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Schiefecker AJ, Kofler M, Gaasch M, Beer R, Unterberger I, Pfausler B, Broessner G, Lackner P, Rhomberg P, Gizewski E, Hackl WO, Mulino M, Ortler M, Thome C, Schmutzhard E, Helbok R. Brain temperature but not core temperature increases during spreading depolarizations in patients with spontaneous intracerebral hemorrhage. J Cereb Blood Flow Metab 2018; 38:549-558. [PMID: 28436257 PMCID: PMC5851146 DOI: 10.1177/0271678x17703940] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Spreading depolarizations (SDs) are highly active metabolic events, commonly occur in patients with intracerebral hemorrhage (ICH) and may be triggered by fever. We investigated the dynamics of brain-temperature (Tbrain) and core-temperature (Tcore) relative to the occurrence of SDs. Twenty consecutive comatose ICH patients with multimodal electrocorticograpy (ECoG) and Tbrain monitoring of the perihematomal area were prospectively enrolled. Clusters of SDs were defined as ≥2 SDs/h. Generalized estimating equations were used for statistical calculations. Data are presented as median and interquartile range. During 3097 h (173 h [81-223]/patient) of ECoG monitoring, 342 SDs were analyzed of which 51 (15%) occurred in clusters. Baseline Tcore and Tbrain was 37.3℃ (36.9-37.8) and 37.4℃ (36.7-37.9), respectively. Tbrain but not Tcore significantly increased 25 min preceding the onset of SDs by 0.2℃ (0.1-0.2; p < 0.001) and returned to baseline 35 min following SDs. During clusters, Tbrain increased to a higher level (+0.4℃ [0.1-0.4]; p = 0.006) when compared to single SDs. A higher probability (OR = 36.9; CI = 36.8-37.1; p < 0.001) of developing SDs was observed during episodes of Tbrain ≥ 38.0℃ (23% probability), than during Tbrain ≤ 36.6℃ (9% probability). Spreading depolarizations - and in particular clusters of SDs - may increase brain temperature following ICH.
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Affiliation(s)
- Alois J Schiefecker
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Mario Kofler
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Max Gaasch
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Iris Unterberger
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Bettina Pfausler
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Gregor Broessner
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Peter Lackner
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Paul Rhomberg
- 2 Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Elke Gizewski
- 2 Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Werner O Hackl
- 3 Institute of Biomedical Informatics, University for Health Sciences, Medical Informatics and Technology (UMIT), Hall, Austria
| | - Miriam Mulino
- 4 Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Martin Ortler
- 4 Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Claudius Thome
- 4 Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- 1 Department of Neurology, Division of Neurocritical Care, Medical University Innsbruck, Innsbruck, Austria
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Kofler M, Schiefecker AJ, Beer R, Gaasch M, Rhomberg P, Stover J, Pfausler B, Thomé C, Schmutzhard E, Helbok R. Enteral nutrition increases interstitial brain glucose levels in poor-grade subarachnoid hemorrhage patients. J Cereb Blood Flow Metab 2018; 38:518-527. [PMID: 28322077 PMCID: PMC5851142 DOI: 10.1177/0271678x17700434] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Low brain tissue glucose levels after acute brain injury are associated with poor outcome. Whether enteral nutrition (EN) reliably increases cerebral glucose levels remains unclear. In this retrospective analysis of prospectively collected observational data, we investigate the effect of EN on brain metabolism in 17 poor-grade subarachnoid hemorrhage (SAH) patients undergoing cerebral microdialysis (CMD) monitoring. CMD-values were obtained hourly. A nutritional intervention was defined as the clinical routine administration of EN without supplemental parenteral nutrition. Sixty-three interventions were analyzed. The mean amount of EN per intervention was 472.4 ± 10.7 kcal. CMD-glucose levels significantly increased from 1.59 ± 0.13 mmol/l at baseline to a maximum of 2.03 ± 0.2 mmol/l after 5 h (p < 0.001), independently of insulin-treatment, baseline serum glucose, baseline brain metabolic distress (CMD-lactate-to-pyruvate-ratio (LPR) > 40) and the microdialysis probe location. The increase in CMD-glucose was directly dependent on the magnitude of increase of serum glucose levels (p = 0.007). No change in CMD-lactate, CMD-pyruvate, CMD-LPR, or CMD-glutamate (p > 0.4) was observed. Routine EN also increased CMD-glucose even if baseline concentrations were critically low ( < 0.7 mmol/l, neuroglucopenia; p < 0.001). These results may have treatment implications regarding glucose management of poor-grade aneurysmal SAH patients.
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Affiliation(s)
- Mario Kofler
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois J Schiefecker
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Maxime Gaasch
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul Rhomberg
- 2 Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - John Stover
- 3 Fresenius Kabi, Bad Homburg vor der Höhe, Germany
| | - Bettina Pfausler
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- 4 Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Kofler M, Schiefecker A, Beer R, Sohm F, Broessner G, Rhomberg P, Lackner P, Pfausler B, Thomé C, Schmutzhard E, Helbok R. Neuroglucopenia and Metabolic Distress in Two Patients with Viral Meningoencephalitis: A Microdialysis Study. Neurocrit Care 2017; 25:273-81. [PMID: 27112148 PMCID: PMC5043006 DOI: 10.1007/s12028-016-0272-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction Viral encephalitis is an emerging disease requiring intensive care management in severe cases. Underlying pathophysiologic mechanisms are incompletely understood and may be elucidated using invasive multimodal neuromonitoring techniques in humans. Methods Two otherwise healthy patients were admitted to our neurological intensive care unit with altered level of consciousness necessitating mechanical ventilation. Brain imaging and laboratory workup suggested viral encephalitis in both patients. Invasive neuromonitoring was initiated when head computed tomography revealed generalized brain edema, including monitoring of intracranial pressure, brain metabolism (cerebral microdialysis; CMD), brain tissue oxygen tension (in one patient), and cerebral blood flow (in one patient). Results Brain metabolism revealed episodes of severe neuroglucopenia (brain glucose <0.7 mM/l) in both patients, which were not attributable to decreased cerebral perfusion or hypoglycemia. CMD-glucose levels changed depending on variations in insulin therapy, nutrition, and systemic glucose administration. The metabolic profile, moreover, showed a pattern of non-ischemic metabolic distress suggestive for mitochondrial dysfunction. Both patients had a prolonged but favorable clinical course and improved to a modified Rankin Scale Score of 1 and 0 three months later. Conclusion Invasive multimodal neuromonitoring is feasible in poor-grade patients with viral meningoencephalitis and may help understand pathophysiologic mechanisms associated with secondary brain injury. The detection of neuroglucopenia and mitochondrial dysfunction may serve as treatment targets in the future.
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Affiliation(s)
- Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alois Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Florian Sohm
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gregor Broessner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Paul Rhomberg
- Department of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Peter Lackner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Erich Schmutzhard
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Lyden P, Mayer SA, Lurie K, Schmutzhard E. Temperature Management in Neurological and Neurosurgical Intensive Care Unit. Ther Hypothermia Temp Manag 2017; 7:70-74. [PMID: 28586295 DOI: 10.1089/ther.2017.29029.pjl] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Patrick Lyden
- 1 Department of Neurology, Cedars-Sinai Medical Center , Los Angeles, California
| | - Stephan A Mayer
- 2 Department of Neurology, Henry Ford Health System , Detroit, Michigan
| | - Keith Lurie
- 3 Department of Internal and Emergency Medicine, University of Minnesota , Minneapolis, Minnesota.,4 St. Cloud Hospital , St. Cloud, Minnesota
| | - Erich Schmutzhard
- 5 Department of Neurology and Neurocritical Care Unit, Medical University Innsbruck , Innsbruck, Austria
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Dai HB, Xu MM, Lv J, Ji XJ, Zhu SH, Ma RM, Miao XL, Duan ML. Mild Hypothermia Combined with Hydrogen Sulfide Treatment During Resuscitation Reduces Hippocampal Neuron Apoptosis Via NR2A, NR2B, and PI3K-Akt Signaling in a Rat Model of Cerebral Ischemia-Reperfusion Injury. Mol Neurobiol 2015; 53:4865-73. [DOI: 10.1007/s12035-015-9391-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 08/11/2015] [Indexed: 10/23/2022]
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