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Balog BM, Sonti A, Zigmond RE. Neutrophil biology in injuries and diseases of the central and peripheral nervous systems. Prog Neurobiol 2023; 228:102488. [PMID: 37355220 PMCID: PMC10528432 DOI: 10.1016/j.pneurobio.2023.102488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 05/24/2023] [Accepted: 06/16/2023] [Indexed: 06/26/2023]
Abstract
The role of inflammation in nervous system injury and disease is attracting increased attention. Much of that research has focused on microglia in the central nervous system (CNS) and macrophages in the peripheral nervous system (PNS). Much less attention has been paid to the roles played by neutrophils. Neutrophils are part of the granulocyte subtype of myeloid cells. These cells, like macrophages, originate and differentiate in the bone marrow from which they enter the circulation. After tissue damage or infection, neutrophils are the first immune cells to infiltrate into tissues and are directed there by specific chemokines, which act on chemokine receptors on neutrophils. We have reviewed here the basic biology of these cells, including their differentiation, the types of granules they contain, the chemokines that act on them, the subpopulations of neutrophils that exist, and their functions. We also discuss tools available for identification and further study of neutrophils. We then turn to a review of what is known about the role of neutrophils in CNS and PNS diseases and injury, including stroke, Alzheimer's disease, multiple sclerosis, amyotrophic lateral sclerosis, spinal cord and traumatic brain injuries, CNS and PNS axon regeneration, and neuropathic pain. While in the past studies have focused on neutrophils deleterious effects, we will highlight new findings about their benefits. Studies on their actions should lead to identification of ways to modify neutrophil effects to improve health.
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Affiliation(s)
- Brian M Balog
- Department of Neurosciences, School of Medicine, Case Western Reserve University, Cleveland, OH 44106-4975, USA
| | - Anisha Sonti
- Department of Neurosciences, School of Medicine, Case Western Reserve University, Cleveland, OH 44106-4975, USA
| | - Richard E Zigmond
- Department of Neurosciences, School of Medicine, Case Western Reserve University, Cleveland, OH 44106-4975, USA.
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2
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Patient-Centered Approaches to Cognitive Assessment in Acute TBI. Curr Neurol Neurosci Rep 2023; 23:59-66. [PMID: 36705882 DOI: 10.1007/s11910-023-01253-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 01/28/2023]
Abstract
PURPOSE OF THE REVIEW The purpose of this article is to help clinicians understand how underlying pathophysiologies and medical comorbidities associated with acute traumatic brain injury (TBI) can impact assessment of cognition during the initial stages of recovery. Clinicians can use information from this article to develop assessment plans rooted in patient-centered care. RECENT FINDINGS The authors conducted a review of the literature related to the assessment of cognition in acute TBI, focusing on pathophysiology, medical comorbidities, and assessment approaches. Results indicated that TBI pathophysiologies associated with white and gray matter changes make many patients vulnerable to cognitive deficits. Acute comorbidities such as psychological and pain status influence cognitive abilities as well. The current approaches to cognitive assessment can be limited in many ways, though by using the patient's neuropathological profile, noted comorbidities, and other patient specific factors, clinicians can potentially improve the effectiveness of assessment.
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3
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Reeder EL, O'Connell CJ, Collins SM, Traubert OD, Norman SV, Cáceres RA, Sah R, Smith DW, Robson MJ. Increased Carbon Dioxide Respiration Prevents the Effects of Acceleration/Deceleration Elicited Mild Traumatic Brain Injury. Neuroscience 2023; 509:20-35. [PMID: 36332692 DOI: 10.1016/j.neuroscience.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 11/07/2022]
Abstract
Acceleration/deceleration forces are a common component of various causes of mild traumatic brain injury (mTBI) and result in strain and shear forces on brain tissue. A small quantifiable volume dubbed the compensatory reserve volume (CRV) permits energy transmission to brain tissue during acceleration/deceleration events. The CRV is principally regulated by cerebral blood flow (CBF) and CBF is primarily determined by the concentration of inspired carbon dioxide (CO2). We hypothesized that experimental hypercapnia (i.e. increased inspired concentration of CO2) may act to prevent and mitigate the actions of acceleration/deceleration-induced TBI. To determine these effects C57Bl/6 mice underwent experimental hypercapnia whereby they were exposed to medical-grade atmospheric air or 5% CO2 immediately prior to an acceleration/deceleration-induced mTBI paradigm. mTBI results in significant increases in righting reflex time (RRT), reductions in core body temperature, and reductions in general locomotor activity-three hours post injury (hpi). Experimental hypercapnia immediately preceding mTBI was found to prevent mTBI-induced increases in RRT and reductions in core body temperature and general locomotor activity. Ribonucleic acid (RNA) sequencing conducted four hpi revealed that CO2 exposure prevented mTBI-induced transcriptional alterations of several targets related to oxidative stress, immune, and inflammatory signaling. Quantitative real-time PCR analysis confirmed the prevention of mTBI-induced increases in mitogen-activated protein kinase kinase kinase 6 and metallothionein-2. These initial proof of concept studies reveal that increases in inspired CO2 mitigate the detrimental contributions of acceleration/deceleration events in mTBI and may feasibly be translated in the future to humans using a medical device seeking to prevent mTBI among high-risk groups.
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Affiliation(s)
- Evan L Reeder
- University of Cincinnati James L. Winkle College of Pharmacy, Division of Pharmaceutical Sciences, Cincinnati, OH 45267, USA
| | - Christopher J O'Connell
- University of Cincinnati James L. Winkle College of Pharmacy, Division of Pharmaceutical Sciences, Cincinnati, OH 45267, USA
| | - Sean M Collins
- University of Cincinnati James L. Winkle College of Pharmacy, Division of Pharmaceutical Sciences, Cincinnati, OH 45267, USA
| | - Owen D Traubert
- University of Cincinnati College of Arts and Sciences, Department of Biological Sciences, Cincinnati, OH 45221, USA
| | - Sophia V Norman
- University of Cincinnati College of Arts and Sciences, Department of Biological Sciences, Cincinnati, OH 45221, USA
| | - Román A Cáceres
- University of Cincinnati College of Medicine, Department of Cancer and Cell Biology Cincinnati, OH 45267, USA
| | - Renu Sah
- University of Cincinnati College of Medicine, Department of Pharmacology and Systems Physiology, Cincinnati, OH 45267, USA
| | | | - Matthew J Robson
- University of Cincinnati James L. Winkle College of Pharmacy, Division of Pharmaceutical Sciences, Cincinnati, OH 45267, USA.
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4
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Mishra RK, Galwankar S, Gerber J, Jain A, Yunus M, Cincu R, Moscote-Salazar LR, Quiñones-Ossa GA, Agrawal A. Neutrophil-lymphocyte ratio as a predictor of outcome following traumatic brain injury: Systematic review and meta-analysis. J Neurosci Rural Pract 2022; 13:618-635. [PMID: 36743744 PMCID: PMC9893942 DOI: 10.25259/jnrp-2022-4-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022] Open
Abstract
Objectives The neutrophil-to-lymphocyte ratio (NLR) is a simple and routinely performed hematological parameter; however, studies on NLR as a prognostic tool in traumatic brain injury (TBI) have yielded contradictory results. Materials and Methods This systematic review and meta-analysis was conducted according to the Preferred Reporting Items in the Systematic Review and Meta-Analysis guidelines 2020. Electronic databases of PubMed, Cochrane Library, Web of Science, and Scopus were searched. The population consisted of TBI patients in the absence of moderate and severe extracranial injury. Day 1 NLR was taken for the analysis. The outcomes evaluated were mortality and the Glasgow Outcome Scale (GOS). No restrictions were placed on the language, year and country of publication, and duration of follow-up. Animal studies were excluded from the study. Studies, where inadequate data were reported for the outcomes, were included in the qualitative synthesis but excluded from the quantitative synthesis. Study quality was evaluated using the Newcastle-Ottawa scale (NOS). The risk of bias was estimated using the Cochrane RoBANS risk of bias tool. Results We retrieved 7213 citations using the search strategy and 2097 citations were excluded based on the screening of the title and abstract. Full text was retrieved for 40 articles and subjected to the eligibility criteria, of which 28 were excluded from the study. Twelve studies were eligible for the synthesis of the systematic review while seven studies qualified for the meta-analysis. The median score of the articles was 8/9 as per NOS. The risk of selection bias was low in all the studies while the risk of detection bias was high in all except one study. Ten studies were conducted on adult patients, while two studies reported pediatric TBI. A meta-analysis for GOS showed that high NLR predicted unfavorable outcomes at ≥6 months with a mean difference of -5.18 (95% confidence interval: -10.04, -0.32); P = 0.04; heterogeneity (I2), being 98%. The effect estimates for NLR and mortality were a mean difference of -3.22 (95% confidence interval: -7.12, 0.68), P = 0.11, and an I2 of 85%. Meta-analysis for Area under the curve (AUC) receiver operating characteristic of the included studies showed good predictive power of NLR in predicting outcomes following TBI with AUC 0.706 (95% CI: 0.582-0.829). Conclusion A higher admission NLR predicts an increased mortality risk and unfavorable outcomes following TBI. However, future research will likely address the existing gaps.
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Affiliation(s)
- Rakesh Kumar Mishra
- Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Sagar Galwankar
- Department of Global Health, University of South Florida, Tampa, Florida, United States
| | - Joel Gerber
- Department of Emergency Medicine, University of South Florida, Tampa, Florida, United States
| | - Anuj Jain
- Department of Anesthesia, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Md. Yunus
- Department of Trauma and Emergency Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Rafael Cincu
- Department of Neurosurgery, Valencia General Hospital, Valencia, Spain
| | | | | | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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5
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Beri A, Pisulkar SG, Bansod AV, Dahihandekar C. Paradigm Shift in Materials for Skull Reconstruction Facilitated by Science and Technological Integration. Cureus 2022; 14:e28731. [PMID: 36204019 PMCID: PMC9528855 DOI: 10.7759/cureus.28731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/03/2022] [Indexed: 12/04/2022] Open
Abstract
The surgical repair of a bone deficiency in the skull caused by a prior procedure or accident is known as cranioplasty. There are various types of cranioplasties, but the majority entail raising the scalp and reshaping the skull using either the original piece of bone from the skull or a specially molded graft created from Titanium (plate or mesh), artificial bone in place of, a stable biomaterial (prefabricated customized implant to match the exact contour and shape of the skull). Cranioplasty, one of the oldest surgical treatments for cranial abnormalities, has undergone several changes throughout the years to discover the best material to improve patient outcomes. Various materials have been utilized in cranioplasty throughout history. As biomedical technology progresses, surgeons will have access to new materials. There is still no agreement on the optimum material, and research into biologic and nonbiologic alternatives is ongoing in the hopes of finding the finest reconstruction material. The materials and techniques used in cranioplasty are covered in this article.
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Huang HK, Liu CY, Tzeng IS, Hsieh TH, Chang CY, Hou YT, Lin PC, Chen YL, Chien DS, Yiang GT, Wu MY. The association between blood pressure and in-hospital mortality in traumatic brain injury: Evidence from a 10-year analysis in a single-center. Am J Emerg Med 2022; 58:265-274. [PMID: 35752084 DOI: 10.1016/j.ajem.2022.05.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022] Open
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7
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Wang HL, Chen JW, Yang SH, Lo YC, Pan HC, Liang YW, Wang CF, Yang Y, Kuo YT, Lin YC, Chou CY, Lin SH, Chen YY. Multimodal Optical Imaging to Investigate Spatiotemporal Changes in Cerebrovascular Function in AUDA Treatment of Acute Ischemic Stroke. Front Cell Neurosci 2021; 15:655305. [PMID: 34149359 PMCID: PMC8209306 DOI: 10.3389/fncel.2021.655305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/10/2021] [Indexed: 01/03/2023] Open
Abstract
Administration of 12-(3-adamantan-1-yl-ureido)-dodecanoic acid (AUDA) has been demonstrated to alleviate infarction following ischemic stroke. Reportedly, the main effect of AUDA is exerting anti-inflammation and neovascularization via the inhibition of soluble epoxide hydrolase. However, the major contribution of this anti-inflammation and neovascularization effect in the acute phase of stroke is not completely elucidated. To investigate the neuroprotective effects of AUDA in acute ischemic stroke, we combined laser speckle contrast imaging and optical intrinsic signal imaging techniques with the implantation of a lab-designed cranial window. Forepaw stimulation was applied to assess the functional changes via measuring cerebral metabolic rate of oxygen (CMRO2) that accompany neural activity. The rats that received AUDA in the acute phase of photothrombotic ischemia stroke showed a 30.5 ± 8.1% reduction in the ischemic core, 42.3 ± 15.1% reduction in the ischemic penumbra (p < 0.05), and 42.1 ± 4.6% increase of CMRO2 in response to forepaw stimulation at post-stroke day 1 (p < 0.05) compared with the control group (N = 10 for each group). Moreover, at post-stroke day 3, increased functional vascular density was observed in AUDA-treated rats (35.9 ± 1.9% higher than that in the control group, p < 0.05). At post-stroke day 7, a 105.4% ± 16.4% increase of astrocytes (p < 0.01), 30.0 ± 10.9% increase of neurons (p < 0.01), and 65.5 ± 15.0% decrease of microglia (p < 0.01) were observed in the penumbra region in AUDA-treated rats (N = 5 for each group). These results suggested that AUDA affects the anti-inflammation at the beginning of ischemic injury and restores neuronal metabolic rate of O2 and tissue viability. The neovascularization triggered by AUDA restored CBF and may contribute to ischemic infarction reduction at post-stroke day 3. Moreover, for long-term neuroprotection, astrocytes in the penumbra region may play an important role in protecting neurons from apoptotic injury.
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Affiliation(s)
- Han-Lin Wang
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jia-Wei Chen
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Hung Yang
- Department of Mechanical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Chun Lo
- The Ph.D. Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
| | - Han-Chi Pan
- National Laboratory Animal Center, Taipei, Taiwan
| | - Yao-Wen Liang
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Fu Wang
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi Yang
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yun-Ting Kuo
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Chen Lin
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin-Yu Chou
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sheng-Huang Lin
- Department of Neurology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.,Department of Neurology, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - You-Yin Chen
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan.,The Ph.D. Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
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8
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Olsen A, Babikian T, Bigler ED, Caeyenberghs K, Conde V, Dams-O'Connor K, Dobryakova E, Genova H, Grafman J, Håberg AK, Heggland I, Hellstrøm T, Hodges CB, Irimia A, Jha RM, Johnson PK, Koliatsos VE, Levin H, Li LM, Lindsey HM, Livny A, Løvstad M, Medaglia J, Menon DK, Mondello S, Monti MM, Newcombe VFJ, Petroni A, Ponsford J, Sharp D, Spitz G, Westlye LT, Thompson PM, Dennis EL, Tate DF, Wilde EA, Hillary FG. Toward a global and reproducible science for brain imaging in neurotrauma: the ENIGMA adult moderate/severe traumatic brain injury working group. Brain Imaging Behav 2021; 15:526-554. [PMID: 32797398 PMCID: PMC8032647 DOI: 10.1007/s11682-020-00313-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The global burden of mortality and morbidity caused by traumatic brain injury (TBI) is significant, and the heterogeneity of TBI patients and the relatively small sample sizes of most current neuroimaging studies is a major challenge for scientific advances and clinical translation. The ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Adult moderate/severe TBI (AMS-TBI) working group aims to be a driving force for new discoveries in AMS-TBI by providing researchers world-wide with an effective framework and platform for large-scale cross-border collaboration and data sharing. Based on the principles of transparency, rigor, reproducibility and collaboration, we will facilitate the development and dissemination of multiscale and big data analysis pipelines for harmonized analyses in AMS-TBI using structural and functional neuroimaging in combination with non-imaging biomarkers, genetics, as well as clinical and behavioral measures. Ultimately, we will offer investigators an unprecedented opportunity to test important hypotheses about recovery and morbidity in AMS-TBI by taking advantage of our robust methods for large-scale neuroimaging data analysis. In this consensus statement we outline the working group's short-term, intermediate, and long-term goals.
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Affiliation(s)
- Alexander Olsen
- Department of Psychology, Norwegian University of Science and Technology, 7491, Trondheim, Norway.
- Department of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Talin Babikian
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA, USA
| | - Erin D Bigler
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, UT, USA
| | - Karen Caeyenberghs
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Burwood, Australia
| | - Virginia Conde
- Department of Psychology, Norwegian University of Science and Technology, 7491, Trondheim, Norway
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ekaterina Dobryakova
- Center for Traumatic Brain Injury, Kessler Foundation, East Hanover, NJ, USA
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Helen Genova
- Center for Traumatic Brain Injury, Kessler Foundation, East Hanover, NJ, USA
| | - Jordan Grafman
- Cognitive Neuroscience Laboratory, Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Medicine & Rehabilitation, Neurology, Department of Psychiatry & Department of Psychology, Cognitive Neurology and Alzheimer's, Center, Feinberg School of Medicine, Weinberg, Chicago, IL, USA
| | - Asta K Håberg
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Radiology and Nuclear Medicine, St. Olavs Hopsital, Trondheim University Hospital, Trondheim, Norway
| | - Ingrid Heggland
- Section for Collections and Digital Services, NTNU University Library, Norwegian University of Science and Technology, Trondheim, Norway
| | - Torgeir Hellstrøm
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Cooper B Hodges
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Psychology, Brigham Young University, Provo, UT, USA
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Andrei Irimia
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
- Department of Biomedical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - Ruchira M Jha
- Departments of Critical Care Medicine, Neurology, Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, Pittsburgh, PA, USA
| | - Paula K Johnson
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- Neuroscience Center, Brigham Young University, Provo, UT, USA
| | - Vassilis E Koliatsos
- Departments of Pathology(Neuropathology), Neurology, and Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Neuropsychiatry Program, Sheppard and Enoch Pratt Hospital, Baltimore, MD, USA
| | - Harvey Levin
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Lucia M Li
- C3NL, Imperial College London, London, UK
- UK DRI Centre for Health Care and Technology, Imperial College London, London, UK
| | - Hannah M Lindsey
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Psychology, Brigham Young University, Provo, UT, USA
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Abigail Livny
- Department of Diagnostic Imaging, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
- Joseph Sagol Neuroscience Center, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
| | - Marianne Løvstad
- Sunnaas Rehabilitation Hospital, Nesodden, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
| | - John Medaglia
- Department of Psychology, Drexel University, Philadelphia, PA, USA
- Department of Neurology, Drexel University, Philadelphia, PA, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Martin M Monti
- Department of Psychology, University of California Los Angeles, Los Angeles, CA, USA
- Department of Neurosurgery, Brain Injury Research Center (BIRC), UCLA, Los Angeles, CA, USA
| | | | - Agustin Petroni
- Department of Psychology, Norwegian University of Science and Technology, 7491, Trondheim, Norway
- Department of Computer Science, Faculty of Exact & Natural Sciences, University of Buenos Aires, Buenos Aires, Argentina
- National Scientific & Technical Research Council, Institute of Research in Computer Science, Buenos Aires, Argentina
| | - Jennie Ponsford
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
- Monash Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
| | - David Sharp
- Department of Brain Sciences, Imperial College London, London, UK
- Care Research & Technology Centre, UK Dementia Research Institute, London, UK
| | - Gershon Spitz
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Lars T Westlye
- Department of Psychology, University of Oslo, Oslo, Norway
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Paul M Thompson
- Imaging Genetics Center, Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of USC, Marina del Rey, CA, USA
- Departments of Neurology, Pediatrics, Psychiatry, Radiology, Engineering, and Ophthalmology, USC, Los Angeles, CA, USA
| | - Emily L Dennis
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- Imaging Genetics Center, Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of USC, Marina del Rey, CA, USA
| | - David F Tate
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Elisabeth A Wilde
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Frank G Hillary
- Department of Neurology, Hershey Medical Center, State College, PA, USA.
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Takahashi CE, Virmani D, Chung DY, Ong C, Cervantes-Arslanian AM. Blunt and Penetrating Severe Traumatic Brain Injury. Neurol Clin 2021; 39:443-469. [PMID: 33896528 DOI: 10.1016/j.ncl.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.
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Affiliation(s)
- Courtney E Takahashi
- Department of Neurology, Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA.
| | - Deepti Virmani
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - David Y Chung
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA; Division of Neurocritical Care, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; Neurovascular Research Unit, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Charlene Ong
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - Anna M Cervantes-Arslanian
- Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
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10
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Launey Y, Fryer TD, Hong YT, Steiner LA, Nortje J, Veenith TV, Hutchinson PJ, Ercole A, Gupta AK, Aigbirhio FI, Pickard JD, Coles JP, Menon DK. Spatial and Temporal Pattern of Ischemia and Abnormal Vascular Function Following Traumatic Brain Injury. JAMA Neurol 2021; 77:339-349. [PMID: 31710336 PMCID: PMC6865302 DOI: 10.1001/jamaneurol.2019.3854] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Question How does 15oxygen positron emission tomography characterization of cerebral physiology after traumatic brain injury inform clinical practice? Findings In this single-center observational cohort study of 68 patients and 27 control participants, early ischemia was common in patients, but hyperemia coexisted in different brain regions. Cerebral blood volume was consistently increased, despite low cerebral blood flow. Meaning Per this analysis, pathophysiologic heterogeneity indicates that bedside physiological monitoring with devices that measure global (jugular venous saturation) or focal (tissue oximetry) brain oxygenation should be interpreted with caution. Importance Ischemia is an important pathophysiological mechanism after traumatic brain injury (TBI), but its incidence and spatiotemporal patterns are poorly characterized. Objective To comprehensively characterize the spatiotemporal changes in cerebral physiology after TBI. Design, Setting, and Participants This single-center cohort study uses 15oxygen positron emission tomography data obtained in a neurosciences critical care unit from February 1998 through July 2014 and analyzed from April 2018 through August 2019. Patients with TBI requiring intracranial pressure monitoring and control participants were recruited. Exposures Cerebral blood flow (CBF), cerebral blood volume (CBV), cerebral oxygen metabolism (CMRO2), and oxygen extraction fraction. Main Outcomes and Measures Ratios (CBF/CMRO2 and CBF/CBV) were calculated. Ischemic brain volume was compared with jugular venous saturation and brain tissue oximetry. Results A total of 68 patients with TBI and 27 control participants were recruited. Results from 1 patient with TBI and 7 health volunteers were excluded. Sixty-eight patients with TBI (13 female [19%]; median [interquartile range (IQR)] age, 29 [22-47] years) underwent 90 studies at early (day 1 [n = 17]), intermediate (days 2-5 [n = 54]), and late points (days 6-10 [n = 19]) and were compared with 20 control participants (5 female [25%]; median [IQR] age, 43 [31-47] years). The global CBF and CMRO2 findings for patients with TBI were less than the ranges for control participants at all stages (median [IQR]: CBF, 26 [22-30] mL/100 mL/min vs 38 [29-49] mL/100 mL/min; P < .001; CMRO2, 62 [55-71] μmol/100 mL/min vs 131 [101-167] μmol/100 mL/min; P < .001). Early CBF reductions showed a trend of high oxygen extraction fraction (suggesting classical ischemia), but this was inconsistent at later phases. Ischemic brain volume was elevated even in the absence of intracranial hypertension and highest at less than 24 hours after TBI (median [IQR], 36 [10-82] mL), but many patients showed later increases (median [IQR] 6-10 days after TBI, 24 [4-42] mL; across all points: patients, 10 [5-39] mL vs control participants, 1 [0-3] mL; P < 001). Ischemic brain volume was a poor indicator of jugular venous saturation and brain tissue oximetry. Patients’ CBF/CMRO2 ratio was higher than controls (median [IQR], 0.42 [0.35-0.49] vs 0.3 [0.28-0.33]; P < .001) and their CBF/CBV ratio lower (median [IQR], 7.1 [6.4-7.9] vs 12.3 [11.0-14.0]; P < .001), suggesting abnormal flow-metabolism coupling and vascular reactivity. Patients’ CBV was higher than controls (median [IQR], 3.7 [3.4-4.1] mL/100 mL vs 3.0 [2.7-3.6] mL/100 mL; P < .001); although values were lower in patients with intracranial hypertension, these were still greater than controls (median [IQR], 3.7 [3.2-4.0] vs 3.0 [2.7-3.6] mL/100 mL; P = .002), despite more profound reductions in partial pressure of carbon dioxide (median [IQR], 4.3 [4.1-4.6] kPa vs 4.7 [4.3-4.9] kPa; P = .001). Conclusions and Relevance Ischemia is common early, detectable up to 10 days after TBI, possible without intracranial hypertension, and inconsistently detected by jugular or brain tissue oximetry. There is substantial between-patient and within-patient pathophysiological heterogeneity; ischemia and hyperemia commonly coexist, possibly reflecting abnormalities in flow-metabolism coupling. Increased CBV may contribute to intracranial hypertension but can coexist with abnormal CBF/CBV ratios. These results emphasize the need to consider cerebrovascular pathophysiological complexity when managing patients with TBI.
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Affiliation(s)
- Yoann Launey
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Anaesthesia and Critical Care Medicine, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Tim D Fryer
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Young T Hong
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Luzius A Steiner
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland.,Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Jurgens Nortje
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Anaesthesia, Norfolk and Norwich University Hospitals National Health Service Foundation Trust, Norwich, United Kingdom
| | - Tonny V Veenith
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Birmingham Acute Care Research Group, Department of Critical Care Medicine, Queen Elizabeth Hospital, University of Birmingham, Birmingham, United Kingdom
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Arun K Gupta
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Franklin I Aigbirhio
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - John D Pickard
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Jonathan P Coles
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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11
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Gaitanidis A, Breen KA, Maurer LR, Saillant NN, Kaafarani HMA, Velmahos GC, Mendoza AE. Systolic Blood Pressure <110 mm Hg as a Threshold of Hypotension in Patients with Isolated Traumatic Brain Injuries. J Neurotrauma 2020; 38:879-885. [PMID: 33107386 DOI: 10.1089/neu.2020.7358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Hypotension is a known risk factor for poor neurologic outcomes after traumatic brain injury (TBI). Current guidelines suggest that higher systolic blood pressure (SBP) thresholds likely confer a mortality benefit. However, there is no consensus on the ideal perfusion pressure among different age groups (i.e., recommended SBP ≥100 mm Hg for patients age 50-69 years; ≥ 110 mm Hg for all other adults). We hypothesize that admission SBP ≥110 mm Hg will be associated with improved outcomes regardless of age group. A retrospective database review of the 2010-2016 Trauma Quality Improvement Program database was performed for adults (≥ 18 years) with isolated moderate-to-severe TBIs (head Abbreviated Injury Scale [AIS] ≥3; all other AIS <3). Sub-analyses were performed after dividing patients by SBP and age; comparison groups were matched with propensity score matching. Primary outcomes were early (6 h, 12 h, and 1 day) and overall in-hospital mortality. Overall, 154,725 patients met the inclusion criteria (mean age 62.8 ± 19.8 years, 89,431 [57.8%] males, Injury Severity Score13.9 ± 6.8). Multi-variate logistic regression showed that the risk of in-hospital mortality decreased with increasing SBP, plateauing at 110 mm Hg. Among patients of all ages, SBP ≥110 mm Hg was associated with improved mortality (SBP 110-129 vs. 90-109 mm Hg: 12 h 0.4% vs. 0.8%, p = 0.001; 1 day 0.8% vs. 1.4%, p = 0.004; overall 3.2% vs. 4.9%, p < 0.001). Among patients age 50-69 years, SBP ≥110 mm Hg was associated with improved mortality (SBP 110-119 vs. 100-109 mm Hg: 12 h 0.3% vs. 0.9%, p = 0.018; 1 day 0.5% vs. 1.5%, p = 0.007; overall 2.7% vs. 4.3%, p = 0.015). In conclusion, SBP ≥110 mm Hg is associated with lower in-hospital mortality in adult patients with isolated TBIs, including patients age 50-69 years. SBP <110 mm Hg should be used to define hypotension in adult patients of all ages.
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Affiliation(s)
- Apostolos Gaitanidis
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry A Breen
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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12
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Melatonin prevents post-traumatic ischemic damage in rats. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.816697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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13
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Wang Y, Wang G, Xu D, Jiang B, Ge M, Wu L, Yang C, Mu N, Wang S, Chang C, Chen T, Feng H, Yao J. Terahertz spectroscopic diagnosis of early blast-induced traumatic brain injury in rats. BIOMEDICAL OPTICS EXPRESS 2020; 11:4085-4098. [PMID: 32923030 PMCID: PMC7449730 DOI: 10.1364/boe.395432] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/10/2020] [Accepted: 06/26/2020] [Indexed: 05/23/2023]
Abstract
The early diagnosis of blast-induced traumatic brain injury (bTBI) is of great clinical significance for prognostication and treatment. Here, we report a new strategy for early bTBI diagnosis through serum and cerebrospinal fluid (CSF) based on terahertz time-domain spectroscopy (THz-TDS). The spectral differences of serum and CSF for different degrees of experimental bTBI in rats have been demonstrated in the early period. In addition, the THz spectra of total protein in the hypothalamus and hippocampus were investigated at different time points after blast exposure, which both showed clear differences with time increasing compared with that in the normal brain. This might help to explain the neurological symptoms caused by bTBI. Moreover, based on the THz absorption spectra of serum and CSF, the principal component analysis and machine learning algorithms were performed to automatically identify the degree of bTBI. The highest diagnostic accuracy was up to 95.5%. It is suggested that this method has potential as an alternative method for high-sensitive, rapid, label-free, economical and early diagnosis of bTBI.
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Affiliation(s)
- Yuye Wang
- Institute of Laser and Optoelectronics, School of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China
- Key Laboratory of Optoelectronics Information Technology (Ministry of Education), Tianjin University, Tianjin 300072, China
| | - Guoqiang Wang
- Institute of Laser and Optoelectronics, School of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China
- Key Laboratory of Optoelectronics Information Technology (Ministry of Education), Tianjin University, Tianjin 300072, China
| | - Degang Xu
- Institute of Laser and Optoelectronics, School of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China
- Key Laboratory of Optoelectronics Information Technology (Ministry of Education), Tianjin University, Tianjin 300072, China
| | - Bozhou Jiang
- Institute of Laser and Optoelectronics, School of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China
- Key Laboratory of Optoelectronics Information Technology (Ministry of Education), Tianjin University, Tianjin 300072, China
| | - Meilan Ge
- Institute of Laser and Optoelectronics, School of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China
- Key Laboratory of Optoelectronics Information Technology (Ministry of Education), Tianjin University, Tianjin 300072, China
| | - Limin Wu
- Institute of Laser and Optoelectronics, School of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China
- Key Laboratory of Optoelectronics Information Technology (Ministry of Education), Tianjin University, Tianjin 300072, China
| | - Chuanyan Yang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Ning Mu
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Shi Wang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Chao Chang
- Innovation Laboratory of Terahertz Biophysics, National Innovation Institute of Defense Technology, Beijing, 100071, China
| | - Tunan Chen
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Hua Feng
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Jianquan Yao
- Institute of Laser and Optoelectronics, School of Precision Instruments and Optoelectronics Engineering, Tianjin University, Tianjin 300072, China
- Key Laboratory of Optoelectronics Information Technology (Ministry of Education), Tianjin University, Tianjin 300072, China
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14
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Wettervik TS, Engquist H, Howells T, Lenell S, Rostami E, Hillered L, Enblad P, Lewén A. Arterial Oxygenation in Traumatic Brain Injury-Relation to Cerebral Energy Metabolism, Autoregulation, and Clinical Outcome. J Intensive Care Med 2020; 36:1075-1083. [PMID: 32715850 PMCID: PMC8343201 DOI: 10.1177/0885066620944097] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Ischemic and hypoxic secondary brain insults are common and detrimental in traumatic brain injury (TBI). Treatment aims to maintain an adequate cerebral blood flow with sufficient arterial oxygen content. It has been suggested that arterial hyperoxia may be beneficial to the injured brain to compensate for cerebral ischemia, overcome diffusion barriers, and improve mitochondrial function. In this study, we investigated the relation between arterial oxygen levels and cerebral energy metabolism, pressure autoregulation, and clinical outcome. Methods: This retrospective study was based on 115 patients with severe TBI treated in the neurointensive care unit, Uppsala university hospital, Sweden, 2008 to 2018. Data from cerebral microdialysis (MD), arterial blood gases, hemodynamics, and intracranial pressure were analyzed the first 10 days post-injury. The first day post-injury was studied in particular. Results: Arterial oxygen levels were higher and with greater variability on the first day post-injury, whereas it was more stable the following 9 days. Normal-to-high mean pO2 was significantly associated with better pressure autoregulation/lower pressure reactivity index (P = .02) and lower cerebral MD-lactate (P = .04) on day 1. Patients with limited cerebral energy metabolic substrate supply (MD-pyruvate below 120 µM) and metabolic disturbances with MD-lactate-/pyruvate ratio (LPR) above 25 had significantly lower arterial oxygen levels than those with limited MD-pyruvate supply and normal MD-LPR (P = .001) this day. Arterial oxygenation was not associated with clinical outcome. Conclusions: Maintaining a pO2 above 12 kPa and higher may improve oxidative cerebral energy metabolism and pressure autoregulation, particularly in cases of limited energy substrate supply in the early phase of TBI. Evaluating the cerebral energy metabolic profile could yield a better patient selection for hyperoxic treatment in future trials.
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Affiliation(s)
| | - Henrik Engquist
- Department of Surgical Sciences/Anesthesia and Intensive Care, 8097Uppsala University, Uppsala, Sweden
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
| | - Samuel Lenell
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
| | - Elham Rostami
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
| | - Lars Hillered
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, 8097Uppsala University, Uppsala, Sweden
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15
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Fan AP, An H, Moradi F, Rosenberg J, Ishii Y, Nariai T, Okazawa H, Zaharchuk G. Quantification of brain oxygen extraction and metabolism with [ 15O]-gas PET: A technical review in the era of PET/MRI. Neuroimage 2020; 220:117136. [PMID: 32634594 PMCID: PMC7592419 DOI: 10.1016/j.neuroimage.2020.117136] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/15/2020] [Accepted: 07/01/2020] [Indexed: 12/31/2022] Open
Abstract
Oxygen extraction fraction (OEF) and the cerebral metabolic rate of oxygen (CMRO2) are key cerebral physiological parameters to identify at-risk cerebrovascular patients and understand brain health and function. PET imaging with [15O]-oxygen tracers, either through continuous or bolus inhalation, provides non-invasive assessment of OEF and CMRO2. Numerous tracer delivery, PET acquisition, and kinetic modeling approaches have been adopted to map brain oxygenation. The purpose of this technical review is to critically evaluate different methods for [15O]-gas PET and its impact on the accuracy and reproducibility of OEF and CMRO2 measurements. We perform a meta-analysis of brain oxygenation PET studies in healthy volunteers and compare between continuous and bolus inhalation techniques. We also describe OEF metrics that have been used to detect hemodynamic impairment in cerebrovascular disease. For these patients, advanced techniques to accelerate the PET scans and potential synthesis with MRI to avoid arterial blood sampling would facilitate broader use of [15O]-oxygen PET for brain physiological assessment.
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Affiliation(s)
- Audrey P Fan
- Department of Radiology, Stanford University, Stanford, CA, USA; Department of Biomedical Engineering and Department of Neurology, University of California Davis, Davis, CA, USA.
| | - Hongyu An
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Farshad Moradi
- Department of Radiology, Stanford University, Stanford, CA, USA
| | | | - Yosuke Ishii
- Department of Radiology, Stanford University, Stanford, CA, USA; Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tadashi Nariai
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hidehiko Okazawa
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Greg Zaharchuk
- Department of Radiology, Stanford University, Stanford, CA, USA
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16
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Patchana T, Dorkoski R, Zampella B, Wiginton JG, Sweiss RB, Menoni R, Miulli DE. The Use of Computed Tomography Perfusion on Admission to Predict Outcomes in Surgical and Nonsurgical Traumatic Brain Injury Patients. Cureus 2019; 11:e5077. [PMID: 31516787 PMCID: PMC6721926 DOI: 10.7759/cureus.5077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction: The objective of this study was to investigate if data obtained from a computed tomography (CT) perfusion study on admission could correlate to outcomes for the patient, including the patient’s length of stay in the hospital and their initial and final Glasgow Coma Scale (GCS), as well as the modified Rankin Scale (mRS) on discharge. We present an initial subset of patients fulfilling the inclusion criteria: over the age of 18 with mild, moderate, or severe traumatic brain injury (TBI). Patients admitted with a diagnosis of TBI had CT perfusion studies performed within 48 hours of admission. GCS, length of stay, mRS, and discharge location were tracked, along with the patient’s course of hospitalization. Initial results and discussion on the utility of CT perfusion for predicting outcomes are presented. Methods: Patients exhibiting mild, moderate, or severe TBI were assessed using CT perfusion within 48 hours of admission from January to July 2019 at the Arrowhead Regional Medical Center (ARMC). The neurosurgery census and patient records were assessed for progression of outcomes. Data obtained from the perfusion scans were correlated to patient outcomes to evaluate the utility of CT perfusion in predicting outcomes in surgical and nonsurgical TBI patients. Results: Preliminary data were obtained on six patients exhibiting TBI, ranging from mild to severe. The mean GCS of our patient cohort on admission was eight, with the most common mechanism of injury found to be falls (50%) and motor vehicle accidents (50%). Cerebral blood volume (CBV) seemed to increase with Rankin value (Pearson's correlations coefficient = 0.43 but was statistically insignificant (P = 0.21)). Cerebral blood flow (CBF) was found to be correlated with CBV, and both increased with Rankin score (Pearson's correlation coefficient = 0.56) but were statistically insignificant (P = 0.27). These results suggest that with a larger sample size, CBV and CBF may be correlated to patient outcome. Conclusion: Although more data is needed, preliminary results suggest that with larger patient populations, CT perfusion may provide information that can be correlated clinically to patient outcomes. This study shows that CBF and CBV may serve as useful indicators for prognostication of TBI patients.
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Affiliation(s)
- Tye Patchana
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Ryan Dorkoski
- Environmental and Plant Science, Ohio University, Athens, USA
| | - Bailey Zampella
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James G Wiginton
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Raed B Sweiss
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Rosalinda Menoni
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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17
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Liu YW, Li S, Dai SS. Neutrophils in traumatic brain injury (TBI): friend or foe? J Neuroinflammation 2018; 15:146. [PMID: 29776443 PMCID: PMC5960133 DOI: 10.1186/s12974-018-1173-x] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/23/2018] [Indexed: 12/26/2022] Open
Abstract
Our knowledge of the pathophysiology about traumatic brain injury (TBI) is still limited. Neutrophils, as the most abundant leukocytes in circulation and the first-line transmigrated immune cells at the sites of injury, are highly involved in the initiation, development, and recovery of TBI. Nonetheless, our understanding about neutrophils in TBI is obsolete, and mounting evidences from recent studies have challenged the conventional views. This review summarizes what is known about the relationships between neutrophils and pathophysiology of TBI. In addition, discussions are made on the complex roles as well as the controversial views of neutrophils in TBI.
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Affiliation(s)
- Yang-Wuyue Liu
- Department of Biochemistry and Molecular Biology, Army Medical University, Chongqing, 400038, People's Republic of China.,Center for Pharmacogenetics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, 15261, USA
| | - Song Li
- Center for Pharmacogenetics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, 15261, USA
| | - Shuang-Shuang Dai
- Department of Biochemistry and Molecular Biology, Army Medical University, Chongqing, 400038, People's Republic of China. .,Molecular Biology Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, People's Republic of China.
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18
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Shi J, Wang Y, Chen T, Xu D, Zhao H, Chen L, Yan C, Tang L, He Y, Feng H, Yao J. Automatic evaluation of traumatic brain injury based on terahertz imaging with machine learning. OPTICS EXPRESS 2018; 26:6371-6381. [PMID: 29529829 DOI: 10.1364/oe.26.006371] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 02/27/2018] [Indexed: 05/18/2023]
Abstract
The imaging diagnosis and prognostication of different degrees of traumatic brain injury (TBI) is very important for early care and clinical treatment. Especially, the exact recognition of mild TBI is the bottleneck for current label-free imaging technologies in neurosurgery. Here, we report an automatic evaluation method for TBI recognition with terahertz (THz) continuous-wave (CW) transmission imaging based on machine learning (ML). We propose a new feature extraction method for biological THz images combined with the transmittance distribution features in spatial domain and statistical distribution features in normalized gray histogram. Based on the extracted feature database, ML algorithms are performed for the classification of different degrees of TBI by feature selection and parameter optimization. The highest classification accuracy is up to 87.5%. The area under the curve (AUC) scores of the receiver operating characteristics (ROC) curve are all higher than 0.9, which shows this evaluation method has a good generalization ability. Furthermore, the excellent performance of the proposed system in the recognition of mild TBI is analyzed by different methodological parameters and diagnostic criteria. The system can be extensible to various diseases and will be a powerful tool in automatic biomedical diagnostics.
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19
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Ghosh A, Highton D, Kolyva C, Tachtsidis I, Elwell CE, Smith M. Hyperoxia results in increased aerobic metabolism following acute brain injury. J Cereb Blood Flow Metab 2017; 37:2910-2920. [PMID: 27837190 PMCID: PMC5536254 DOI: 10.1177/0271678x16679171] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Acute brain injury is associated with depressed aerobic metabolism. Below a critical mitochondrial pO2 cytochrome c oxidase, the terminal electron acceptor in the mitochondrial respiratory chain, fails to sustain oxidative phosphorylation. After acute brain injury, this ischaemic threshold might be shifted into apparently normal levels of tissue oxygenation. We investigated the oxygen dependency of aerobic metabolism in 16 acutely brain-injured patients using a 120-min normobaric hyperoxia challenge in the acute phase (24-72 h) post-injury and multimodal neuromonitoring, including transcranial Doppler ultrasound-measured cerebral blood flow velocity, cerebral microdialysis-derived lactate-pyruvate ratio (LPR), brain tissue pO2 (pbrO2), and tissue oxygenation index and cytochrome c oxidase oxidation state (oxCCO) measured using broadband spectroscopy. Increased inspired oxygen resulted in increased pbrO2 [ΔpbrO2 30.9 mmHg p < 0.001], reduced LPR [ΔLPR -3.07 p = 0.015], and increased cytochrome c oxidase (CCO) oxidation (Δ[oxCCO] + 0.32 µM p < 0.001) which persisted on return-to-baseline (Δ[oxCCO] + 0.22 µM, p < 0.01), accompanied by a 7.5% increase in estimated cerebral metabolic rate for oxygen ( p = 0.038). Our results are consistent with an improvement in cellular redox state, suggesting oxygen-limited metabolism above recognised ischaemic pbrO2 thresholds. Diffusion limitation or mitochondrial inhibition might explain these findings. Further investigation is warranted to establish optimal oxygenation to sustain aerobic metabolism after acute brain injury.
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Affiliation(s)
- Arnab Ghosh
- 1 Neurocritical Care, University College London Hospitals, National Hospital for Neurology & Neurosurgery, London, UK
| | - David Highton
- 1 Neurocritical Care, University College London Hospitals, National Hospital for Neurology & Neurosurgery, London, UK
| | - Christina Kolyva
- 2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Ilias Tachtsidis
- 2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Clare E Elwell
- 2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Martin Smith
- 1 Neurocritical Care, University College London Hospitals, National Hospital for Neurology & Neurosurgery, London, UK.,2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK.,3 University College London Hospitals National Institute for Health Research Biomedical Research Centre, London, UK
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20
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Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F. Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension. Front Neurol 2017; 8:250. [PMID: 28769857 PMCID: PMC5511895 DOI: 10.3389/fneur.2017.00250] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/19/2017] [Indexed: 12/30/2022] Open
Abstract
During traumatic brain injury, intracranial hypertension (ICH) can become a life-threatening condition if it is not managed quickly and adequately. Physicians use therapeutic hyperventilation to reduce elevated intracranial pressure (ICP) by manipulating autoregulatory functions connected to cerebrovascular CO2 reactivity. Inducing hypocapnia via hyperventilation reduces the partial pressure of arterial carbon dioxide (PaCO2), which incites vasoconstriction in the cerebral resistance arterioles. This constriction decrease cerebral blood flow, which reduces cerebral blood volume and, ultimately, decreases the patient’s ICP. The effects of therapeutic hyperventilation (HV) are transient, but the risks accompanying these changes in cerebral and systemic physiology must be carefully considered before the treatment can be deemed advisable. The most prominent criticism of this approach is the cited possibility of developing cerebral ischemia and tissue hypoxia. While it is true that certain measures, such as cerebral oxygenation monitoring, are needed to mitigate these dangerous conditions, using available evidence of potential poor outcomes associated with HV as justification to dismiss the implementation of therapeutic HV is debatable and remains a controversial subject among physicians. This review highlights various issues surrounding the use of HV as a means of controlling posttraumatic ICH, including indications for treatment, potential risks, and benefits, and a discussion of what techniques can be implemented to avoid adverse complications.
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Affiliation(s)
- Daniel Agustín Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina.,Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina
| | - Ali Seifi
- University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - David Garza
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
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21
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Prabhakaran K, Petrone P, Lombardo G, Stoller C, Policastro A, Marini CP. Mortality rates of severe traumatic brain injury patients: impact of direct versus nondirect transfers. J Surg Res 2017; 219:66-71. [PMID: 29078912 DOI: 10.1016/j.jss.2017.05.103] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/15/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Direct transport of patients with severe traumatic brain injury (sTBI) to trauma centers (TCs) that can provide definitive care results in lower mortality rates. This study investigated the impact of direct versus nondirect transfers on the mortality rates of patients with sTBI. METHODS Data on patients with TBI admitted between January 1, 2012, and December 31, 2013, to our Level I TC were obtained from the trauma registry. Data included patient age, sex, mechanism, and type of injury, comorbidities, Glasgow Coma Scale, Injury Severity scores, prehospital time, time to request and to transfer, time to initiation of multimodality monitoring and goal-directed therapy protocol, dwell time in the emergency department (EDT), and mortality. Data, reported in means ± standard deviation, were analyzed with the Student t-test and chi-square. Statistical significance was accepted at a P value < 0.05. RESULTS sTBI direct transfer to TC versus transfer from non-TCs (NTC): Of the 1187 patients with TBI admitted to our TC, 768 (64.7%) were admitted directly from the scene, whereas 419 (35.3%) were admitted after secondary transfer. One hundred seventy-one (22.2%) of the direct transfers had Glasgow Coma Scale < 8 (sTBI) and 92 (21.9%) of the secondary transfers had sTBI. The transfer time: Time from scene to arrival to the EDT was significantly shorter for TC versus NTCs 43 ± 14 versus 77 ± 26 min, respectively (P < 0.05). EDT dwell time before transfer and time from injury to arrival to TC were 4.2 ± 2.1 and 6.2 ± 8.3 h, respectively. Mortality: There was a statistically significant lower mortality for patients with sTBI transferred directly from the scene to TCs as opposed to patients secondarily transferred, 33/171 (19.3%) versus 33/92 (35.8%), respectively (P < 0.05). CONCLUSIONS To decrease TBI-related mortality, patients with suspected sTBI should be taken directly to a Level I or II TC unless they require life-saving stabilization at NTCs.
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Affiliation(s)
- Kartik Prabhakaran
- Division of Trauma Surgery, Surgical Critical Care and Emergency General Surgery, Department of Surgery New York Medical College, Westchester Medical Center University Hospital, Valhalla, New York.
| | - Patrizio Petrone
- Division of Trauma Surgery, Surgical Critical Care and Emergency General Surgery, Winthrop University Hospital, Mineola, New York
| | - Gary Lombardo
- Division of Trauma Surgery, Surgical Critical Care and Emergency General Surgery, Department of Surgery New York Medical College, Westchester Medical Center University Hospital, Valhalla, New York
| | - Christy Stoller
- Division of Trauma Surgery, Surgical Critical Care and Emergency General Surgery, Department of Surgery New York Medical College, Westchester Medical Center University Hospital, Valhalla, New York
| | - Anthony Policastro
- Division of Trauma Surgery, Surgical Critical Care and Emergency General Surgery, Department of Surgery New York Medical College, Westchester Medical Center University Hospital, Valhalla, New York
| | - Corrado P Marini
- Division of Trauma Surgery, Surgical Critical Care and Emergency General Surgery, Winthrop University Hospital, Mineola, New York
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22
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Vidal-Jorge M, Sánchez-Guerrero A, Mur-Bonet G, Castro L, Rădoi A, Riveiro M, Fernández-Prado N, Baena J, Poca MA, Sahuquillo J. Does Normobaric Hyperoxia Cause Oxidative Stress in the Injured Brain? A Microdialysis Study Using 8-Iso-Prostaglandin F2α as a Biomarker. J Neurotrauma 2017; 34:2731-2742. [PMID: 28323516 DOI: 10.1089/neu.2017.4992] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Significant controversy exists regarding the potential clinical benefit of normobaric hyperoxia (NBO) in patients with traumatic brain injury (TBI). This study consisted of two aims: 1) to assess whether NBO improves brain oxygenation and metabolism and 2) to determine whether this therapy may increase the risk of oxidative stress (OxS), using 8-iso-Prostaglandin F2α (PGF2α) as a biomarker. Thirty-one patients with a median admission Glasgow Coma Scale score of 4 (min: 3, max: 12) were monitored with cerebral microdialysis and brain tissue oxygen sensors and treated with fraction of inspired oxygen (FiO2) of 1.0 for 4 h. Patients were divided into two groups according to the area monitored by the probes: normal injured brain and traumatic penumbra/traumatic core. NBO maintained for 4 h did not induce OxS in patients without preOxS at baseline, except in one case. However, for patients in whom OxS was detected at baseline, NBO induced a significant increase in 8-iso-PGF2α. The results of our study showed that NBO did not change energy metabolism in the whole group of patients. In the five patients with brain lactate concentration ([Lac]brain) > 3.5 mmol/L at baseline, NBO induced a marked reduction in both [Lac]brain and lactate-to-pyruvate ratio. Although these differences were not statistically significant, together with the results of our previous study, they suggest that TBI patients would benefit from receiving NBO when they show indications of disturbed brain metabolism. These findings, in combination with increasing evidence that TBI metabolic crises are common without brain ischemia, open new possibilities for the use of this accessible therapeutic strategy in TBI patients.
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Affiliation(s)
- Marian Vidal-Jorge
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Angela Sánchez-Guerrero
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Gemma Mur-Bonet
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Lidia Castro
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Andreea Rădoi
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Marilyn Riveiro
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Natalia Fernández-Prado
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jacinto Baena
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria-Antonia Poca
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain .,3 Department of Neurosurgery, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sahuquillo
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain .,3 Department of Neurosurgery, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
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23
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Bragin DE, Kameneva MV, Bragina OA, Thomson S, Statom GL, Lara DA, Yang Y, Nemoto EM. Rheological effects of drag-reducing polymers improve cerebral blood flow and oxygenation after traumatic brain injury in rats. J Cereb Blood Flow Metab 2017; 37:762-775. [PMID: 28155574 PMCID: PMC5363490 DOI: 10.1177/0271678x16684153] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cerebral ischemia has been clearly demonstrated after traumatic brain injury (TBI); however, neuroprotective therapies have not focused on improvement of the cerebral microcirculation. Blood soluble drag-reducing polymers (DRP), prepared from high molecular weight polyethylene oxide, target impaired microvascular perfusion by altering the rheological properties of blood and, until our recent reports, has not been applied to the brain. We hypothesized that DRP improve cerebral microcirculation and oxygenation after TBI. DRP were studied in healthy and traumatized rat brains and compared to saline controls. Using in-vivo two-photon laser scanning microscopy over the parietal cortex, we showed that after TBI, nanomolar concentrations of intravascular DRP significantly enhanced microvascular perfusion and tissue oxygenation in peri-contusional areas, preserved blood-brain barrier integrity and protected neurons. The mechanisms of DRP effects were attributable to reduction of the near-vessel wall cell-free layer which increased near-wall blood flow velocity, microcirculatory volume flow, and number of erythrocytes entering capillaries, thereby reducing capillary stasis and tissue hypoxia as reflected by a reduction in NADH. Our results indicate that early reduction in CBF after TBI is mainly due to ischemia; however, metabolic depression of contused tissue could be also involved.
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Affiliation(s)
- Denis E Bragin
- 1 Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Marina V Kameneva
- 2 McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,3 Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,4 Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Olga A Bragina
- 1 Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Susan Thomson
- 1 Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Gloria L Statom
- 1 Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Devon A Lara
- 1 Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Yirong Yang
- 5 College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
| | - Edwin M Nemoto
- 1 Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, NM, USA
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24
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Evaluating the Role of Reduced Oxygen Saturation and Vascular Damage in Traumatic Brain Injury Using Magnetic Resonance Perfusion-Weighted Imaging and Susceptibility-Weighted Imaging and Mapping. Top Magn Reson Imaging 2016; 24:253-65. [PMID: 26502307 DOI: 10.1097/rmr.0000000000000064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The cerebral vasculature, along with neurons and axons, is vulnerable to biomechanical insult during traumatic brain injury (TBI). Trauma-induced vascular injury is still an underinvestigated area in TBI research. Cerebral blood flow and metabolism could be important future treatment targets in neural critical care. Magnetic resonance imaging offers a number of key methods to probe vascular injury and its relationship with traumatic hemorrhage, perfusion deficits, venous blood oxygen saturation changes, and resultant tissue damage. They make it possible to image the hemodynamics of the brain, monitor regional damage, and potentially show changes induced in the brain's function not only acutely but also longitudinally following treatment. These methods have recently been used to show that even mild TBI (mTBI) subjects can have vascular abnormalities, and thus they provide a major step forward in better diagnosing mTBI patients.
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25
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Zhou BC, Liu LJ, Liu B. Neuroprotection of hyperbaric oxygen therapy in sub-acute traumatic brain injury: not by immediately improving cerebral oxygen saturation and oxygen partial pressure. Neural Regen Res 2016; 11:1445-1449. [PMID: 27857747 PMCID: PMC5090846 DOI: 10.4103/1673-5374.191218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Although hyperbaric oxygen (HBO) therapy can promote the recovery of neural function in patients who have suffered traumatic brain injury (TBI), the underlying mechanism is unclear. We hypothesized that hyperbaric oxygen treatment plays a neuroprotective role in TBI by increasing regional transcranial oxygen saturation (rSO2) and oxygen partial pressure (PaO2). To test this idea, we compared two groups: a control group with 20 healthy people and a treatment group with 40 TBI patients. The 40 patients were given 100% oxygen of HBO for 90 minutes. Changes in rSO2 were measured. The controls were also examined for rSO2 and PaO2, but received no treatment. rSO2 levels in the patients did not differ significantly after treatment, but levels before and after treatment were significantly lower than those in the control group. PaO2 levels were significantly decreased after the 30-minute HBO treatment. Our findings suggest that there is a disorder of oxygen metabolism in patients with sub-acute TBI. HBO does not immediately affect cerebral oxygen metabolism, and the underlying mechanism still needs to be studied in depth.
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Affiliation(s)
- Bao-Chun Zhou
- Department of Emergency and Intensive Care Unit, the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Li-Jun Liu
- Department of Emergency and Intensive Care Unit, the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Bing Liu
- Department of Neurosurgery, High-tech District Branch of the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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26
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Hook G, Jacobsen JS, Grabstein K, Kindy M, Hook V. Cathepsin B is a New Drug Target for Traumatic Brain Injury Therapeutics: Evidence for E64d as a Promising Lead Drug Candidate. Front Neurol 2015; 6:178. [PMID: 26388830 PMCID: PMC4557097 DOI: 10.3389/fneur.2015.00178] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 07/31/2015] [Indexed: 12/22/2022] Open
Abstract
There is currently no therapeutic drug treatment for traumatic brain injury (TBI) despite decades of experimental clinical trials. This may be because the mechanistic pathways for improving TBI outcomes have yet to be identified and exploited. As such, there remains a need to seek out new molecular targets and their drug candidates to find new treatments for TBI. This review presents supporting evidence for cathepsin B, a cysteine protease, as a potentially important drug target for TBI. Cathepsin B expression is greatly up-regulated in TBI animal models, as well as in trauma patients. Importantly, knockout of the cathepsin B gene in TBI mice results in substantial improvements of TBI-caused deficits in behavior, pathology, and biomarkers, as well as improvements in related injury models. During the process of TBI-induced injury, cathepsin B likely escapes the lysosome, its normal subcellular location, into the cytoplasm or extracellular matrix (ECM) where the unleashed proteolytic power causes destruction via necrotic, apoptotic, autophagic, and activated glia-induced cell death, together with ECM breakdown and inflammation. Significantly, chemical inhibitors of cathepsin B are effective for improving deficits in TBI and related injuries including ischemia, cerebral bleeding, cerebral aneurysm, edema, pain, infection, rheumatoid arthritis, epilepsy, Huntington's disease, multiple sclerosis, and Alzheimer's disease. The inhibitor E64d is unique among cathepsin B inhibitors in being the only compound to have demonstrated oral efficacy in a TBI model and prior safe use in man and as such it is an excellent tool compound for preclinical testing and clinical compound development. These data support the conclusion that drug development of cathepsin B inhibitors for TBI treatment should be accelerated.
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Affiliation(s)
- Gregory Hook
- American Life Science Pharmaceuticals, Inc. , San Diego, CA , USA
| | | | - Kenneth Grabstein
- Department of Chemical Engineering, University of Washington , Seattle, WA , USA
| | - Mark Kindy
- Department of Neurosciences, Medical University of South Carolina , Charleston, SC , USA ; Ralph H. Johnson Veterans Administration Medical Center , Charleston, SC , USA
| | - Vivian Hook
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego , La Jolla, CA , USA ; Department of Neurosciences, Department of Pharmacology, University of California San Diego , La Jolla, CA , USA
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27
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Peng F, Muzik O, Gatson J, Kernie SG, Diaz-Arrastia R. Assessment of Traumatic Brain Injury by Increased 64Cu Uptake on 64CuCl2 PET/CT. J Nucl Med 2015; 56:1252-7. [PMID: 26112025 DOI: 10.2967/jnumed.115.154575] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 06/17/2015] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Copper is a nutritional trace element required for cell proliferation and wound repair. METHODS To explore increased copper uptake as a biomarker for noninvasive assessment of traumatic brain injury (TBI), experimental TBI in C57BL/6 mice was induced by controlled cortical impact, and (64)Cu uptake in the injured cortex was assessed with (64)CuCl2 PET/CT. RESULTS At 24 h after intravenous injection of the tracer, uptake was significantly higher in the injured cortex of TBI mice (1.15 ± 0.53 percentage injected dose per gram of tissue [%ID/g]) than in the uninjured cortex of mice without TBI (0.53 ± 0.07 %ID/g, P = 0.027) or the cortex of mice that received an intracortical injection of zymosan A (0.62 ± 0.22 %ID/g, P = 0.025). Furthermore, uptake in the traumatized cortex of untreated TBI mice (1.15 ± 0.53 %ID/g) did not significantly differ from that in minocycline-treated TBI mice (0.93 ± 0.30 %ID/g, P = 0.33). CONCLUSION Overall, the data suggest that increased (64)Cu uptake in traumatized brain tissues holds potential as a new biomarker for noninvasive assessment of TBI with (64)CuCl2 PET/CT.
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Affiliation(s)
- Fangyu Peng
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Otto Muzik
- Carman and Ann Adams Department of Pediatrics, School of Medicine, Wayne State University, Detroit, Michigan Department of Radiology, School of Medicine, Wayne State University, Detroit, Michigan
| | - Joshua Gatson
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Steven G Kernie
- Department of Pediatrics and Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, New York; and
| | - Ramon Diaz-Arrastia
- Center for Neurosciences and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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28
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Abstract
Traumatic brain injury (TBI) is a major cause of death and disability, and therefore an important health and socioeconomic problem for our society. Individuals surviving from a moderate to severe TBI frequently suffer from long-lasting cognitive deficits. Such deficits include different aspects of cognition such as memory, attention, executive functions, and awareness of their deficits. This chapter presents a review of the main neuropsychological and neuroimaging studies of patients with TBI. These studies found that patients evolve differently according to the severity of the injury, the mechanism causing the injury, and the lesion location. Further research is necessary to develop rehabilitation methods that enhance brain plasticity and recovery after TBI. In this chapter, we summarize current knowledge and controversies, focusing on cognitive sequelae after TBI. Recommendations from the Common Data Elements are provided, with an emphasis on diagnosis, outcome measures, and studies organization to make data more comparable across studies. Final considerations on neuroimaging advances, rehabilitation approaches, and genetics are described in the final section of the chapter.
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Affiliation(s)
- Irene Cristofori
- Cognitive Neuroscience Laboratory, Rehabilitation Institute of Chicago, Chicago, IL, USA
| | - Harvey S Levin
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA.
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29
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Fridley J, Robertson C, Gopinath S. Quantitative lobar cerebral blood flow for outcome prediction after traumatic brain injury. J Neurotrauma 2014; 32:75-82. [PMID: 25019579 DOI: 10.1089/neu.2014.3350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The aim of this study was to examine cortical cerebral blood flow (CBF) in patients with traumatic brain injury (TBI) and determine whether lobar cortical CBF is a better predictor of long-term neurological outcome assessed by the Glasgow Outcome Scale (GOS) than global cortical CBF. Ninety-eight patients with TBI had a stable xenon computed tomography scan (Xe/CT-CBF study) performed at various time points after their initial injury. Spearman's correlation coefficients and Kruskall-Wallis' test were used to examine the relationship between patient age, emergency room Glasgow Coma Scale (GCS), Injury Severity Score, prehospital hypotension, prehospital hypoxia, mechanism of injury, type of injury, side of injury, global average CBF, lobar CBF, number of lobes with CBF below normal, and GOS (discharge, 3 and 6 months). Univariate ordinal regression was performed using these same variables and in combination with principle component analysis (PCA) to determine independent variables for multi-variate ordinal regression. Significant correlation between age, GCS, prehospital hypotension, type of injury, global average CBF, lobar CBF, number of lobes below normal CBF, and GOS was found. Individual lobar CBF was highly correlated with global CBF and the number of lobes below normal CBF. PCA found one principle component among these three CBF variables; therefore, average global CBF and number of lobes with CBF below normal were each chosen as independent variables for multiple ordinal regression, which found age, GCS, and prehospital hypotension, global average CBF, and number of lobes below normal CBF significantly associated with GOS. This study found global average CBF and lobar CBF significantly correlated with GOS at follow-up. There was, however, no individual cerebral lobe that was more predictive than any other, which puts into question the value of calculating lobar CBF versus global CBF in predicting GOS.
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Affiliation(s)
- Jared Fridley
- Department of Neurosurgery, Baylor College of Medicine , Houston, Texas
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30
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Veenith TV, Carter EL, Grossac J, Newcombe VF, Outtrim JG, Nallapareddy S, Lupson V, Correia MM, Mada MM, Williams GB, Menon DK, Coles JP. Use of diffusion tensor imaging to assess the impact of normobaric hyperoxia within at-risk pericontusional tissue after traumatic brain injury. J Cereb Blood Flow Metab 2014; 34:1622-7. [PMID: 25005875 PMCID: PMC4269721 DOI: 10.1038/jcbfm.2014.123] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 05/15/2014] [Accepted: 06/09/2014] [Indexed: 12/31/2022]
Abstract
Ischemia and metabolic dysfunction remain important causes of neuronal loss after head injury, and we have shown that normobaric hyperoxia may rescue such metabolic compromise. This study examines the impact of hyperoxia within injured brain using diffusion tensor imaging (DTI). Fourteen patients underwent DTI at baseline and after 1 hour of 80% oxygen. Using the apparent diffusion coefficient (ADC) we assessed the impact of hyperoxia within contusions and a 1 cm border zone of normal appearing pericontusion, and within a rim of perilesional reduced ADC consistent with cytotoxic edema and metabolic compromise. Seven healthy volunteers underwent imaging at 21%, 60%, and 100% oxygen. In volunteers there was no ADC change with hyperoxia, and contusion and pericontusion ADC values were higher than volunteers (P<0.01). There was no ADC change after hyperoxia within contusion, but an increase within pericontusion (P<0.05). We identified a rim of perilesional cytotoxic edema in 13 patients, and hyperoxia resulted in an ADC increase towards normal (P=0.02). We demonstrate that hyperoxia may result in benefit within the perilesional rim of cytotoxic edema. Future studies should address whether a longer period of hyperoxia has a favorable impact on the evolution of tissue injury.
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Affiliation(s)
- Tonny V Veenith
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Eleanor L Carter
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Julia Grossac
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Virginia F Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Joanne G Outtrim
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Sridhar Nallapareddy
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Victoria Lupson
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Marta M Correia
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Marius M Mada
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Guy B Williams
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Jonathan P Coles
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
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31
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Abstract
Critically ill neurologic patients are common in the hospital practice of neurology and are often in extreme states requiring accurate and specific information. Imaging, especially using advanced imaging techniques, can provide an important means of garnering this information. This article focuses on the clinical utilization of selective imaging methods that are commonly used in critically ill neurologic patients to render diagnoses, to monitor effects of treatment, or have contributed to a better understanding of pathophysiology in the intensive care unit.
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Affiliation(s)
- Paul M Vespa
- David Geffen School of Medicine at UCLA, 757 Westwood Boulevard, Room 6236A, Los Angeles, CA 90095, USA.
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32
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Rostami E, Engquist H, Enblad P. Imaging of cerebral blood flow in patients with severe traumatic brain injury in the neurointensive care. Front Neurol 2014; 5:114. [PMID: 25071702 PMCID: PMC4083561 DOI: 10.3389/fneur.2014.00114] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 06/16/2014] [Indexed: 12/21/2022] Open
Abstract
Ischemia is a common and deleterious secondary injury following traumatic brain injury (TBI). A great challenge for the treatment of TBI patients in the neurointensive care unit (NICU) is to detect early signs of ischemia in order to prevent further advancement and deterioration of the brain tissue. Today, several imaging techniques are available to monitor cerebral blood flow (CBF) in the injured brain such as positron emission tomography (PET), single-photon emission computed tomography, xenon computed tomography (Xenon-CT), perfusion-weighted magnetic resonance imaging (MRI), and CT perfusion scan. An ideal imaging technique would enable continuous non-invasive measurement of blood flow and metabolism across the whole brain. Unfortunately, no current imaging method meets all these criteria. These techniques offer snapshots of the CBF. MRI may also provide some information about the metabolic state of the brain. PET provides images with high resolution and quantitative measurements of CBF and metabolism; however, it is a complex and costly method limited to few TBI centers. All of these methods except mobile Xenon-CT require transfer of TBI patients to the radiological department. Mobile Xenon-CT emerges as a feasible technique to monitor CBF in the NICU, with lower risk of adverse effects. Promising results have been demonstrated with Xenon-CT in predicting outcome in TBI patients. This review covers available imaging methods used to monitor CBF in patients with severe TBI.
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Affiliation(s)
- Elham Rostami
- Section of Neurosurgery, Department of Neuroscience, Uppsala University , Uppsala , Sweden ; Department of Neuroscience, Karolinska Institutet , Stockholm , Sweden
| | - Henrik Engquist
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University , Uppsala , Sweden
| | - Per Enblad
- Section of Neurosurgery, Department of Neuroscience, Uppsala University , Uppsala , Sweden
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De Georgia MA. Brain Tissue Oxygen Monitoring in Neurocritical Care. J Intensive Care Med 2014; 30:473-83. [PMID: 24710714 DOI: 10.1177/0885066614529254] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/14/2014] [Indexed: 11/15/2022]
Abstract
Brain injury results from ischemia, tissue hypoxia, and a cascade of secondary events. The cornerstone of neurocritical care management is optimization and maintenance of cerebral blood flow (CBF) and oxygen and substrate delivery to prevent or attenuate this secondary damage. New techniques for monitoring brain tissue oxygen tension (PtiO2) are now available. Brain PtiO2 reflects both oxygen delivery and consumption. Brain hypoxia (low brain PtiO2) has been associated with poor outcomes in patients with brain injury. Strategies to improve brain PtiO2 have focused mainly on increasing oxygen delivery either by increasing CBF or by increasing arterial oxygen content. The results of nonrandomized studies comparing brain PtiO2-guided therapy with intracranial pressure/cerebral perfusion pressure-guided therapy, while promising, have been mixed. More studies are needed including prospective, randomized controlled trials to assess the true value of this approach. The following is a review of the physiology of brain tissue oxygenation, the effect of brain hypoxia on outcome, strategies to increase oxygen delivery, and outcome studies of brain PtiO2-guided therapy in neurocritical care.
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Affiliation(s)
- Michael A De Georgia
- Case Western Reserve University School of Medicine, Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH, USA
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Anand KJS. Pediatric critical care: grand challenges for a glowing future. Front Pediatr 2014; 2:35. [PMID: 24818121 PMCID: PMC4012217 DOI: 10.3389/fped.2014.00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 04/16/2014] [Indexed: 01/19/2023] Open
Affiliation(s)
- Kanwaljeet J S Anand
- Pain Neurobiology Laboratory, Department of Pediatrics, University of Tennessee Neuroscience Institute, University of Tennessee Health Science Center , Memphis, TN , USA
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Wu HM, Huang SC, Vespa P, Hovda DA, Bergsneider M. Redefining the pericontusional penumbra following traumatic brain injury: evidence of deteriorating metabolic derangements based on positron emission tomography. J Neurotrauma 2013; 30:352-60. [PMID: 23461651 DOI: 10.1089/neu.2012.2610] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract The pathophysiological changes in the pericontusional region after traumatic brain injury (TBI) have classically been considered to be ischemic. Using [F-18]fluorodeoxyglucose (FDG) and triple-oxygen PET studies, we examined the pericontusional "penumbra" to assess for increased oxygen extraction fraction (OEF), anaerobic metabolism, and tissue viability. Acute (≤4 days) CT, MRI, and PET studies were performed in eight patients with TBI who had contusions. Four regions-of-interest (ROI) containing the contusion core, pericontusional hypodense gray matter (GM), pericontusional normal-appearing GM, and remote normal-appearing GM, were defined using a semi-automatic method. The correlations of cerebral blood flow (CBF) with OEF, cerebral metabolic rate of oxygen (CMRO2), and cerebral metabolic rate of glucose (CMRglc) were examined. The oxygen-glucose ratio (OGR) in each brain region was evaluated for anaerobic metabolism. The results show that pericontusional tissue had progressively diminishing OEF, CBF, CMRO2, or CMRglc approaching the contusion core. In general, there was a preserved ratio of CBF to CMRO2 in pericontusional hypodense GM. The OGR of the pericontusional hypodense GM was low (<4.0) and was inversely correlated (r=-0.68) with time after injury. A large proportion (%area: 22-76%) of pericontusional hypodense GM tissue had CMRO2 values less than 35 μmol/100 g/min, with this percentage increased with time after injury.
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Affiliation(s)
- Hsiao-Ming Wu
- Department of Molecular and Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095-7039, USA
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Abstract
PURPOSE OF REVIEW Although adherence to traumatic brain injury (TBI) guidelines has been associated with improved patient outcomes, guideline adherence remains suboptimal in practice. With neurologists becoming increasingly involved in specialized neurointensive care units and in the care of patients with severe TBI, familiarization with these guidelines is essential. RECENT FINDINGS Intracranial monitoring of different physiologic variables has increased in the past few years. Intracranial pressure (ICP)-driven therapy has been replaced by ICP-cerebral perfusion pressure (CPP)-driven therapy. More recently, the importance of brain oxygen optimization in addition to ICP-CPP has been recognized, and clinical trials are underway to study the effect of this approach. Surgical management of patients with TBI is also evolving rapidly with further studies on decompressive craniectomy. These are significant advances to improve TBI outcomes. SUMMARY This article summarizes the routine monitoring of patients with severe TBI and offers insight into some novel physiologic monitoring devices available. The guidelines for management of patients with severe TBI are summarized along with outcome measures.
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Affiliation(s)
- Halinder S Mangat
- Weill Cornell Medical College, Department of Neurology and Neuroscience, New York, NY 10021, USA.
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Kaloostian P, Robertson C, Gopinath SP, Stippler M, King CC, Qualls C, Yonas H, Nemoto EM. Outcome prediction within twelve hours after severe traumatic brain injury by quantitative cerebral blood flow. J Neurotrauma 2012; 29:727-34. [PMID: 22111910 DOI: 10.1089/neu.2011.2147] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We measured quantitative cortical mantle cerebral blood flow (CBF) by stable xenon computed tomography (CT) within the first 12 h after severe traumatic brain injury (TBI) to determine whether neurologic outcome can be predicted by CBF stratification early after injury. Stable xenon CT was used for quantitative measurement of CBF (mL/100 g/min) in 22 cortical mantle regions stratified as follows: low (0-8), intermediate (9-30), normal (31-70), and hyperemic (>70) in 120 patients suffering severe (Glasgow Coma Scale [GCS] score ≤8) TBI. For each of these CBF strata, percentages of total cortical mantle volume were calculated. Outcomes were assessed by Glasgow Outcome Scale (GOS) score at discharge (DC), and 1, 3, and 6 months after discharge. Quantitative cortical mantle CBF differentiated GOS 1 and GOS 2 (dead or vegetative state) from GOS 3-5 (severely disabled to good recovery; p<0.001). Receiver operating characteristic (ROC) curve analysis for percent total normal plus hyperemic flow volume (TNHV) predicting GOS 3-5 outcome at 6 months for CBF measured <6 and <12 h after injury showed ROC area under the curve (AUC) cut-scores of 0.92 and 0.77, respectively. In multivariate analysis, percent TNHV is an independent predictor of GOS 3-5, with an odds ratio of 1.460 per 10 percentage point increase, as is initial GCS score (OR=1.090). The binary version of the Marshall CT score was an independent predictor of 6-month outcome, whereas age was not. These results suggest that quantitative cerebral cortical CBF measured within the first 6 and 12 h after TBI predicts 6-month outcome, which may be useful in guiding patient care and identifying patients for randomized clinical trials. A larger multicenter randomized clinical trial is indicated.
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Affiliation(s)
- Paul Kaloostian
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico 87131-0001, USA
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Tight glycemic control increases metabolic distress in traumatic brain injury: a randomized controlled within-subjects trial. Crit Care Med 2012; 40:1923-9. [PMID: 22610193 DOI: 10.1097/ccm.0b013e31824e0fcc] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the effects of tight glycemic control on brain metabolism after traumatic brain injury using brain positron emission tomography and microdialysis. DESIGN Single-center, randomized controlled within-subject crossover observational trial. SETTING Academic intensive care unit. METHODS We performed a prospective, unblinded randomized controlled within-subject crossover trial of tight (80-110 mg/dL) vs. loose (120-150 mg/dL) glycemic control in patients with severe traumatic brain injury to determine the effects of glycemic control on brain glucose metabolism, as measured by [18F] deoxy-D-glucose brain positron emission tomography. Brain microdialysis was done simultaneously. MEASUREMENTS AND MAIN RESULTS Thirteen severely injured traumatic brain injury patients underwent the study between 3 and 8 days (mean 4.8 days) after traumatic brain injury. In ten of these subjects, global brain and gray matter tissues demonstrated higher glucose metabolic rates while glucose was under tight control as compared with loose control (3.2 ± 0.6 vs. 2.4 + 0.4, p = .02 [whole brain] and 3.8 ± 1.4 vs. 2.9 ± 0.8, p = .05 [gray matter]). However, the responses were heterogeneous with pericontusional tissue demonstrating the least state-dependent change. Cerebral microdialysis demonstrated more frequent critical reductions in glucose (p = .02) and elevations of lactate/pyruvate ratio (p = .03) during tight glycemic control. CONCLUSION Tight glycemic control results in increased global glucose uptake and an increased cerebral metabolic crisis after traumatic brain injury. The mechanisms leading to the enhancement of metabolic crisis are unclear, but delivery of more glucose through mild hyperglycemia may be necessary after traumatic brain injury.
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Kramer AH, Le Roux P. Red Blood Cell Transfusion and Transfusion Alternatives in Traumatic Brain Injury. Curr Treat Options Neurol 2012; 14:150-163. [PMID: 22314930 DOI: 10.1007/s11940-012-0167-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OPINION STATEMENT: Anemia develops in about 50% of patients hospitalized with traumatic brain injury (TBI) and is recognized as a cause of secondary brain injury. This review examines the effects of anemia and transfusion on TBI patients through a literature search to identify original research on anemia and transfusion in TBI, the effects of transfusion on brain physiology, and the role of erythropoietin or hemoglobin-based blood substitutes (HBBSs). However, the amount of high-quality, prospective data available to help make decisions about when TBI patients should be transfused is very small. Randomized transfusion trials have involved far too few TBI patients to reach definitive conclusions. Thus, it is hardly surprising that there is widespread practice variation. In our opinion, a hemoglobin transfusion threshold of 7 g/dL cannot yet be considered safe for TBI patients admitted to hospital, and in particular to the ICU, as it is for other critically ill patients. Red blood cell transfusions often have immediate, seemingly beneficial effects on cerebral physiology, but the magnitude of this effect may depend in part upon how long the cells have been stored before administration. In light of existing physiological data, we generally aim to keep hemoglobin concentrations greater than 9 g/dL during the first several days after TBI. In part, the decision is based on the patient's risk of or development of secondary ischemia or brain injury. An increasing number of centers use multimodal neurologic monitoring, which may help to individualize transfusion goals based on the degree of cerebral hypoxia or metabolic distress. When available, brain tissue oxygen tension values less than 15-20 mm Hg or a lactate:pyruvate ratio greater than 30-40 would influence us to use more aggressive hemoglobin correction (e.g., a transfusion threshold of 10 g/dL). Clinicians can attempt to reduce transfusion requirements by limiting phlebotomy, minimizing hemodilution, and providing appropriate prophylaxis against gastrointestinal hemorrhage. Administration of exogenous erythropoietin may have a small impact in further reducing the need for transfusion, but it also may increase complications, most notably deep venous thrombosis. Erythropoietin is currently of great interest as a potential neuroprotective agent, but until it is adequately evaluated in randomized controlled trials, it should not be used routinely for this purpose. HBBSs are also of interest, but existing preparations have not been shown to be beneficial-or even safe-in the context of TBI.
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Affiliation(s)
- Andreas H Kramer
- Department of Critical Care Medicine & Clinical Neurosciences, University of Calgary, Ground Floor, McCaig Tower, 3134 Hospital Dr NW, Calgary, AB, T2N 2T9, Canada
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Scalfani MT, Dhar R, Zazulia AR, Videen TO, Diringer MN. Effect of osmotic agents on regional cerebral blood flow in traumatic brain injury. J Crit Care 2011; 27:526.e7-12. [PMID: 22176808 DOI: 10.1016/j.jcrc.2011.10.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 10/21/2011] [Indexed: 11/16/2022]
Abstract
PURPOSE Cerebral blood flow (CBF) is reduced after severe traumatic brain injury (TBI) with considerable regional variation. Osmotic agents are used to reduce elevated intracranial pressure (ICP), improve cerebral perfusion pressure, and presumably improve CBF. Yet, osmotic agents have other physiologic effects that can influence CBF. We sought to determine the regional effect of osmotic agents on CBF when administered to treat intracranial hypertension. MATERIALS AND METHODS In 8 patients with acute TBI, we measured regional CBF with positron emission tomography before and 1 hour after administration of equi-osmolar 20% mannitol (1 g/kg) or 23.4% hypertonic saline (0.686 mL/kg) in regions with focal injury and baseline hypoperfusion (CBF <25 mL per 100 g/min). RESULTS The ICP fell (22.4 ± 5.1 to 15.7 ± 7.2 mm Hg, P = .007), and cerebral perfusion pressure rose (75.7 ± 5.9 to 81.9 ± 10.3 mm Hg, P = .03). Global CBF tended to rise (30.9 ± 3.7 to 33.1 ± 4.2 mL per 100 g/min, P = .07). In regions with focal injury, baseline flow was 25.7 ± 9.1 mL per 100 g/min and was unchanged; in hypoperfused regions (15% of regions), flow rose from 18.6 ± 5.0 to 22.4 ± 6.4 mL per 100 g/min (P < .001). Osmotic therapy reduced the number of hypoperfused brain regions by 40% (P < .001). CONCLUSION Osmotic agents, in addition to lowering ICP, improve CBF to hypoperfused brain regions in patients with intracranial hypertension after TBI.
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Affiliation(s)
- Michael T Scalfani
- Department of Neurology, Washington University School of Medicine, St Louis, MO 63110, USA
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Diringer MN, Zazulia AR, Powers WJ. Does Ischemia Contribute to Energy Failure in Severe TBI? Transl Stroke Res 2011; 2:517-23. [DOI: 10.1007/s12975-011-0119-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 10/12/2011] [Accepted: 10/14/2011] [Indexed: 12/12/2022]
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Prophylactic hypothermia for traumatic brain injury: a quantitative systematic review. CAN J EMERG MED 2010; 12:355-64. [PMID: 20650030 DOI: 10.1017/s1481803500012471] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION During the past 7 years, considerable new evidence has accumulated supporting the use of prophylactic hypothermia for traumatic brain injury (TBI). Studies can be divided into 2 broad categories: studies with protocols for cooling for a short, predetermined period (e.g., 24-48 h), and those that cool for longer periods and/or terminate based on the normalization of intracranial pressure (ICP). There have been no systematic reviews of hypothermia for TBI that include this recent new evidence. METHODS This analysis followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the QUOROM (quality of reporting of meta-analyses) statement. We developed a comprehensive search strategy to identify all randomized controlled trials (RCTs) comparing therapeutic hypothermia with standard management in TBI patients. We searched Embase, MEDLINE, Web of Science, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, ProceedingsFirst and PapersFirst. Additional relevant articles were identified by hand-searching conference proceedings and bibliographies. All stages of study identification and selection, quality assessment and analysis were conducted according to prospectively defined criteria. Study quality was determined by assessment of each study for the use of allocation concealment and outcome assessment blinding. Studies were divided into 2 a priori-defined subgroups for analysis based on cooling strategy: short term (< or = 48 h), and long term or goal-directed (> 48 h and/or continued until normalization of ICP). Outcomes included mortality and good neurologic outcome (defined as Glasgow Outcome Scale score of 4 or 5). Pooling of primary outcomes was completed using relative risk (RR) and reported with 95% confidence intervals (CIs). RESULTS Of 1709 articles, 12 studies with 1327 participants were selected for quantitative analysis. Eight of these studies cooled according to a long-term or goal-directed strategy, and 4 used a short-term strategy. Summary results demonstrated lower mortality (RR 0.73, 95% CI 0.62-0.85) and more common good neurologic outcome (RR 1.52, 95% CI 1.28-1.80). When only short-term cooling studies were analyzed, neither mortality (RR 0.98, 95% CI 0.75-1.30) nor neurologic outcome (RR 1.31, 95% CI 0.94-1.83) were improved. In 8 studies of long-term or goal-directed cooling, mortality was reduced (RR 0.62, 95% CI 0.51-0.76) and good neurologic outcome was more common (RR 1.68, 95% CI 1.44-1.96). CONCLUSION The best available evidence to date supports the use of early prophylactic mild-to-moderate hypothermia in patients with severe TBI (Glasgow Coma Scale score < or = 8) to decrease mortality and improve rates of good neurologic recovery. This treatment should be commenced as soon as possible after injury (e.g., in the emergency department after computed tomography) regardless of initial ICP, or before ICP is measured. Most studies report using a temperature of 32 degrees -34 degrees C. The maximal benefit occurred with a long-term or goal-directed cooling protocol, in which cooling was continued for at least 72 hours and/or until stable normalization of intracranial pressure for at least 24 hours was achieved. There is large potential for further research on this therapy in prehospital and emergency department settings.
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Kunz A, Dirnagl U, Mergenthaler P. Acute pathophysiological processes after ischaemic and traumatic brain injury. Best Pract Res Clin Anaesthesiol 2010; 24:495-509. [DOI: 10.1016/j.bpa.2010.10.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 10/11/2010] [Indexed: 12/23/2022]
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Lee SK, Goh JPS. Neuromonitoring for Traumatic Brain Injury in Neurosurgical Intensive Care. PROCEEDINGS OF SINGAPORE HEALTHCARE 2010. [DOI: 10.1177/201010581001900407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The primary aim of neuromonitoring in patients with traumatic brain injury is early detection of secondary brain insults so that timely interventions can be instituted to prevent or treat secondary brain injury. Intracranial pressure monitoring has been a stalwart in neuromonitoring and is still very much the main parameter to guide therapy in brain injured patients in many centres. Cerebral oxygenation is also established as an important parameter for monitoring: global cerebral oxygenation is reliably measured using jugular venous oxygen saturation while brain tissue oxygen tension measurement allows focal brain oxygenation to be monitored. Near-infrared spectroscopy allows a non-invasive option for monitoring of regional cerebral oxygenation. Cerebral microdialysis makes focal measurements of markers of cellular metabolism and cellular injury and death possible, and it is in transition from being a research tool to being an important clinical tool in neuromonitoring. Multimodal monitoring allows different parameters of brain physiology and function to be monitored and can improve identification and prediction of secondary cerebral insults. Multimodal monitoring can potentially improve outcomes in patients with traumatic brain injury by promoting customised treatment strategies for individual patients in place of the commonplace practice of strict adherence to achieving the same standard physiological targets for every patient.
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Affiliation(s)
- Say Kiat Lee
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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Nielsen TH, Nordström CH. Hyperoxia. J Neurosurg 2010; 113:1333-4; author reply 1334-5. [PMID: 20887094 DOI: 10.3171/2010.7.jns101038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Traumatic brain injury represents a substantial public health problem for which clinicians have limited treatment avenues. Traditional FDG-positron emission tomography (PET) brain imaging has provided unique insights into this disease including prognostic information. With the advent and implementation of novel tracers as well as improvement in instrumentation, molecular brain imaging using PET can further illustrate traumatic brain injury pathophysiology and point to novel treatment strategies.
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Affiliation(s)
- Jacob G Dubroff
- Division of Nuclear Medicine, Department of Radiology, Hospital of the University of Pennsylvania, Room 110, Donner Building, Philadelphia, PA 19104, USA
| | - Andrew B Newberg
- Division of Nuclear Medicine, Department of Radiology, Hospital of the University of Pennsylvania, Room 110, Donner Building, Philadelphia, PA 19104, USA.
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Rockswold SB, Rockswold GL, Zaun DA, Zhang X, Cerra CE, Bergman TA, Liu J. A prospective, randomized clinical trial to compare the effect of hyperbaric to normobaric hyperoxia on cerebral metabolism, intracranial pressure, and oxygen toxicity in severe traumatic brain injury. J Neurosurg 2010; 112:1080-94. [DOI: 10.3171/2009.7.jns09363] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Object
Oxygen delivered in supraphysiological amounts is currently under investigation as a therapy for severe traumatic brain injury (TBI). Hyperoxia can be delivered to the brain under normobaric as well as hyperbaric conditions. In this study the authors directly compare hyperbaric oxygen (HBO2) and normobaric hyperoxia (NBH) treatment effects.
Methods
Sixty-nine patients who had sustained severe TBIs (mean Glasgow Coma Scale Score 5.8) were prospectively randomized to 1 of 3 groups within 24 hours of injury: 1) HBO2, 60 minutes of HBO2 at 1.5 ATA; 2) NBH, 3 hours of 100% fraction of inspired oxygen at 1 ATA; and 3) control, standard care. Treatments occurred once every 24 hours for 3 consecutive days. Brain tissue PO2, microdialysis, and intracranial pressure were continuously monitored. Cerebral blood flow (CBF), arteriovenous differences in oxygen, cerebral metabolic rate of oxygen (CMRO2), CSF lactate and F2-isoprostane concentrations, and bronchial alveolar lavage (BAL) fluid interleukin (IL)–8 and IL-6 assays were obtained pretreatment and 1 and 6 hours posttreatment. Mixed-effects linear modeling was used to statistically test differences among the treatment arms as well as changes from pretreatment to posttreatment.
Results
In comparison with values in the control group, the brain tissue PO2 levels were significantly increased during treatment in both the HBO2 (mean ± SEM, 223 ± 29 mm Hg) and NBH (86 ± 12 mm Hg) groups (p < 0.0001) and following HBO2 until the next treatment session (p = 0.003). Hyperbaric O2 significantly increased CBF and CMRO2 for 6 hours (p ≤ 0.01). Cerebrospinal fluid lactate concentrations decreased posttreatment in both the HBO2 and NBH groups (p < 0.05). The dialysate lactate levels in patients who had received HBO2 decreased for 5 hours posttreatment (p = 0.017). Microdialysis lactate/pyruvate (L/P) ratios were significantly decreased posttreatment in both HBO2 and NBH groups (p < 0.05). Cerebral blood flow, CMRO2, microdialysate lactate, and the L/P ratio had significantly greater improvement when a brain tissue PO2 ≥ 200 mm Hg was achieved during treatment (p < 0.01). Intracranial pressure was significantly lower after HBO2 until the next treatment session (p < 0.001) in comparison with levels in the control group. The treatment effect persisted over all 3 days. No increase was seen in the CSF F2-isoprostane levels, microdialysate glycerol, and BAL inflammatory markers, which were used to monitor potential O2 toxicity.
Conclusions
Hyperbaric O2 has a more robust posttreatment effect than NBH on oxidative cerebral metabolism related to its ability to produce a brain tissue PO2 ≥ 200 mm Hg. However, it appears that O2 treatment for severe TBI is not an all or nothing phenomenon but represents a graduated effect. No signs of pulmonary or cerebral O2 toxicity were present.
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Affiliation(s)
- Sarah B. Rockswold
- 1Department of Physical Medicine and Rehabilitation
- 2Division of Neurosurgery, Department of Surgery, Hennepin County Medical Center
| | - Gaylan L. Rockswold
- 2Division of Neurosurgery, Department of Surgery, Hennepin County Medical Center
- 3Department of Neurosurgery, University of Minnesota; and
| | - David A. Zaun
- 4Analytical Services, Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Xuewei Zhang
- 2Division of Neurosurgery, Department of Surgery, Hennepin County Medical Center
| | - Carla E. Cerra
- 2Division of Neurosurgery, Department of Surgery, Hennepin County Medical Center
| | - Thomas A. Bergman
- 2Division of Neurosurgery, Department of Surgery, Hennepin County Medical Center
- 3Department of Neurosurgery, University of Minnesota; and
| | - Jiannong Liu
- 4Analytical Services, Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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Figaji AA. Practical aspects of bedside cerebral hemodynamics monitoring in pediatric TBI. Childs Nerv Syst 2010; 26:431-9. [PMID: 19937247 DOI: 10.1007/s00381-009-1036-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Disturbances in cerebral hemodynamics may have a profound influence on secondary injury after traumatic brain injury (TBI), and many therapies in the neurocritical care unit may adversely affect cerebral blood flow. However, the clinician is often unaware of this when it occurs because practical methods for monitoring cerebral hemodynamics by the bedside have been lacking. Current imaging studies only provide a snapshot of the brain at one point in time, giving limited information about a dynamic condition. DISCUSSION This review will focus on key pathophysiological concepts required to understand changes in cerebral hemodynamics after TBI and the principles, potential benefits, and limitations of currently available bedside monitoring techniques, including transcranial Doppler, autoregulation, and local/regional cerebral blood flow.
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Affiliation(s)
- Anthony A Figaji
- Division of Neurosurgery, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa.
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Xu Y, McArthur DL, Alger JR, Etchepare M, Hovda DA, Glenn TC, Huang S, Dinov I, Vespa PM. Early nonischemic oxidative metabolic dysfunction leads to chronic brain atrophy in traumatic brain injury. J Cereb Blood Flow Metab 2010; 30:883-94. [PMID: 20029449 PMCID: PMC2949156 DOI: 10.1038/jcbfm.2009.263] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic brain atrophy after traumatic brain injury (TBI) is a well-known phenomenon, the causes of which are unknown. Early nonischemic reduction in oxidative metabolism is regionally associated with chronic brain atrophy after TBI. A total of 32 patients with moderate-to-severe TBI prospectively underwent positron emission tomography (PET) and volumetric magnetic resonance imaging (MRI) within the first week and at 6 months after injury. Regional lobar assessments comprised oxidative metabolism and glucose metabolism. Acute MRI showed a preponderance of hemorrhagic lesions with few irreversible ischemic lesions. Global and regional chronic brain atrophy occurred in all patients by 6 months, with the temporal and frontal lobes exhibiting the most atrophy compared with the occipital lobe. Global and regional reduction in cerebral metabolic rate of oxygen (CMRO(2)), cerebral blood flow (CBF), oxygen extraction fraction (OEF), and cerebral metabolic rate of glucose were observed. The extent of metabolic dysfunction was correlated with the total hemorrhage burden on initial MRI (r=0.62, P=0.01). The extent of regional brain atrophy correlated best with CMRO(2) and CBF. Lobar values of OEF were not in the ischemic range and did not correlate with chronic brain atrophy. Chronic brain atrophy is regionally specific and associated with regional reductions in oxidative brain metabolism in the absence of irreversible ischemia.
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Affiliation(s)
- Yueqiao Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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DeWitt DS, Prough DS. Blast-induced brain injury and posttraumatic hypotension and hypoxemia. J Neurotrauma 2009; 26:877-87. [PMID: 18447627 DOI: 10.1089/neu.2007.0439] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Explosive munitions account for more than 50% of all wounds sustained in military combat, and the proportion of civilian casualties due to explosives is increasing as well. But there has been only limited research on the pathophysiology of blast-induced brain injury, and the contributions of alterations in cerebral blood flow (CBF) or cerebral vascular reactivity to blast-induced brain injury have not been investigated. Although secondary hypotension and hypoxemia are associated with increased mortality and morbidity after closed head injury, the effects of secondary insults on outcome after blast injury are unknown. Hemorrhage accounted for approximately 50% of combat deaths, and the lungs are one of the primary organs damaged by blast overpressure. Thus, it is likely that blast-induced lung injury and/or hemorrhage leads to hypotensive and hypoxemic secondary injury in a significant number of combatants exposed to blast overpressure injury. Although the effects of blast injury on CBF and cerebral vascular reactivity are unknown, blast injury may be associated with impaired cerebral vascular function. Reactive oxygen species (ROS) such as the superoxide anion radical and other ROS, likely major contributors to traumatic cerebral vascular injury, are produced by traumatic brain injury (TBI). Superoxide radicals combine with nitric oxide (NO), another ROS produced by blast injury as well as other types of TBI, to form peroxynitrite, a powerful oxidant that impairs cerebral vascular responses to reduced intravascular pressure and other cerebral vascular responses. While current research suggests that blast injury impairs cerebral vascular compensatory responses, thereby leaving the brain vulnerable to secondary insults, the effects of blast injury on the cerebral vascular reactivity have not been investigated. It is clear that further research is necessary to address these critical concerns.
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Affiliation(s)
- Douglas S DeWitt
- Moody Center for Traumatic Brain & Spinal Cord Injury Research, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0830, USA.
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