCID: PMC7828225 DOI: 10.3390/ijms22020707] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 12/19/2022] Open
Abstract
Neonatal encephalopathy (NE) is a global burden, as more than 90% of NE occurs in low- and middle-income countries (LMICs). Perinatal infection seems to limit the neuroprotective efficacy of therapeutic hypothermia. Efforts made to use therapeutic hypothermia in LMICs treating NE has led to increased neonatal mortality rates. The heat shock and cold shock protein responses are essential for survival against a wide range of stressors during which organisms raise their core body temperature and temporarily subject themselves to thermal and cold stress in the face of infection. The characteristic increase and decrease in core body temperature activates and utilizes elements of the heat shock and cold shock response pathways to modify cytokine and chemokine gene expression, cellular signaling, and immune cell mobilization to sites of inflammation, infection, and injury. Hypothermia stimulates microglia to secret cold-inducible RNA-binding protein (CIRP), which triggers NF-κB, controlling multiple inflammatory pathways, including nod-like receptor family pyrin domain containing 3 (NLRP3) inflammasomes and cyclooxygenase-2 (COX-2) signaling. Brain responses through changes in heat shock protein and cold shock protein transcription and gene-expression following fever range and hyperthermia may be new promising potential therapeutic targets.
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Affiliation(s)
- Jibrin Danladi
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital University of Bonn, 53127 Bonn, Germany;
- German Center for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
- Correspondence:
| | - Hemmen Sabir
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital University of Bonn, 53127 Bonn, Germany;
- German Center for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
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Escamilla-Ocañas CE, Albores-Ibarra N. Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. Neurologia 2020; 38:S0213-4853(20)30274-7. [PMID: 33069447 DOI: 10.1016/j.nrl.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/20/2020] [Accepted: 08/04/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Increased intracranial pressure has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury. Traditionally, intracranial pressure-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe traumatic brain injury in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.
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Affiliation(s)
- C E Escamilla-Ocañas
- Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, EE. UU..
| | - N Albores-Ibarra
- División de Ciencias de la Salud, Universidad de Monterrey, San Pedro Garza García, Nuevo León, México
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40
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Hirst TC, Klasen MG, Rhodes JK, Macleod MR, Andrews PJD. A Systematic Review and Meta-Analysis of Hypothermia in Experimental Traumatic Brain Injury: Why Have Promising Animal Studies Not Been Replicated in Pragmatic Clinical Trials? J Neurotrauma 2020; 37:2057-2068. [PMID: 32394804 DOI: 10.1089/neu.2019.6923] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Therapeutic hypothermia was a mainstay of severe traumatic brain injury (TBI) management for half a century. Recent trials have suggested that its effect on long-term functional outcome is neutral or negative, despite apparently promising pre-clinical data. Systematic review and meta-analysis is a useful tool to collate experimental data and investigate the basis of its conclusions. We searched three online databases to identify studies testing systemic hypothermia as monotherapy for treatment of animals subjected to a TBI. Data pertaining to TBI paradigm, animal subjects, and hypothermia management were extracted as well as those relating to risk of bias. We pooled outcome data where sufficient numbers allowed and investigated heterogeneity in neurobehavioral outcomes using multi-variate meta-regression. We identified 90 publications reporting 272 experiments testing hypothermia in animals subject to TBI. The subjects were mostly small animals, with well-established models predominating. Target temperature was comparable to clinical trial data but treatment was initiated very early. Study quality was low and there was some evidence of publication bias. Delay to treatment, comorbidity, and blinded outcome assessment appeared to predict neurobehavioral outcome on multi-variate meta-regression. Therapeutic hypothermia appears to be an efficacious treatment in experimental TBI, which differs from the clinical evidence. The pre-clinical literature showed limitations in quality and design and these both appeared to affect neurobehavioral experiment outcome. These should be acknowledged when designing and interpreting pre-clinical TBI studies in the future.
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Affiliation(s)
- Theodore C Hirst
- Centre for Clinical Brain Sciences, Anesthesia and Pain Medicine, University of Edinburgh, Edinburgh, United Kingdom
- Department of Neurosurgery, Royal Victoria Hospital, Belfast, United Kingdom
| | | | - Jonathan K Rhodes
- Department of Critical Care, Anesthesia and Pain Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Malcolm R Macleod
- Centre for Clinical Brain Sciences, Anesthesia and Pain Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Peter J D Andrews
- Centre for Clinical Brain Sciences, Anesthesia and Pain Medicine, University of Edinburgh, Edinburgh, United Kingdom
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41
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Bernstein JE, Ghanchi H, Kashyap S, Podkovik S, Miulli DE, Wacker MR, Sweiss R. Pentobarbital Coma With Therapeutic Hypothermia for Treatment of Refractory Intracranial Hypertension in Traumatic Brain Injury Patients: A Single Institution Experience. Cureus 2020; 12:e10591. [PMID: 33110727 PMCID: PMC7581220 DOI: 10.7759/cureus.10591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Introduction Traumatic brain injury (TBI) results in primary and secondary brain injuries. Secondary brain injury can lead to cerebral edema resulting in increased intracranial pressure (ICP) secondary to the rigid encasement of the skull. Increased ICP leads to decreased cerebral perfusion pressure which leads to cerebral ischemia. Refractory intracranial hypertension (RICH) occurs when ICP remains elevated despite first-tier therapies such as head elevation, straightening of the neck, analgesia, sedation, paralytics, cerebrospinal fluid (CSF) drainage, mannitol and/or hypertonic saline administration. If unresponsive to these measures, second-tier therapies such as hypothermia, barbiturate infusion, and/or surgery are employed. Methods This was a retrospective review of patients admitted at Arrowhead Regional Medical Center from 2008 to 2019 for severe TBI who developed RICH requiring placement into a pentobarbital-induced coma with therapeutic hypothermia. Primary endpoints included mortality, good recovery which was designated at Glasgow outcome scale (GOS) of 4 or 5, and improvement in ICP (goal is <20 mmHg). Secondary endpoints included complications, length of intensive care unit (ICU) stay, length of hospital stay, length of pentobarbital coma, length of hypothermia, need for vasopressors, and decompressive surgery versus no decompressive surgery. Results Our study included 18 patients placed in pentobarbital coma with hypothermia for RICH. The overall mortality rate in our study was 50%; with 60% mortality in pentobarbital/hypothermia only group, and 46% mortality in surgery plus pentobarbital/hypothermia group. Maximum ICP prior to pentobarbital/hypothermia was significantly lower in patients who had a prior decompressive craniectomy than in patients who were placed into pentobarbital/hypothermia protocol first (28.3 vs 35.4, p<0.0238). ICP was significantly reduced at 4 hours, 8 hours, 12 hours, 24 hours, and 48 hours after pentobarbital and hypothermia treatment. Initial ICP and maximum ICP prior to pentobarbital/hypothermia was significantly correlated with mortality (p=0.022 and p=0.026). Patients with an ICP>25 mmHg prior to pentobarbital/hypothermia initiation had an increased risk of mortality (p=0.0455). There was no statistically significant difference in mean ICP after 24 hours after pentobarbital/hypothermia protocol in survivors vs non-survivors. Increased time to reach 33°C was associated with increased mortality (r=0.47, p=0.047); with a 10.5-fold increase in mortality for >7 hours (OR 10.5, p=0.039). Conclusion Prolonged cooling time >7 hours was associated with a 10.5-fold increase in mortality and ICP>25 mmHg prior to initiation of pentobarbital and hypothermia is suggestive of a poor response to treatment. We recommend patients with severe TBI who develop RICH should first undergo a 12 x 15 cm decompressive hemicraniectomy because they have better survival and are more likely to have ICP <25 mmHg as the highest elevation of ICP if the ICP were to become and stay elevated again. Pentobarbital and hypothermia should be initiated if the ICP becomes elevated and sustained above 20 mmHg with a prior decompressive hemicraniectomy and refractory to other medical therapies. However, our data suggests that patients are unlikely to survive if there ICP does not decrease to less than 15mmHg at 8 and 12 hours after pentobarbital/hypothermia and remain less than 20 mmHg within first 48 hours.
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Affiliation(s)
- Jacob E Bernstein
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Hammad Ghanchi
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Samir Kashyap
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Stacey Podkovik
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
| | | | - Raed Sweiss
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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Wu X, Tao Y, Marsons L, Dee P, Yu D, Guan Y, Zhou X. The effectiveness of early prophylactic hypothermia in adult patients with traumatic brain injury: A systematic review and meta-analysis. Aust Crit Care 2021; 34:83-91. [PMID: 32698987 DOI: 10.1016/j.aucc.2020.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 05/04/2020] [Accepted: 05/19/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Previously published systematic reviews have explored the effects of therapeutic hypothermia on adult patients with traumatic brain injury (TBI). However, none explored the effect of early prophylactic hypothermia (within 6 h from injury to hypothermia induction). Animal studies indicated that early prophylactic hypothermia may reduce secondary injury and improve neurological outcomes. This systematic review aimed to investigate the effects of early prophylactic hypothermia on adult TBI regarding mortality, favourable outcomes, and complications. DATA SOURCE We searched electronic databases including Cochrane CENTRAL, PubMed, MEDLINE, CINAHL, EMBASE, Web of Science, OpenGrey, and ClinicalTrials.gov from inception to June 12, 2019. Manual search was conducted for additional information. REVIEW METHODS Only randomised controlled trials were included. The Cochrane Collaboration Risk of Bias Tool was used to assess the quality of included studies. We extracted general demographic characteristics, the initiation timing, methods of cooling, duration, target temperature, rewarming rate, mortality, neurological outcomes, and complications. RESULTS Six studies with a total of 1207 participants were included. Meta-analyses showed no significant difference in mortality and favourable outcomes (risk ratio = 1.11, 95% confidence interval = 0.90-1.37, P = 0.32; risk ratio = 1.03, 95% confidence interval = 0.91-1.16, P = 0.65, respectively). Similar results were found regarding different durations of hypothermia and different rewarming rates. Various complications were reported in the included studies. No statistical difference was found in three studies, while complications were reported to be significantly higher in the hypothermia group in the other three studies. CONCLUSIONS This review does not support the use of early prophylactic hypothermia (within 6 h after injury) as a neurological protection strategy in adult patients with TBI, irrespective of the short term or long term. No significant benefits were found regarding hypothermia with different rewarming rates. Owing to the limited number of studies, more randomised controlled trials with higher quality are required to establish true effects of early hypothermia in adult TBI.
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Gallagher MJ, Hogg FRA, Kearney S, Kopp MA, Blex C, Serdani L, Sherwood O, Schwab JM, Zoumprouli A, Papadopoulos MC, Saadoun S. Effects of local hypothermia-rewarming on physiology, metabolism and inflammation of acutely injured human spinal cord. Sci Rep 2020; 10:8125. [PMID: 32415143 PMCID: PMC7229228 DOI: 10.1038/s41598-020-64944-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/21/2020] [Indexed: 02/06/2023] Open
Abstract
In five patients with acute, severe thoracic traumatic spinal cord injuries (TSCIs), American spinal injuries association Impairment Scale (AIS) grades A-C, we induced cord hypothermia (33 °C) then rewarming (37 °C). A pressure probe and a microdialysis catheter were placed intradurally at the injury site to monitor intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), tissue metabolism and inflammation. Cord hypothermia-rewarming, applied to awake patients, did not cause discomfort or neurological deterioration. Cooling did not affect cord physiology (ISP, SCPP), but markedly altered cord metabolism (increased glucose, lactate, lactate/pyruvate ratio (LPR), glutamate; decreased glycerol) and markedly reduced cord inflammation (reduced IL1β, IL8, MCP, MIP1α, MIP1β). Compared with pre-cooling baseline, rewarming was associated with significantly worse cord physiology (increased ICP, decreased SCPP), cord metabolism (increased lactate, LPR; decreased glucose, glycerol) and cord inflammation (increased IL1β, IL8, IL4, IL10, MCP, MIP1α). The study was terminated because three patients developed delayed wound infections. At 18-months, two patients improved and three stayed the same. We conclude that, after TSCI, hypothermia is potentially beneficial by reducing cord inflammation, though after rewarming these benefits are lost due to increases in cord swelling, ischemia and inflammation. We thus urge caution when using hypothermia-rewarming therapeutically in TSCI.
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Affiliation(s)
- Mathew J Gallagher
- Academic Neurosurgery Unit, Molecular and Clinical Sciences Institute, St. George's, University of London, London, UK
| | - Florence R A Hogg
- Academic Neurosurgery Unit, Molecular and Clinical Sciences Institute, St. George's, University of London, London, UK
| | - Siobhan Kearney
- Academic Neurosurgery Unit, Molecular and Clinical Sciences Institute, St. George's, University of London, London, UK
| | - Marcel A Kopp
- Clinical and Experimental Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Berlin Institute of Health, QUEST-Center for Transforming Biomedical Research, Berlin, Germany
| | - Christian Blex
- Clinical and Experimental Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Leonarda Serdani
- Clinical and Experimental Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Oliver Sherwood
- Academic Neurosurgery Unit, Molecular and Clinical Sciences Institute, St. George's, University of London, London, UK
| | - Jan M Schwab
- Clinical and Experimental Spinal Cord Injury Research (Neuroparaplegiology), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Belford Center for Spinal Cord Injury, Departments of Neurology, Neuroscience and Physical Medicine and Rehabilitation, The Neurological Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, 43210, USA
| | - Argyro Zoumprouli
- Neuro-Anaesthesia and Neuro-Intensive Care Unit, St. George's Hospital, London, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery Unit, Molecular and Clinical Sciences Institute, St. George's, University of London, London, UK
| | - Samira Saadoun
- Academic Neurosurgery Unit, Molecular and Clinical Sciences Institute, St. George's, University of London, London, UK.
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Abstract
We review state-of-the-art monitoring techniques for acute, severe traumatic spinal cord injury (TSCI) to facilitate targeted perfusion of the injured cord rather than applying universal mean arterial pressure targets. Key concepts are discussed such as intraspinal pressure and spinal cord perfusion pressure (SCPP) at the injury site, respectively, analogous to intracranial pressure and cerebral perfusion pressure for traumatic brain injury. The concept of spinal cord autoregulation is introduced and quantified using spinal pressure reactivity index (sPRx), which is analogous to pressure reactivity index for traumatic brain injury. The U-shaped relationship between sPRx and SCPP defines the optimum SCPP as the SCPP that minimizes sPRx (i.e., maximizes autoregulation), and suggests that not only ischemia but also hyperemia at the injury site may be detrimental. The observation that optimum SCPP varies between patients and temporally in each patient supports individualized management. We discuss multimodality monitoring, which revealed strong correlations between SCPP and injury site metabolism (tissue glucose, lactate, pyruvate, glutamate, glycerol), monitored by surface microdialysis. Evidence is presented that the dura is a major, but unappreciated, cause of spinal cord compression after TSCI; we thus propose expansion duroplasty as a novel treatment. Monitoring spinal cord blood flow at the injury site has revealed novel phenomena, e.g., 3 distinct blood flow patterns, local steal, and diastolic ischemia. We conclude that monitoring from the injured spinal cord in the intensive care unit is a safe technique that appears to enable optimized and individualized spinal cord perfusion.
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Affiliation(s)
- Samira Saadoun
- Academic Neurosurgery Unit, St. George's University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery Unit, St. George's University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK.
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Panesar SS, Fernandez-Miranda JC, Kliot M, Ashkan K. Neurosurgery and Manned Spaceflight. Neurosurgery 2020; 86:317-324. [PMID: 30407580 DOI: 10.1093/neuros/nyy531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/07/2018] [Indexed: 12/26/2022] Open
Abstract
There has been a renewed interest in manned spaceflight due to endeavors by private and government agencies. Publicized goals include manned trips to or colonization of Mars. These missions will likely be of long duration, exceeding existing records for human exposure to extra-terrestrial conditions. Participants will be exposed to microgravity, temperature extremes, and radiation, all of which may adversely affect their physiology. Moreover, pathological mechanisms may differ from those of a terrestrial nature. Known central nervous system (CNS) changes occurring in space include rises in intracranial pressure and spinal unloading. Intracranial pressure increases are thought to occur due to cephalad re-distribution of body fluids secondary to microgravity exposure. Spinal unloading in microgravity results in potential degenerative changes to the bony vertebrae, intervertebral discs, and supportive musculature. These phenomena are poorly understood. Trauma is of highest concern due to its potential to seriously incapacitate crewmembers and compromise missions. Traumatic pathology may also be exacerbated in the setting of altered CNS physiology. Though there are no documented instances of CNS pathologies arising in space, existing diagnostic and treatment capabilities will be limited relative to those on Earth. In instances where neurosurgical intervention is required in space, it is not known whether open or endoscopic approaches are feasible. It is obvious that prevention of trauma and CNS pathology should be emphasized. Further research into neurosurgical pathology, its diagnosis, and treatment in space are required should exploratory or colonization missions be attempted.
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Affiliation(s)
| | | | - Michel Kliot
- Department of Neurosurgery, Stanford University, Stanford
| | - Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
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Tan HX, Borgo MPD, Aguilar MI, Forsythe JS, Taylor JM, Crack PJ. The use of bioactive matrices in regenerative therapies for traumatic brain injury. Acta Biomater 2020; 102:1-12. [PMID: 31751809 DOI: 10.1016/j.actbio.2019.11.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/22/2019] [Accepted: 11/13/2019] [Indexed: 01/01/2023]
Abstract
Functional deficits due to neuronal loss are a common theme across multiple neuropathologies, including traumatic brain injury (TBI). Apart from mitigating cell death, another approach to treating brain injuries involves re-establishing the neural circuitry at the lesion site by utilizing exogeneous and/or endogenous stem cells to achieve functional recovery. While there has been limited success, the emergence of new bioactive matrices that promote neural repair introduces new perspectives on the development of regenerative therapies for TBI. This review briefly discusses current development on cell-based therapies and the use of bioactive matrices, hydrogels in particular, when incorporated in regenerative therapies. Desirable characteristics of bioactive matrices that have been shown to augment neural repair in TBI models were identified and further discussed. Understanding the relative outcomes of newly developed biomaterials implanted in vivo can better guide the development of biomaterials as a therapeutic strategy, for biomaterial-based cellular therapies are still in their nascent stages. Nonetheless, the value of bioactive matrices as a treatment for acute brain injuries should be appreciated and further developed. STATEMENT OF SIGNIFICANCE: Cell-based therapies have received attention as an alternative therapeutic strategy to improve clinical outcome post-traumatic brain injury but have achieved limited success. Whilst the incorporation of newly developed biomaterials in regenerative therapies has shown promise in augmenting neural repair, studies have revealed new hurdles which must be overcome to improve their therapeutic efficacy. This review discusses the recent development of cell-based therapies with a specific focus on the use of bioactive matrices in the form of hydrogels, to complement cell transplantation within the injured brain. Moreover, this review consolidates in vivo animal studies that demonstrate relative functional outcome upon the implantation of different biomaterials to highlight their desirable traits to guide their development for regenerative therapies in traumatic brain injury.
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Koren O, Rozner E, Yosefia S, Turgeman Y. Therapeutic hypothermia after out of hospital cardiac arrest improve 1-year survival rate for selective patients. PLoS One 2020; 15:e0226956. [PMID: 31910226 PMCID: PMC6946126 DOI: 10.1371/journal.pone.0226956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/30/2019] [Indexed: 11/30/2022] Open
Abstract
Background Therapeutic Hypothermia (TH) is a standard of care after out-of-hospital cardiac arrest (OHCA). Previous reports failed to prove a significant benefit for survival or neurological outcomes. We examined whether the proper selection of patients would enhance treatment efficacy. Method We conducted a retrospective cohort study. Data was collected from January 2000 and August 2018. Patients were enrolled after OHCA and classified into two groups, patients treated with TH and patients who were not treated with TH. Results A total of 92 patients were included in the study. 57 (63%) patients were in the TH Group and 34 (37%) in the Non-TH group. There was no statistical difference in favorable neurological outcomes between the groups. Patients presenting with ventricular fibrillation had a higher 1-year survival rate from TH, while patients with asystole were found to benefit only if they were younger than 65 years (p < .007, p < .02, respectively). Conclusion Therapeutic Hypothermia patients failed to demonstrate a significant benefit in terms of improved neurological outcomes. Patients treated with TH following ventricular fibrillation experienced the most benefit in terms of 1-year survival, while patients who had suffered from asystole experienced a modest benefit only if they were younger than 65 years of age. Guidelines should address age and primary arrhythmia for proper treatment selection.
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Affiliation(s)
- Ofir Koren
- Heart Institute, Emek Medical Center, Afula, Israel.,Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ehud Rozner
- Heart Institute, Emek Medical Center, Afula, Israel
| | | | - Yoav Turgeman
- Heart Institute, Emek Medical Center, Afula, Israel.,Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Chen H, Wu F, Yang P, Shao J, Chen Q, Zheng R. A meta-analysis of the effects of therapeutic hypothermia in adult patients with traumatic brain injury. Crit Care 2019; 23:396. [PMID: 31806001 PMCID: PMC6896404 DOI: 10.1186/s13054-019-2667-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/12/2019] [Indexed: 11/10/2022] Open
Abstract
Purpose Therapeutic hypothermia management remains controversial in patients with traumatic brain injury. We conducted a meta-analysis to evaluate the risks and benefits of therapeutic hypothermia management in patients with traumatic brain injury. Methods We searched the Web of Science, PubMed, Embase, Cochrane (Central) and Clinical Trials databases from inception to January 17, 2019. Eligible studies were randomised controlled trials that investigated therapeutic hypothermia management versus normothermia management in patients with traumatic brain injury. We collected the individual data of the patients from each included study. Meta-analyses were performed for 6-month mortality, unfavourable functional outcome and pneumonia morbidity. The risk of bias was evaluated using the Cochrane Risk of Bias tool. Results Twenty-three trials involving a total of 2796 patients were included. The randomised controlled trials with a high quality show significantly more mortality in the therapeutic hypothermia group [risk ratio (RR) 1.26, 95% confidence interval (CI) 1.04 to 1.53, p = 0.02]. Lower mortality in the therapeutic hypothermia group occurred when therapeutic hypothermia was received within 24 h (RR 0.83, 95% CI 0.71 to 0.96, p = 0.01), when hypothermia was received for treatment (RR 0.66, 95% CI 0.49 to 0.88, p = 0.006) or when hypothermia was combined with post-craniectomy measures (RR 0.69, 95% CI 0.48 to 1.00, p = 0.05). The risk of unfavourable functional outcome following therapeutic hypothermia management appeared to be significantly reduced (RR 0.78, 95% CI 0.67 to 0.91, p = 0.001). The meta-analysis suggested that there was a significant increase in the risk of pneumonia with therapeutic hypothermia management (RR 1.48, 95% CI 1.11 to 1.97, p = 0.007). Conclusions Our meta-analysis demonstrated that therapeutic hypothermia did not reduce but might increase the mortality rate of patients with traumatic brain injury in some high-quality studies. However, traumatic brain injury patients with elevated intracranial hypertension could benefit from hypothermia in therapeutic management instead of prophylaxis when initiated within 24 h.
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Affiliation(s)
- Hanbing Chen
- Graduate School of Dalian Medical University; Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, No.98 Nantong West Road, Yangzhou, 225001, Jiangsu, China
| | - Fei Wu
- Department of Intensive Care Unit, Affiliated Hospital of Yangzhou University, Clinical Medical College, Yangzhou University, No.368 Hanjiangzhonglu Road, Yangzhou, 225001, Jiangsu, China
| | - Penglei Yang
- Graduate School of Dalian Medical University; Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, No.98 Nantong West Road, Yangzhou, 225001, Jiangsu, China
| | - Jun Shao
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, No.98 Nantong West Road, Yangzhou, 225001, Jiangsu, China
| | - Qihong Chen
- Department of Critical Care Medicine, Jiangdu People's Hospital of Yangzhou, Jiangdu People's Hospital Affiliated to Medical College of Yangzhou University, No 9 Dongfanghong Road of Jiangdu District, Yangzhou, 225001, Jiangsu, China.
| | - Ruiqiang Zheng
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, No.98 Nantong West Road, Yangzhou, 225001, Jiangsu, China
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Abstract
Status epilepticus (SE) is associated with high mortality and morbidity rates, notably in its refractory and super-refractory forms. This narrative review discusses recent data on the potential benefits of targeted temperature management. In studies of patients with cerebral injury due to various factors, therapeutic hypothermia had variable effects on survival and functional outcomes. Sources of this variability may include the underlying etiology, whether hypothermia was used for prophylaxis or treatment, the degree and duration of hypothermia, and the hypothermia application modalities. Data from animal studies strongly suggest benefits from therapeutic hypothermia in SE. In humans, beneficial effects have been described in anecdotal case reports and small case series, but the level of evidence is low. A randomized controlled trial found no evidence that moderate hypothermia (32-34 °C) was neuroprotective in critically ill patients with convulsive SE. Nevertheless, some promising effects were noted, suggesting that therapeutic hypothermia might have a role as an adjuvant to anticonvulsant drug therapy in patients with refractory or super-refractory SE. This article is part of a Special Issue entitled "Status Epilepticus". This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Stéphane Legriel
- Medico-Surgical Intensive Care Department, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150 Le Chesnay Cedex, France; Paris Descartes University, Sorbonne Paris Cité-Medical School, Paris, France; INSERM U970, Paris Cardiovascular Research Center, Paris, France; IctalGroup, France.
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50
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Huang HP, Zhao WJ, Pu J. Effect of mild hypothermia on prognosis of patients with severe traumatic brain injury: A meta-analysis with trial sequential analysis. Aust Crit Care 2019; 33:375-381. [PMID: 31753512 DOI: 10.1016/j.aucc.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/09/2019] [Accepted: 08/29/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Severe traumatic brain injury (sTBI) is a leading cause of death and neurologic disability worldwide. Although numerous previous studies have reported a positive effect of mild hypothermia treatment on sTBI, recent randomised controlled trials have not shown consistent benefits. OBJECTIVE The objective of this study was to explore the effects of mild hypothermia on prognosis in patients with sTBI and provide the best evidence to clinical practice. METHODS The databases PubMed, Embase, the Cochrane Library, ClinicalTrials.gov, and China National Knowledge Infrastructure (CNKI) were systematically searched from their inception to December 31, 2018, to identify relevant randomised controlled trials. Two authors independently reviewed and extracted data from included studies. The outcomes of interest were mortality and favourable neurological outcome. Review Manager, version 5.3, and trial sequential analysis (TSA) (beta = 0.9) were used to evaluate the collected data. RESULTS A total of 15 trials involving 2523 patients with sTBI were included. The pooled results showed that there was no significant statistical difference of mortality between two groups (risk ratio [RR] = 0.94, 95% confidence interval [CI] = 0.77-1.14, P = 0.53), and TSA indicated that the current available evidence was conclusive. However, patients receiving mild hypothermia therapy had better neurological outcome than those receiving normothermia therapy (RR = 1.20, 95% CI = 1.01-1.42, P = 0.04), and TSA indicated that more studies should be conducted to clarify this issue. CONCLUSION Our findings suggest that mild hypothermia can improve long-term neurological recovery for patients with sTBI, but which is not helpful to decrease the mortality. More well-designed rigorous clinical trials are needed to verify these results.
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Affiliation(s)
- Hua-Ping Huang
- Operation Room of Mianyang Central Hospital, Sichuan, China.
| | - Wen-Jun Zhao
- Operation Room of Mianyang Central Hospital, Sichuan, China
| | - Jia Pu
- Nursing Department of Mianyang Central Hospital, Sichuan, China
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