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Suerte ACC, Liddle LJ, Abrahart A, Khiabani E, Colbourne F. A Systematic Review and Meta-Analysis of Therapeutic Hypothermia and Pharmacological Cotherapies in Animal Models of Ischemic Stroke. Ther Hypothermia Temp Manag 2024. [PMID: 38946643 DOI: 10.1089/ther.2024.0012] [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: 07/02/2024] Open
Abstract
Therapeutic hypothermia (TH) lessens ischemic brain injury. Cytoprotective agents can augment protection, although it is unclear which combinations are most effective. The objective of this study is to identify which cytoprotective drug works best with delayed TH. Following PRISMA guidelines, a systematic review (PubMed, Web of Science, MEDLINE, Scopus) identified controlled experiments that used an in vivo focal ischemic stroke model and evaluated the efficacy of TH (delay of ≥1 hour) coupled with cytoprotective agents. This combination was our main intervention compared with single treatments with TH, drug, or no treatment. Endpoints were brain injury and neurological impairment. The CAMARADES checklist for study quality and the SYRCLE's risk of bias tool gauged study quality. Twenty-five studies were included. Most used young, healthy male rats, with only one using spontaneously hypertensive rats. Two studies used mice models, and six used adult animals. Study quality was moderate (median score = 6), and risk of bias was high. Pharmacological agents provided an additive effect on TH for all outcomes measured. Magnesium coupled with TH had the greatest impact compared with other agent-TH combinations on all outcomes. Longer TH durations improved both behavioral and histological outcomes and had greater cytoprotective efficacy than shorter durations. Anti-inflammatories were the most effective in reducing infarction (standardized mean difference [SMD]: -1.64, confidence interval [CI]: [-2.13, -1.15]), sulfonylureas reduced edema the most (SMD: -2.32, CI: [-3.09, -1.54]), and antiapoptotic agents improved behavioral outcomes the most (normalized mean difference: 52.38, CI: [45.29, 59.46]). Statistically significant heterogeneity was observed (I2 = 82 - 98%, all p < 0.001), indicating that studies wildly differ in their effect size estimates. Our results support the superiority of adding cytoprotective therapies with TH (vs. individual or no therapy). Additional exploratory and confirmatory studies are required to identify and thoroughly assess combination therapies owing to limited work and inconsistent translational quality.
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Affiliation(s)
| | - Lane J Liddle
- Department of Psychology, Faculty of Science, University of Alberta, Edmonton, Canada
| | - Ashley Abrahart
- Department of Psychology, Faculty of Science, University of Alberta, Edmonton, Canada
| | - Elmira Khiabani
- Department of Psychology, Faculty of Science, University of Alberta, Edmonton, Canada
| | - Frederick Colbourne
- Department of Psychology, Faculty of Science, University of Alberta, Edmonton, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
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Lin V, Tian C, Wahlster S, Castillo-Pinto C, Mainali S, Johnson NJ. Temperature Control in Acute Brain Injury: An Update. Semin Neurol 2024; 44:308-323. [PMID: 38593854 DOI: 10.1055/s-0044-1785647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Temperature control in severe acute brain injury (SABI) is a key component of acute management. This manuscript delves into the complex role of temperature management in SABI, encompassing conditions like traumatic brain injury (TBI), acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (aSAH), and hypoxemic/ischemic brain injury following cardiac arrest. Fever is a common complication in SABI and is linked to worse neurological outcomes due to increased inflammatory responses and intracranial pressure (ICP). Temperature management, particularly hypothermic temperature control (HTC), appears to mitigate these adverse effects primarily by reducing cerebral metabolic demand and dampening inflammatory pathways. However, the effectiveness of HTC varies across different SABI conditions. In the context of post-cardiac arrest, the impact of HTC on neurological outcomes has shown inconsistent results. In cases of TBI, HTC seems promising for reducing ICP, but its influence on long-term outcomes remains uncertain. For AIS, clinical trials have yet to conclusively demonstrate the benefits of HTC, despite encouraging preclinical evidence. This variability in efficacy is also observed in ICH, aSAH, bacterial meningitis, and status epilepticus. In pediatric and neonatal populations, while HTC shows significant benefits in hypoxic-ischemic encephalopathy, its effectiveness in other brain injuries is mixed. Although the theoretical basis for employing temperature control, especially HTC, is strong, the clinical outcomes differ among various SABI subtypes. The current consensus indicates that fever prevention is beneficial across the board, but the application and effectiveness of HTC are more nuanced, underscoring the need for further research to establish optimal temperature management strategies. Here we provide an overview of the clinical evidence surrounding the use of temperature control in various types of SABI.
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Affiliation(s)
- Victor Lin
- Department of Neurology, University of Washington, Seattle, Washington
| | - Cindy Tian
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, Washington
- Department of Neurosurgery, University of Washington, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
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Díaz-Peregrino R, Kentar M, Trenado C, Sánchez-Porras R, Albiña-Palmarola P, Ramírez-Cuapio FL, San-Juan D, Unterberg A, Woitzik J, Santos E. The neurophysiological effect of mild hypothermia in gyrencephalic brains submitted to ischemic stroke and spreading depolarizations. Front Neurosci 2024; 18:1302767. [PMID: 38567280 PMCID: PMC10986791 DOI: 10.3389/fnins.2024.1302767] [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: 09/27/2023] [Accepted: 02/22/2024] [Indexed: 04/04/2024] Open
Abstract
Objective Characterize the neurophysiological effects of mild hypothermia on stroke and spreading depolarizations (SDs) in gyrencephalic brains. Methods Left middle cerebral arteries (MCAs) of six hypothermic and six normothermic pigs were permanently occluded (MCAo). Hypothermia began 1 h after MCAo and continued throughout the experiment. ECoG signals from both frontoparietal cortices were recorded. Five-minute ECoG epochs were collected 5 min before, at 5 min, 4, 8, 12, and 16 h after MCAo, and before, during, and after SDs. Power spectra were decomposed into fast (alpha, beta, and gamma) and slow (delta and theta) frequency bands. Results In the vascular insulted hemisphere under normothermia, electrodes near the ischemic core exhibited power decay across all frequency bands at 5 min and the 4th hour after MCAo. The same pattern was registered in the two furthest electrodes at the 12th and 16th hour. When mild hypothermia was applied in the vascular insulted hemispheres, the power decay was generalized and seen even in electrodes with uncompromised blood flow. During SD analysis, hypothermia maintained increased delta and beta power during the three phases of SDs in the furthest electrode from the ischemic core, followed by the second furthest and third electrode in the beta band during preSD and postSD segments. However, in hypothermic conditions, the third electrode showed lower delta, theta, and alpha power. Conclusion Mild hypothermia attenuates all frequency bands in the vascularly compromised hemisphere, irrespective of the cortical location. During SD formation, it preserves power spectra more significantly in electrodes further from the ischemic core.
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Affiliation(s)
- Roberto Díaz-Peregrino
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Modar Kentar
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
- Departement of Neurosurgery, Städtisches Klinikum Braunschweig gGmbH, Braunschweig, Germany
| | - Carlos Trenado
- Heinrich Heine University, Medical Faculty, Institute of Clinical Neuroscience and Medical Psychology, Düsseldorf, Germany
- Institute for the Future of Education Europe, Tecnológico de Monterrey, Cantabria, Spain
| | - Renán Sánchez-Porras
- Department of Neurosurgery, Evangelisches Krankenhaus, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Pablo Albiña-Palmarola
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
- Department of Anatomy, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco L. Ramírez-Cuapio
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Daniel San-Juan
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery, Manuel Velasco Suárez, Mexico City, Mexico
| | - Andreas Unterberg
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Evangelisches Krankenhaus, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Edgar Santos
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
- Department of Neurosurgery, Evangelisches Krankenhaus, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Patel MS, Salcedo-Betancourt JD, Saunders C, Broglio K, Malinoski D, Niemann CU. Therapeutic Hypothermia in Low-Risk Nonpumped Brain-Dead Kidney Donors: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2353785. [PMID: 38416500 PMCID: PMC10902731 DOI: 10.1001/jamanetworkopen.2023.53785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/07/2023] [Indexed: 02/29/2024] Open
Abstract
Importance Delayed graft function in kidney-transplant recipients is associated with increased financial cost and patient burden. In donors with high Kidney Donor Profile Index whose kidneys are not pumped, therapeutic hypothermia has been shown to confer a protective benefit against delayed graft function. Objective To determine whether hypothermia is superior to normothermia in preventing delayed graft function in low-risk nonpumped kidney donors after brain death. Design, Setting, and Participants In a multicenter randomized clinical trial, brain-dead kidney donors deemed to be low risk and not requiring machine perfusion per Organ Procurement Organization protocol were prospectively randomized to hypothermia (34.0-35 °C) or normothermia (36.5-37.5 °C) between August 10, 2017, and May 21, 2020, across 4 Organ Procurement Organizations in the US (Arizona, Upper Midwest, Pacific Northwest, and Texas). The final analysis report is dated June 15, 2022, based on the data set received from the United Network for Organ Sharing on June 2, 2021. A total of 509 donors (normothermia: n = 245 and hypothermia: n = 236; 1017 kidneys) met inclusion criteria over the study period. Intervention Donor hypothermia (34.0-35.0 °C) or normothermia (36.5-37.5 °C). Main Outcomes and Measures The primary outcome was delayed graft function in the kidney recipients, defined as the need for dialysis within the first week following kidney transplant. The primary analysis follows the intent-to-treat principle. Results A total of 934 kidneys were transplanted from 481 donors, of which 474 were randomized to the normothermia group and 460 to the hypothermia group. Donor characteristics were similar between the groups, with overall mean (SD) donor age 34.2 (11.1) years, and the mean donor creatinine level at enrollment of 1.03 (0.53) mg/dL. There was a predominance of Standard Criteria Donors (98% in each treatment arm) with similar low mean (SD) Kidney Donor Profile Index (normothermia: 28.99 [20.46] vs hypothermia: 28.32 [21.9]). Cold ischemia time was similar in the normothermia and hypothermia groups (15.99 [7.9] vs 15.45 [7.63] hours). Delayed graft function developed in 87 of the recipients (18%) in the normothermia group vs 79 (17%) in the hypothermia group (adjusted odds ratio, 0.92; 95% CI, 0.64-1.33; P = .66). Conclusions and Relevance The findings of this study suggest that, in low-risk non-pumped kidneys from brain-dead kidney donors, therapeutic hypothermia compared with normothermia does not appear to prevent delayed graft function in kidney transplant recipients. Trial Registration ClinicalTrials.gov Identifier: NCT02525510.
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Affiliation(s)
- Madhukar S. Patel
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas
| | | | | | - Kristine Broglio
- Oncology Statistical Innovation, AstraZeneca, Gaithersburg, Maryland
| | - Darren Malinoski
- Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health & Science University, Portland
| | - Claus U. Niemann
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, California
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Vacek A, Mair G, White P, Bath PM, Muir KW, Al-Shahi Salman R, Martin C, Dye D, Chappell FM, von Kummer R, Macleod M, Sprigg N, Wardlaw JM. Evaluating artificial intelligence software for delineating hemorrhage extent on CT brain imaging in stroke: AI delineation of ICH on CT. J Stroke Cerebrovasc Dis 2024; 33:107512. [PMID: 38007987 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/25/2023] [Accepted: 11/21/2023] [Indexed: 11/28/2023] Open
Abstract
BACKGROUND The extent and distribution of intracranial hemorrhage (ICH) directly affects clinical management. Artificial intelligence (AI) software can detect and may delineate ICH extent on brain CT. We evaluated e-ASPECTS software (Brainomix Ltd.) performance for ICH delineation. METHODS We qualitatively assessed software delineation of ICH on CT using patients from six stroke trials. We assessed hemorrhage delineation in five compartments: lobar, deep, posterior fossa, intraventricular, extra-axial. We categorized delineation as excellent, good, moderate, or poor. We assessed quality of software delineation with number of affected compartments in univariate analysis (Kruskall-Wallis test) and ICH location using logistic regression (dependent variable: dichotomous delineation categories 'excellent-good' versus 'moderate-poor'), and report odds ratios (OR) and 95 % confidence intervals (95 %CI). RESULTS From 651 patients with ICH (median age 75 years, 53 % male), we included 628 with assessable CTs. Software delineation of ICH extent was 'excellent' in 189/628 (30 %), 'good' in 255/628 (41 %), 'moderate' in 127/628 (20 %), and 'poor' in 57/628 cases (9 %). The quality of software delineation of ICH was better when fewer compartments were affected (Z = 3.61-6.27; p = 0.0063). Software delineation of ICH extent was more likely to be 'excellent-good' quality when lobar alone (OR = 1.56, 95 %CI = 0.97-2.53) but 'moderate-poor' with any intraventricular (OR = 0.56, 95 %CI = 0.39-0.81, p = 0.002) or any extra-axial (OR = 0.41, 95 %CI = 0.27-0.62, p<0.001) extension. CONCLUSIONS Delineation of ICH extent on stroke CT scans by AI software was excellent or good in 71 % of cases but was more likely to over- or under-estimate extent when ICH was either more extensive, intraventricular, or extra-axial.
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Affiliation(s)
- Adam Vacek
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - Grant Mair
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK.
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Keith W Muir
- School of Psychology & Neuroscience, University of Glasgow, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - Chloe Martin
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - David Dye
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - Francesca M Chappell
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - Rüdiger von Kummer
- Department of Neuroradiology, University Hospital, Technische Universität Dresden, Germany
| | - Malcolm Macleod
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences & UK Dementia Research Institute Centre, University of Edinburgh, UK
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Palà E, Penalba A, Bustamante A, García‐Berrocoso T, Lamana‐Vallverdú M, Meisel C, Meisel A, van der Worp HB, R Macleod M, Kallmünzer B, Schwab S, Montaner J. Blood biomarker changes following therapeutic hypothermia in ischemic stroke. Brain Behav 2023; 13:e3230. [PMID: 37721534 PMCID: PMC10636403 DOI: 10.1002/brb3.3230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/23/2023] [Accepted: 08/09/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION Therapeutic hypothermia is a promising candidate for stroke treatment although its efficacy has not yet been demonstrated in patients. Changes in blood molecules could act as surrogate markers to evaluate the efficacy and safety of therapeutic cooling. METHODS Blood samples from 54 patients included in the EuroHYP-1 study (27 treated with hypothermia, and 27 controls) were obtained at baseline, 24 ± 2 h, and 72 ± 4 h. The levels of a panel of 27 biomarkers, including matrix metalloproteinases and cardiac and inflammatory markers, were measured. RESULTS Metalloproteinase-3 (MMP-3), fatty-acid-binding protein (FABP), and interleukin-8 (IL-8) increased over time in relation to the hypothermia treatment. Statistically significant correlations between the minimum temperature achieved by each patient in the hypothermia group and the MMP-3 level measured at 72 h, FABP level measured at 24 h, and IL-8 levels measured at 24 and 72 h were found. No differential biomarker levels were observed in patients with poor or favorable outcomes according to modified Rankin Scale scores. CONCLUSION Although the exact roles of MMP3, FABP, and IL-8 in hypothermia-treated stroke patients are not known, further exploration is needed to confirm their roles in brain ischemia.
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Affiliation(s)
- Elena Palà
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Anna Penalba
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Alejandro Bustamante
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- Stroke Unit, Hospital Universitari Germans Trias i PujolBadalonaSpain
| | - Teresa García‐Berrocoso
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- CSIC/UAB Proteomics LaboratoryInstitute of Biomedical Research of BarcelonaSpanish National Research Council (IIBB‐CSIC/IDIBAPS)BarcelonaSpain
| | - Marcel Lamana‐Vallverdú
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
| | - Christian Meisel
- Institute for Medical ImmunologyCharité–Universitätsmedizin BerlinBerlinGermany
- Department of ImmunologyLabor Berlin–Charité VivantesBerlinGermany
| | - Andreas Meisel
- Department of Neurology and Center for Stroke Research BerlinCharité University Hospital BerlinBerlinGermany
| | - H. Bart van der Worp
- Department of Neurology and NeurosurgeryBrain CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Malcolm R Macleod
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghScotlandUK
| | - Bernd Kallmünzer
- Department of NeurologyUniversitätsklinikum ErlangenErlangenGermany
| | - Stefan Schwab
- Department of NeurologyUniversitätsklinikum ErlangenErlangenGermany
| | - Joan Montaner
- Neurovascular Research LaboratoryVall d'Hebron Institute of Research (VHIR)–Universitat Autónoma de BarcelonaBarcelonaSpain
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville & Department of NeurologyHospital Universitario Virgen MacarenaSevilleSpain
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Kentar M, Ramirez-Cuapio FL, Gutiérrez-Herrera MA, Sanchez-Porras R, Díaz-Peregrino R, Holzwarth N, Maier-Hein L, Woitzik J, Santos E. Mild hypothermia reduces spreading depolarizations and infarct size in a swine model. J Cereb Blood Flow Metab 2023; 43:999-1009. [PMID: 36722153 PMCID: PMC10196741 DOI: 10.1177/0271678x231154604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/06/2022] [Accepted: 12/15/2022] [Indexed: 02/02/2023]
Abstract
Spreading depolarizations (SDs) have been linked to infarct volume expansion following ischemic stroke. Therapeutic hypothermia provides a neuroprotective effect after ischemic stroke. This study aimed to evaluate the effect of hypothermia on the propagation of SDs and infarct volume in an ischemic swine model. Through left orbital exenteration, middle cerebral arteries were surgically occluded (MCAo) in 16 swine. Extensive craniotomy and durotomy were performed. Six hypothermic and five normothermic animals were included in the analysis. An intracranial temperature probe was placed right frontal subdural. One hour after ischemic onset, mild hypothermia was induced and eighteen hours of electrocorticographic (ECoG) and intrinsic optical signal (IOS) recordings were acquired. Postmortem, 4 mm-thick slices were stained with 2,3,5-triphenyltetrazolium chloride to estimate the infarct volume. Compared to normothermia (36.4 ± 0.4°C), hypothermia (32.3 ± 0.2°C) significantly reduced the frequency and expansion of SDs (ECoG: 3.5 ± 2.1, 73.2 ± 5.2% vs. 1.0 ± 0.7, 41.9 ± 21.8%; IOS 3.9 ± 0.4, 87.6 ± 12.0% vs. 1.4 ± 0.7, 67.7 ± 8.3%, respectively). Further, infarct volume among hypothermic animals (23.2 ± 1.8% vs. 32.4 ± 2.5%) was significantly reduced. Therapeutic hypothermia reduces infarct volume and the frequency and expansion of SDs following cerebral ischemia.
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Affiliation(s)
- Modar Kentar
- Department of Neurosurgery,
University of Heidelberg, Heidelberg, Germany
| | | | | | - Renan Sanchez-Porras
- Department of Neurosurgery,
Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg,
Oldenburg, Germany
| | | | - Niklas Holzwarth
- Division of Intelligent Medical
Systems, German Cancer Research Center, Heidelberg, Germany
| | - Lena Maier-Hein
- Division of Intelligent Medical
Systems, German Cancer Research Center, Heidelberg, Germany
| | - Johannes Woitzik
- Department of Neurosurgery,
Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg,
Oldenburg, Germany
| | - Edgar Santos
- Department of Neurosurgery,
University of Heidelberg, Heidelberg, Germany
- Department of Neurosurgery,
Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg,
Oldenburg, Germany
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Mair G, White P, Bath PM, Muir KW, Al‐Shahi Salman R, Martin C, Dye D, Chappell FM, Vacek A, von Kummer R, Macleod M, Sprigg N, Wardlaw JM. External Validation of e-ASPECTS Software for Interpreting Brain CT in Stroke. Ann Neurol 2022; 92:943-957. [PMID: 36053916 PMCID: PMC9826303 DOI: 10.1002/ana.26495] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 07/08/2022] [Accepted: 08/29/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The purpose of this study was to test e-ASPECTS software in patients with stroke. Marketed as a decision-support tool, e-ASPECTS may detect features of ischemia or hemorrhage on computed tomography (CT) imaging and quantify ischemic extent using Alberta Stroke Program Early CT Score (ASPECTS). METHODS Using CT from 9 stroke studies, we compared software with masked experts. As per indications for software use, we assessed e-ASPECTS results for patients with/without middle cerebral artery (MCA) ischemia but no other cause of stroke. In an analysis outside the intended use of the software, we enriched our dataset with non-MCA ischemia, hemorrhage, and mimics to simulate a representative "front door" hospital population. With final diagnosis as the reference standard, we tested the diagnostic accuracy of e-ASPECTS for identifying stroke features (ischemia, hyperattenuated arteries, and hemorrhage) in the representative population. RESULTS We included 4,100 patients (51% women, median age = 78 years, National Institutes of Health Stroke Scale [NIHSS] = 10, onset to scan = 2.5 hours). Final diagnosis was ischemia (78%), hemorrhage (14%), or mimic (8%). From 3,035 CTs with expert-rated ASPECTS, most (2084/3035, 69%) e-ASPECTS results were within one point of experts. In the representative population, the diagnostic accuracy of e-ASPECTS was 71% (95% confidence interval [CI] = 70-72%) for detecting ischemic features, 85% (83-86%) for hemorrhage. Software identified more false positive ischemia (12% vs 2%) and hemorrhage (14% vs <1%) than experts. INTERPRETATION On independent testing, e-ASPECTS provided moderate agreement with experts and overcalled stroke features. Therefore, future prospective trials testing impacts of artificial intelligence (AI) software on patient care and outcome are required before widespread implementation of stroke decision-support software. ANN NEUROL 2022;92:943-957.
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Affiliation(s)
- Grant Mair
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Philip White
- Translational and Clinical Research InstituteNewcastle University and Newcastle upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical NeuroscienceUniversity of NottinghamNottinghamUK
| | - Keith W. Muir
- School of Psychology & NeuroscienceUniversity of GlasgowGlasgowUK
| | | | - Chloe Martin
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - David Dye
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | | | - Adam Vacek
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Rüdiger von Kummer
- Department of NeuroradiologyUniversity Hospital, Technische Universität DresdenDresdenGermany
| | - Malcolm Macleod
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
| | - Nikola Sprigg
- Translational and Clinical Research InstituteNewcastle University and Newcastle upon Tyne Hospitals NHS TrustNewcastle upon TyneUK
| | - Joanna M. Wardlaw
- Centre for Clinical Brain SciencesUniversity of EdinburghEdinburghUK
- UK Dementia Research Institute Centre at the University of EdinburghEdinburghUK
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Lima R, Monteiro A, Salgado AJ, Monteiro S, Silva NA. Pathophysiology and Therapeutic Approaches for Spinal Cord Injury. Int J Mol Sci 2022; 23:ijms232213833. [PMID: 36430308 PMCID: PMC9698625 DOI: 10.3390/ijms232213833] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 11/12/2022] Open
Abstract
Spinal cord injury (SCI) is a disabling condition that disrupts motor, sensory, and autonomic functions. Despite extensive research in the last decades, SCI continues to be a global health priority affecting thousands of individuals every year. The lack of effective therapeutic strategies for patients with SCI reflects its complex pathophysiology that leads to the point of no return in its function repair and regeneration capacity. Recently, however, several studies started to uncover the intricate network of mechanisms involved in SCI leading to the development of new therapeutic approaches. In this work, we present a detailed description of the physiology and anatomy of the spinal cord and the pathophysiology of SCI. Additionally, we provide an overview of different molecular strategies that demonstrate promising potential in the modulation of the secondary injury events that promote neuroprotection or neuroregeneration. We also briefly discuss other emerging therapies, including cell-based therapies, biomaterials, and epidural electric stimulation. A successful therapy might target different pathologic events to control the progression of secondary damage of SCI and promote regeneration leading to functional recovery.
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Affiliation(s)
- Rui Lima
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s Associate Laboratory, PT Government Associated Laboratory, 4806-909 Braga/Guimarães, Portugal
| | - Andreia Monteiro
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s Associate Laboratory, PT Government Associated Laboratory, 4806-909 Braga/Guimarães, Portugal
| | - António J. Salgado
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s Associate Laboratory, PT Government Associated Laboratory, 4806-909 Braga/Guimarães, Portugal
| | - Susana Monteiro
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s Associate Laboratory, PT Government Associated Laboratory, 4806-909 Braga/Guimarães, Portugal
| | - Nuno A. Silva
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal
- ICVS/3B’s Associate Laboratory, PT Government Associated Laboratory, 4806-909 Braga/Guimarães, Portugal
- Correspondence:
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10
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Blanco S, Martínez-Lara E, Siles E, Peinado MÁ. New Strategies for Stroke Therapy: Nanoencapsulated Neuroglobin. Pharmaceutics 2022; 14:pharmaceutics14081737. [PMID: 36015363 PMCID: PMC9412405 DOI: 10.3390/pharmaceutics14081737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 01/12/2023] Open
Abstract
Stroke is a global health and socio-economic problem. However, no efficient preventive and/or palliative treatments have yet been found. Neuroglobin (Ngb) is an endogen neuroprotective protein, but it only exerts its beneficial action against stroke after increasing its basal levels. Therefore, its systemic administration appears to be an efficient therapy applicable to stroke and other neurodegenerative pathologies. Unfortunately, Ngb cannot cross the blood-brain barrier (BBB), making its direct pharmacological use unfeasible. Thus, the association of Ngb with a drug delivery system (DDS), such as nanoparticles (NPs), appears to be a good strategy for overcoming this handicap. NPs are a type of DDS which efficiently transport Ngb and increase its bioavailability in the infarcted area. Hence, we previously built hyaluronate NPS linked to Ngb (Ngb-NPs) as a therapeutic tool against stroke. This nanoformulation induced an improvement of the cerebral infarct prognosis. However, this innovative therapy is still in development, and a more in-depth study focusing on its long-lasting neuroprotectant and neuroregenerative capabilities is needed. In short, this review aims to update the state-of-the-art of stroke therapies based on Ngb, paying special attention to the use of nanotechnological drug-delivering tools.
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11
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Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Peinado MÁ, Ovelleiro D, del Moral ML, Hernández R, Martínez-Lara E, Siles E, Pedrajas JR, García-Martín ML, Caro C, Peralta S, Morales ME, Ruiz MA, Blanco S. Biological Implications of a Stroke Therapy Based in Neuroglobin Hyaluronate Nanoparticles. Neuroprotective Role and Molecular Bases. Int J Mol Sci 2021; 23:247. [PMID: 35008673 PMCID: PMC8745106 DOI: 10.3390/ijms23010247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 12/23/2021] [Indexed: 12/11/2022] Open
Abstract
Exogenous neuroprotective protein neuroglobin (Ngb) cannot cross the blood-brain barrier. To overcome this difficulty, we synthesized hyaluronate nanoparticles (NPs), able to deliver Ngb into the brain in an animal model of stroke (MCAO). These NPs effectively reached neurons, and were microscopically identified after 24 h of reperfusion. Compared to MCAO non-treated animals, those treated with Ngb-NPs showed survival rates up to 50% higher, and better neurological scores. Tissue damage improved with the treatment, but no changes in the infarct volume or in the oxidative/nitrosative values were detected. A proteomics approach (p-value < 0.02; fold change = 0.05) in the infarcted areas showed a total of 219 proteins that significantly changed their expression after stroke and treatment with Ngb-NPs. Of special interest, are proteins such as FBXO7 and NTRK2, which were downexpressed in stroke, but overexpressed after treatment with Ngb-NPs; and ATX2L, which was overexpressed only under the effect of Ngb. Interestingly, the proteins affected by the treatment with Ngb were involved in mitochondrial function and cell death, endocytosis, protein metabolism, cytoskeletal remodeling, or synaptic function, and in regenerative processes, such as dendritogenesis, neuritogenesis, or sinaptogenesis. Consequently, our pharmaceutical preparation may open new therapeutic scopes for stroke and possibly for other neurodegenerative pathologies.
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Affiliation(s)
- María Ángeles Peinado
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - David Ovelleiro
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - María Luisa del Moral
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - Raquel Hernández
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - Esther Martínez-Lara
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - Eva Siles
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - José Rafael Pedrajas
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
| | - María Luisa García-Martín
- BIONAND-Centro Andaluz de Nanomedicina y Biotecnología, Junta de Andalucía, Universidad de Málaga, Parque Tecnológico de Andalucía, 29590 Malaga, Spain; (M.L.G.-M.); (C.C.)
| | - Carlos Caro
- BIONAND-Centro Andaluz de Nanomedicina y Biotecnología, Junta de Andalucía, Universidad de Málaga, Parque Tecnológico de Andalucía, 29590 Malaga, Spain; (M.L.G.-M.); (C.C.)
| | - Sebastián Peralta
- Department of Pharmacy and Pharmaceutical Technology, Campus de Cartuja s/n, School of Pharmacy, University of Granada, 18071 Granada, Spain; (S.P.); (M.E.M.); (M.A.R.)
| | - María Encarnación Morales
- Department of Pharmacy and Pharmaceutical Technology, Campus de Cartuja s/n, School of Pharmacy, University of Granada, 18071 Granada, Spain; (S.P.); (M.E.M.); (M.A.R.)
| | - María Adolfina Ruiz
- Department of Pharmacy and Pharmaceutical Technology, Campus de Cartuja s/n, School of Pharmacy, University of Granada, 18071 Granada, Spain; (S.P.); (M.E.M.); (M.A.R.)
| | - Santos Blanco
- Department of Experimental Biology, Campus de Las Lagunillas s/n, University of Jaén, Building B3, 23071 Jaen, Spain; (D.O.); (M.L.d.M.); (R.H.); (E.M.-L.); (E.S.); (J.R.P.)
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13
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Omileke D, Pepperall D, Bothwell SW, Mackovski N, Azarpeykan S, Beard DJ, Coupland K, Patabendige A, Spratt NJ. Ultra-Short Duration Hypothermia Prevents Intracranial Pressure Elevation Following Ischaemic Stroke in Rats. Front Neurol 2021; 12:684353. [PMID: 34616350 PMCID: PMC8488292 DOI: 10.3389/fneur.2021.684353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
There is a transient increase in intracranial pressure (ICP) 18–24 h after ischaemic stroke in rats, which is prevented by short-duration hypothermia using rapid cooling methods. Clinical trials of long-duration hypothermia have been limited by feasibility and associated complications, which may be avoided by short-duration cooling. Animal studies have cooled faster than is achievable in patients. We aimed to determine whether gradual cooling at a rate of 2°C/h to 33°C or 1°C/h to 34.5°C, with a 30 min duration at target temperatures, prevented ICP elevation and reduced infarct volume in rats. Transient middle cerebral artery occlusion was performed, followed by gradual cooling to target temperature. Hypothermia to 33°C prevented significant ICP elevation (hypothermia ΔICP = 1.56 ± 2.26 mmHg vs normothermia ΔICP = 8.93 ± 4.82 mmHg; p = 0.02) and reduced infarct volume (hypothermia = 46.4 ± 12.3 mm3 vs normothermia = 85.0 ± 17.5 mm3; p = 0.01). Hypothermia to 34.5°C did not significantly prevent ICP elevation or reduce infarct volume. We showed that gradual cooling to 33°C, at cooling rates achievable in patients, had the same ICP preventative effect as traditional rapid cooling methods. This suggests that this paradigm could be translated to prevent delayed ICP rise in stroke patients.
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Affiliation(s)
- Daniel Omileke
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Debbie Pepperall
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Steven W Bothwell
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Nikolce Mackovski
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Sara Azarpeykan
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Daniel J Beard
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Kirsten Coupland
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Adjanie Patabendige
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Neil J Spratt
- The School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton, NSW, Australia.,Department of Neurology, John Hunter Hospital, Hunter New England Local Health District, New Lambton, NSW, Australia
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14
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Becker A, Helmuth M, Trzeczak D, Chindo BA. Methanol extract of Ficus platyphylla decreases cerebral ischemia induced injury in mice. JOURNAL OF ETHNOPHARMACOLOGY 2021; 278:114219. [PMID: 34058316 DOI: 10.1016/j.jep.2021.114219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/07/2021] [Accepted: 05/17/2021] [Indexed: 06/12/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Extracts of the stem bark of Ficus paltyphylla (FP) are used in the Nigerian traditional medicine to manage psychoses, depression, epilepsy, pain, and inflammation. Our previous studies revealed that the methanol extract of FP ameliorate body core temperature. AIM OF THE STUDY A number of pharmacological agents that utilize mechanisms that enhanced neuronal survival and/or neural regeneration have been developed for the treatment of stroke. Hypothermia protects the brain from damage caused by ischemia by attenuating destructive processes such as neuroinflammation, excitotoxicity, blood-brain barrier disruption, apoptosis, and free radical formation following cerebral ischemia. In the present study, we examined the neuroprotective potential of FP on permanent occlusion of the middle cerebral artery (MCAO)-induced ischemia in mice. MATERIAL AND METHODS C57Bl mice were subjected to MCAO. FP was administered 1 h prior to and immediately after surgery. The brains were collected 24 h later and infarct volumes were measured using immune-histochemical staining, DAPI, NeuN, synaptophysin, and NR2B were quantified. RESULTS Administration of FP prior to MCAO significantly reduced infarct volume, with no effect on infarct volume immediately after MCAO. Higher numbers of cells and neurons were observed in the peri-infarct area in both groups of mice. FP-induced hypothermia protected tissue in the peri-infarct region from synaptophysin reduction. NMDA receptor 2 (NR2B) immunoreactivity is enhanced by MCAO, with no difference observed in both sham-operated and FP-induced hypothermia groups of mice. CONCLUSIONS The data suggest that FP might be useful in the reduction of ischemia-induced infarct volume when administered prior to the initiation of ischemia with no effect observed after ischemia induction.
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Affiliation(s)
- Axel Becker
- Institute for Pharmacology and Toxicology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.
| | - Martin Helmuth
- Institute for Pharmacology and Toxicology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Doris Trzeczak
- Institute for Pharmacology and Toxicology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Ben A Chindo
- Department of Pharmacology and Toxicology, Faculty of Pharmaceutical Sciences, Kaduna State University, Kaduna, Nigeria; Department of Pharmacology and Toxicology, National Institute for Pharmaceutical Research & Development, Abuja, Nigeria
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15
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Bannach-Brown A, Hair K, Bahor Z, Soliman N, Macleod M, Liao J. Technological advances in preclinical meta-research. BMJ OPEN SCIENCE 2021; 5:e100131. [PMID: 35047701 PMCID: PMC8647618 DOI: 10.1136/bmjos-2020-100131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Alexandra Bannach-Brown
- Berlin Institute of Health, QUEST Center, Charité Universitätsmedizin Berlin, Berlin, Germany
- Institute for Evidence-Based Practice, Bond University, Robina, Queensland, Australia
| | - Kaitlyn Hair
- Centre for Clinical Brain Sciences, The University of Edinburgh Edinburgh Medical School, Edinburgh, Scotland, UK
| | - Zsanett Bahor
- Centre for Clinical Brain Sciences, The University of Edinburgh Edinburgh Medical School, Edinburgh, Scotland, UK
| | - Nadia Soliman
- Pain Research; Faculty of Medicine, Department of Surgery and Cancer, Imperial College London, London, Greater London, UK
| | - Malcolm Macleod
- Centre for Clinical Brain Sciences, The University of Edinburgh Edinburgh Medical School, Edinburgh, Scotland, UK
| | - Jing Liao
- Centre for Clinical Brain Sciences, The University of Edinburgh Edinburgh Medical School, Edinburgh, Scotland, UK
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16
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Mullhi RK, Singh N, Veenith T. Critical care management of the patient with an acute ischaemic stroke. Br J Hosp Med (Lond) 2021; 82:1-9. [PMID: 33512282 DOI: 10.12968/hmed.2020.0123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Acute ischaemic stroke is a leading cause of morbidity and mortality worldwide. In the UK alone, there are more than 100 000 strokes per year, causing 38 000 deaths. While the incidence remains high, there has been significant medical progress in reducing mortality following a stroke. Admission of patients to specialised stroke units has led to an improvement in clinical outcomes, but the role of intensive care is less well defined. This article reviews the current critical care management and neuro-therapeutic options after an acute ischaemic stroke.
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Affiliation(s)
- Randeep K Mullhi
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Intensive Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Naginder Singh
- Department of Anaesthesia, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tonny Veenith
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Intensive Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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17
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Kannan A, Delgardo M, Pennington-FitzGerald W, Jiang EX, Christophe BR, Connolly ES. Pharmacological management of cerebral ischemia in the elderly. Expert Opin Pharmacother 2020; 22:897-906. [PMID: 33382005 DOI: 10.1080/14656566.2020.1856815] [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: 10/22/2022]
Abstract
Introduction: For elderly adults in the United States, stroke is the fifth leading cause of death of which ischemic strokes comprise a vast majority. Optimal pharmacological management of elderly ischemic stroke patients involves both reperfusion and supportive care. Recent research into pharmacological management has focused on vascular, immunomodulatory, cytoprotective, and alternative agents, some of which have shown limited success in clinical trials. However, no treatments have been established as a reliable mode for management of cerebral ischemia for elderly adults beyond acute thrombolysis.Areas covered: The authors conducted a literature search for ischemic stroke management in the elderly and a search for human drug studies for managing ischemic stroke on clinicaltrials.gov. Here, they describe recent progress in the pharmacological management of cerebral ischemia in the elderly.Expert opinion: Many drug classes (antihypertensive, cytoprotective and immunomodulatory, and alternative agents) have been explored with limited success in managing ischemic stroke, though some have shown preventative benefits. We generally observed a broad gap in evidence on elderly patients from studies across all drug classes, necessitating further studies to gain an understanding of effective management of ischemic stroke in this large demographic of patients.
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Affiliation(s)
- Adithya Kannan
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Mychael Delgardo
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Enoch X Jiang
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Brandon R Christophe
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
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18
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Lutz Y, Meiner T, Krames L, Cattaneo G, Meckel S, Dossel O, Loewe A. Selective Brain Hypothermia for Ischemic MCA-M1 Stroke: Influence of Cerebral Arterial Circulation in a 3D Brain Temperature Model. IEEE Trans Biomed Eng 2020; 68:404-415. [PMID: 32746020 DOI: 10.1109/tbme.2020.3000521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Acute ischemic stroke is a major health problem with a high mortality rate and a high risk for permanent disabilities. Selective brain hypothermia has the neuroprotective potential to possibly lower cerebral harm. A recently developed catheter system enables to combine endovascular blood cooling and thrombectomy using the same endovascular access. By using the penumbral perfusion via leptomeningeal collaterals, the catheter aims at enabling a cold reperfusion, which mitigates the risk of a reperfusion injury. However, cerebral circulation is highly patient-specific and can vary greatly. Since direct measurement of remaining perfusion and temperature decrease induced by the catheter is not possible without additional harm to the patient, computational modeling provides an alternative to gain knowledge about resulting cerebral temperature decrease. In this work, we present a brain temperature model with a realistic division into gray and white matter and consideration of spatially resolved perfusion. Furthermore, it includes detailed anatomy of cerebral circulation with possibility of personalizing on base of real patient anatomy. For evaluation of catheter performance in terms of cold reperfusion and to analyze its general performance, we calculated the decrease in brain temperature in case of a large vessel occlusion in the middle cerebral artery (MCA) for different scenarios of cerebral arterial anatomy. Congenital arterial variations in the circle of Willis had a distinct influence on the cooling effect and the resulting spatial temperature distribution before vessel recanalization. Independent of the branching configurations, the model predicted a cold reperfusion due to a strong temperature decrease after recanalization (1.4-2.2 °C after 25 min of cooling, recanalization after 20 min of cooling). Our model illustrates the effectiveness of endovascular cooling in combination with mechanical thrombectomy and its results serve as an adequate substitute for temperature measurement in a clinical setting in the absence of direct intraparenchymal temperature probes.
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19
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Ávila-Gómez P, Hervella P, Da Silva-Candal A, Pérez-Mato M, Rodríguez-Yáñez M, López-Dequidt I, Pumar JM, Castillo J, Sobrino T, Iglesias-Rey R, Campos F. Temperature-Induced Changes in Reperfused Stroke: Inflammatory and Thrombolytic Biomarkers. J Clin Med 2020; 9:jcm9072108. [PMID: 32635529 PMCID: PMC7408797 DOI: 10.3390/jcm9072108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 12/14/2022] Open
Abstract
Although hyperthermia is associated with poor outcomes in ischaemic stroke (IS), some studies indicate that high body temperature may benefit reperfusion therapies. We assessed the association of temperature with effective reperfusion (defined as a reduction of ≥8 points in the National Institute of Health Stroke Scale (NIHSS) within the first 24 h) and poor outcome (modified Rankin Scale (mRS) > 2) in 875 retrospectively-included IS patients. We also studied the influence of temperature on thrombolytic (cellular fibronectin (cFn); matrix metalloproteinase 9 (MMP-9)) and inflammatory biomarkers (tumour necrosis factor-alpha (TNF-α), interleukin 6 (IL-6)) and their relationship with effective reperfusion. Our results showed that a higher temperature at 24 but not 6 h after stroke was associated with failed reperfusion (OR: 0.373, p = 0.001), poor outcome (OR: 2.190, p = 0.005) and higher IL-6 levels (OR: 0.958, p < 0.0001). Temperature at 6 h was associated with higher MMP-9 levels (R = 0.697; p < 0.0001) and effective reperfusion, although this last association disappeared after adjusting for confounding factors (OR: 1.178, p = 0.166). Our results suggest that body temperature > 37.5 °C at 24 h, but not at 6 h after stroke, is correlated with reperfusion failure, poor clinical outcome, and infarct size. Mild hyperthermia (36.5–37.5 °C) in the first 6 h window might benefit drug reperfusion therapies by promoting clot lysis.
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Affiliation(s)
- Paulo Ávila-Gómez
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
| | - Pablo Hervella
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
| | - Andrés Da Silva-Candal
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
| | - María Pérez-Mato
- Neuroscience and Cerebrovascular Research Laboratory, Department of Neurology and Stroke Center, La Paz University Hospital, Neuroscience Area of IdiPAZ Health Research Institute, Universidad Autónoma de Madrid, E28046 Madrid, Spain;
| | - Manuel Rodríguez-Yáñez
- Stroke Unit, Department of Neurology, Health Research Institute of Santiago de Compostela, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain; (M.R.-Y.); (I.L.-D.)
| | - Iria López-Dequidt
- Stroke Unit, Department of Neurology, Health Research Institute of Santiago de Compostela, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain; (M.R.-Y.); (I.L.-D.)
| | - José M. Pumar
- Department of Neuroradiology, Hospital Clínico Universitario, Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain;
| | - José Castillo
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
| | - Tomás Sobrino
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
| | - Ramón Iglesias-Rey
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
- Correspondence: (R.I.-R.); (F.C.); Tel./Fax: +34-981951098 (R.I.-R. & F.C.)
| | - Francisco Campos
- Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), E15706 Santiago de Compostela, Spain; (P.Á.-G.); (P.H.); (A.D.S.-C.); (J.C.); (T.S.)
- Correspondence: (R.I.-R.); (F.C.); Tel./Fax: +34-981951098 (R.I.-R. & F.C.)
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20
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Ávila-Gómez P, Vieites-Prado A, Dopico-López A, Bashir S, Fernández-Susavila H, Gubern C, Pérez-Mato M, Correa-Paz C, Iglesias-Rey R, Sobrino T, Bustamante A, Wellmann S, Montaner J, Serena J, Castillo J, Hervella P, Campos F. Cold stress protein RBM3 responds to hypothermia and is associated with good stroke outcome. Brain Commun 2020; 2:fcaa078. [PMID: 33585816 PMCID: PMC7869850 DOI: 10.1093/braincomms/fcaa078] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/22/2020] [Accepted: 05/04/2020] [Indexed: 12/20/2022] Open
Abstract
RNA-binding motif protein 3 is a molecular marker of hypothermia that has proved neuroprotective in neurodegenerative disease models. However, its relationship to the well-recognized therapeutic effect of hypothermia in ischaemic stroke had not been studied. In this work, the expression of RNA-binding motif protein 3 was investigated in ischaemic animal models subjected to systemic and focal brain hypothermia, specifically the effects of RNA-binding motif protein 3 silencing and overexpression on ischaemic lesions. Moreover, the association of RNA-binding motif protein 3 levels with body temperature and clinical outcome was evaluated in two independent cohorts of acute ischaemic stroke patients (n = 215); these levels were also determined in a third cohort of 31 patients derived from the phase III EuroHYP-1 trial of therapeutic cooling in ischaemic stroke. The preclinical data confirmed the increase of brain RNA-binding motif protein 3 levels in ischaemic animals subjected to systemic and focal hypothermia; this increase was selectively higher in the cooled hemisphere of animals undergoing focal brain hypothermia, thus confirming the direct effect of hypothermia on RNA-binding motif protein 3 expression, while RNA-binding motif protein 3 up-regulation in ischaemic brain regions led to functional recovery. Clinically, patients with body temperature <37.5°C in the first two cohorts had higher RNA-binding motif protein 3 values at 24 h and good outcome at 3 months post-ischaemic stroke, while RNA-binding motif protein 3 levels in the cooled third cohort tended to exceed those in placebo-treated patients. These results make RNA-binding motif protein 3 a molecular marker associated with the effect of hypothermia in ischaemic stroke and suggest its potential application as a promising protective target.
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Affiliation(s)
- Paulo Ávila-Gómez
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain
| | - Alba Vieites-Prado
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain
| | - Antonio Dopico-López
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain
| | - Saima Bashir
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta de Girona, IDIBGI, Girona 17007, Spain
| | - Héctor Fernández-Susavila
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain
| | - Carme Gubern
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta de Girona, IDIBGI, Girona 17007, Spain
| | - María Pérez-Mato
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain.,Neuroscience and Cerebrovascular Research Laboratory, Department of Neurology and Stroke Center, La Paz University Hospital, Hospital La Paz Institute for Health Research (IdiPAZ), Autonomous University of Madrid, 28046, Madrid, Spain
| | - Clara Correa-Paz
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain
| | - Ramón Iglesias-Rey
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain
| | - Tomás Sobrino
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona, Barcelona 08035, Spain
| | - Sven Wellmann
- Department of Neonatology, University Children's Hospital Regensburg (KUNO), University of Regensburg, 93049 Regensburg, Germany
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona, Barcelona 08035, Spain
| | - Joaquín Serena
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta de Girona, IDIBGI, Girona 17007, Spain
| | - José Castillo
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain
| | - Pablo Hervella
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain
| | - Francisco Campos
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela (IDIS), Hospital Clínico Universitario, Santiago de Compostela 15706, Spain
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21
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Mair G, Chappell F, Martin C, Dye D, Bath PM, Muir KW, von Kummer R, Al-Shahi Salman R, Sandercock PAG, Macleod M, Sprigg N, White P, Wardlaw JM. Real-world Independent Testing of e-ASPECTS Software (RITeS): statistical analysis plan. AMRC OPEN RESEARCH 2020; 2:20. [PMID: 35800260 PMCID: PMC7612993 DOI: 10.12688/amrcopenres.12904.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background: Artificial intelligence-based software may automatically detect ischaemic stroke lesions and provide an Alberta Stroke Program Early CT score (ASPECTS) on CT, and identify arterial occlusion and provide a collateral score on CTA. Large-scale independent testing will inform clinical use, but is lacking. We aim to test e-ASPECTS and e-CTA (Brainomix, Oxford UK) using CT scans obtained from a range of clinical studies. Methods: Using prospectively collected baseline CT and CTA scans from 10 national/international clinical stroke trials or registries (total >6600 patients), we will select a large clinically representative sample for testing e-ASPECTS and e-CTA compared to previously acquired independent expert human interpretation (reference standard). Our primary aims are to test agreement between software-derived and masked human expert ASPECTS, and the diagnostic accuracy of e-ASPECTS for identifying all causes of stroke symptoms using follow-up imaging and final clinical opinion as diagnostic ground truth. Our secondary aims are to test when and why e-ASPECTS is more or less accurate, or succeeds/fails to produce results, agreement between e-CTA and human expert CTA interpretation, and repeatability of e-ASPECTS/e-CTA results. All testing will be conducted on an intention-to-analyse basis. We will assess agreement between software and expert-human ratings and test the diagnostic accuracy of software. Conclusions: RITeS will provide comprehensive, robust and representative testing of e-ASPECTS and e-CTA against the current gold-standard, expert-human interpretation.
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Affiliation(s)
- Grant Mair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Chloe Martin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - David Dye
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Philip M. Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Keith W. Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, G51 4TF, UK
| | - Rüdiger von Kummer
- Department of Neuroradiology, University Hospital Dresden, Dresden, 01309, Germany
| | | | | | - Malcolm Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Joanna M. Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
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22
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Dong Y, Qu J, Zhang Z, Wang C, Dong Q. Human urinary kallidinogenase in treating acute ischemic stroke patients: analyses of pooled data from a randomized double-blind placebo-controlled phase IIb and phase III clinical trial. Neurol Res 2020; 42:286-290. [PMID: 32138624 DOI: 10.1080/01616412.2020.1711648] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: Intravenous thrombolysis and thrombectomy are recommended for patients whose stroke onsets are within first 6 h, and very few options are available for patients whose stroke onset is more than 6 h, which includes most ischemic stroke patients. Human urinary kallidinogenase (HUK) showed potential clinical benefits in acute ischemic stroke patients. This study aims to investigate the safety and clinical benefits of HUK in ischemic stroke patients.Patients and methods: Patients were recruited for a multicenter double-blind, placebo-controlled phase II b and phase III trial. Neurophysiological outcomes were assessed by the European Stroke Scale (ESS) and the functional outcomes were assessed by the activity of daily living scale (ADL). Safety was monitored by recording adverse events.Results: The improvements in ESS scores and ADL scores in the HUK group were significantly greater than that in patients receiving placebo. Furthermore, HUK treatment was also associated with a lower rate of disable, according to ADL. HUK-related adverse events occurred at a low rate, in 1.73% of HUK-treated patients.Conclusion: HUK is safe and provides potential clinical benefits as a treatment for acute ischemic stroke. Further large post-marketing observational studies are needed.
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Affiliation(s)
- Yi Dong
- Department of Neurology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jiazhi Qu
- Department of Medical Affairs, Techpool Bio-Pharma Co., LTD, Chengdu, China
| | - Zhijun Zhang
- Department of Medical Affairs, Techpool Bio-Pharma Co., LTD, Chengdu, China
| | - Changjun Wang
- Department of Medical Affairs, Techpool Bio-Pharma Co., LTD, Chengdu, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
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23
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Katica-Mulalic A, Suljic E, Begic E, Mukanovic-Alihodzic A, Straus S, Feto A, Dedovic Z, Gojak R. Effect of Therapeutic Hypothermia on Liver Enzymes in Patients With Stroke. Med Arch 2020; 74:470-473. [PMID: 33603273 PMCID: PMC7879342 DOI: 10.5455/medarh.2020.74.470-473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: A promising strategy that can lead to longer brain cell survival after an acute stroke is therapeutic hypothermia. It represents a controlled decrease in body temperature for therapeutic reasons. It is increasingly represented as a therapeutic option and is one of the most challenging treatments that improves neurological recovery and treatment outcome in patients with acute stroke. Aim: To examine the effect of therapeutic hypothermia on liver enzymes in patients with diagnosis of stroke. Methods: A total of 101 patients diagnosed with acute stroke were treated. The first group (n=40) were treated with conventional treatment and therapeutic hypothermia, while the second group (n=61) only with conventional treatment. Cooling of the body to a target body temperature of 34°C to 35°C was performed for up to 24 hours. Outcome (survival or death) of treatment was monitored, degree of disability was determined by National Institutes of Health Stroke Scale (NIHSS) and assessment of consciousness using the Glasgow Coma Scale (GCS). Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values were taken at admission, after 24 hours, and were monitored upon discharge. Results: There was a significant difference in AST values at admission relative to disease outcome (p = 0.002), as well as for ALT (p = 0.008). In patients treated with therapeutic hypothermia, mean AST values decreased after 24 hours (32.50 to 31.00 IU/mL) as well as ALT values (27.50 to 26.50 IU/mL), without statistical significance. In the group of subjects who survived with sequela, AST values correlated with GCS (rho = -0.489; p = 0.002) and NIHSS (rho = 0.492; p = 0.003), ALT values correlated with GCS (rho = -0.356; p = 0.03) but not with NIHSS. Conclusion: AST and ALT values at admission correlate with the severity of the clinical picture. Therapeutic hypothermia is hepatoprotective and lowers AST and ALT values.
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Affiliation(s)
- Amela Katica-Mulalic
- Clinic Anesthesiology and Resuscitation, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Enra Suljic
- Department for Science, Teaching and Clinical Trials, Clinical Centre University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Edin Begic
- Department of Cardiology, General Hospital «Prim. dr. Abdulah Nakas», Sarajevo, Bosnia and Herzegovina
| | - Azra Mukanovic-Alihodzic
- Clinic Anesthesiology and Resuscitation, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Slavenka Straus
- Clinic for Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Amila Feto
- Clinic Anesthesiology and Resuscitation, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Zenaida Dedovic
- Clinic Anesthesiology and Resuscitation, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Refet Gojak
- Clinic for Infectious Diseases, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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24
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Intraoperative Hypothermia Is Associated with Reduced Acute Kidney Injury After Spine Surgery Under General Anesthesia: A Retrospective Observational Study. J Neurosurg Anesthesiol 2020; 32:63-69. [DOI: 10.1097/ana.0000000000000552] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Vaughan BC, Jones MER, Browne IL, Olshavsky JM, Schultz RD. Selective retrograde cerebral cooling in complete cerebral circulatory arrest. Brain Circ 2019; 5:234-240. [PMID: 31950100 PMCID: PMC6950516 DOI: 10.4103/bc.bc_60_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/09/2019] [Accepted: 12/16/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE: Cerebral hypothermia is a known neuroprotectant with promising applications in the treatment of ischemic events. Although systemic cooling is standard in post-cardiac arrest care, the deleterious effects of whole-body cooling have precluded it from translation into a viable treatment option for acute ischemic stroke (AIS). Selective cerebral cooling has been proposed as a method to minimize these risks while granting the neuroprotection of therapeutic hypothermia in AIS. METHODS: In a porcine model (n = 3), the efficacy of selective retrograde cerebral cooling through the internal jugular vein was evaluated in the setting of complete cerebral circulatory arrest. Furthermore, a novel endovascular device and cooling system enabling selective retrograde cerebral cooling were studied in a normothermic perfused cadaver. RESULTS AND CONCLUSION: Neurologic assessment of animals receiving this therapy reflected substantial neuroprotection in animals undergoing both 15 min and 30 min of otherwise catastrophic complete cerebral circulatory arrest. The novel endovascular device and cooling system were validated in human anatomy, demonstrating successful cerebral cooling, and feasibility of this mechanism of selective retrograde cerebral cooling.
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Affiliation(s)
| | - Melissa E R Jones
- Voyage Biomedical Inc., Berkeley, CA, United States.,Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ikennah L Browne
- Voyage Biomedical Inc., Berkeley, CA, United States.,Department of Surgery, Division of General Surgery, University of Calgary, Calgary, AB, Canada
| | | | - Robert D Schultz
- Voyage Biomedical Inc., Berkeley, CA, United States.,Section of Cardiac Surgery, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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26
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27
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Lutz Y, Daschner R, Krames L, Loewe A, Cattaneo G, Meckel S, Dösse O. Modeling selective therapeutic hypothermia in case of acute ischemic stroke using a 1D hemodynamics model and a simplified brain geometry. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2019; 17:1147-1167. [PMID: 32233574 DOI: 10.3934/mbe.2020060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Therapeutic hypothermia (TH) is an approved neuroproctetive treatment to reduce neurological morbidity and mortality after hypoxic-ischemic damage related to cardiac arrest and neonatal asphyxia. Also in the treatment of acute ischemic stroke (AIS), which in Western countries still shows a very high mortality rate of about 25 %, selective mild TH by means of Targeted Temperature Management (TTM) could potentially decrease final infarct volume. In this respect, a novel intracarotid blood cooling catheter system has recently been developed, which allows for combined carotid blood cooling and mechanical thrombectomy (MT) and aims at selective mild TH in the affected ischemic brain (core and penumbra). Unfortunately, so far direct measurement and control of cooled cerebral temperature requires invasive or elaborate MRI-assisted measurements. Computational modeling provides unique opportunities to predict the resulting cerebral temperatures on the other hand. In this work, a simplified 3D brain model was generated and coupled with a 1D hemodynamics model to predict spatio-temporal cerebral temperature profiles using finite element modeling. Cerebral blood and tissue temperatures as well as the systemic temperature were analyzed for physiological conditions as well as for a middle cerebral artery (MCA) M1 occlusion. Furthermore, vessel recanalization and its effect on cerebral temperature was analyzed. The results show a significant influence of collateral flow on the cooling effect and are in accordance with experimental data in animals. Our model predicted a possible neuroprotective temperature decrease of 2.5 ℃ for the territory of MCA perfusion after 60 min of blood cooling, which underlines the potential of the new device and the use of TTM in case of AIS.
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Affiliation(s)
- Yannick Lutz
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Rosa Daschner
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Lorena Krames
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Giorgio Cattaneo
- Adceris GmbH & Co KG, Pforzheim, Germany (now at University of Stuttgart, Stuttgart, Germany)
| | - Stephan Meckel
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Olaf Dösse
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
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28
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Campbell BCV, De Silva DA, Macleod MR, Coutts SB, Schwamm LH, Davis SM, Donnan GA. Ischaemic stroke. Nat Rev Dis Primers 2019; 5:70. [PMID: 31601801 DOI: 10.1038/s41572-019-0118-8] [Citation(s) in RCA: 841] [Impact Index Per Article: 168.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
Stroke is the second highest cause of death globally and a leading cause of disability, with an increasing incidence in developing countries. Ischaemic stroke caused by arterial occlusion is responsible for the majority of strokes. Management focuses on rapid reperfusion with intravenous thrombolysis and endovascular thrombectomy, which both reduce disability but are time-critical. Accordingly, improving the system of care to reduce treatment delays is key to maximizing the benefits of reperfusion therapies. Intravenous thrombolysis reduces disability when administered within 4.5 h of the onset of stroke. Thrombolysis also benefits selected patients with evidence from perfusion imaging of salvageable brain tissue for up to 9 h and in patients who awake with stroke symptoms. Endovascular thrombectomy reduces disability in a broad group of patients with large vessel occlusion when performed within 6 h of stroke onset and in patients selected by perfusion imaging up to 24 h following stroke onset. Secondary prevention of ischaemic stroke shares many common elements with cardiovascular risk management in other fields, including blood pressure control, cholesterol management and antithrombotic medications. Other preventative interventions are tailored to the mechanism of stroke, such as anticoagulation for atrial fibrillation and carotid endarterectomy for severe symptomatic carotid artery stenosis.
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia. .,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia.
| | - Deidre A De Silva
- Department of Neurology, Singapore General Hospital campus, National Neuroscience Institute, Singapore, Singapore
| | - Malcolm R Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Shelagh B Coutts
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lee H Schwamm
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
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29
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Salehpour F, Majdi A, Pazhuhi M, Ghasemi F, Khademi M, Pashazadeh F, Hamblin MR, Cassano P. Transcranial Photobiomodulation Improves Cognitive Performance in Young Healthy Adults: A Systematic Review and Meta-Analysis. Photobiomodul Photomed Laser Surg 2019; 37:635-643. [PMID: 31549906 PMCID: PMC6818490 DOI: 10.1089/photob.2019.4673] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 06/20/2019] [Indexed: 02/07/2023] Open
Abstract
Background: Transcranial photobiomodulation (t-PBM) is a noninvasive modality that may improve cognitive function in both healthy and diseased subjects. Objective: This systematic review and meta-analysis addresses the question of whether t-PBM improves cognitive function in healthy adults. Methods: We searched MEDLINE using PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane Library up to March 2019. We also searched ProQuest and Google Scholar databases for unpublished material. The search was limited to articles on the procognitive effects of t-PBM in healthy adults. The initial search resulted in 871 studies, of which nine publications met our criteria for inclusion and exclusion. Seven studies were performed on young, healthy subjects (17-35 years), and two studies were conducted on older (≥49 years), normal subjects. A meta-analysis was performed on six full-text publications whose subjects were young adults. Results: t-PBM administration improved cognition-related outcomes by an 0.833 standardized mean difference (SMD; 95% confidence interval (CI): 0.458-1.209, 14 comparisons) in young, healthy participants. Funnel plotting revealed asymmetry, which was validated using Egger's (p = 0.030) and Begg's regression (p = 0.006) tests. However after reanalysis, this asymmetry disappeared in the attention subgroup, but not in the memory subgroup. The trim-and-fill analysis indicated two studies were lacking required data. Thus, the effect size was adjusted from an SMD of 0.761 (95% CI: 0.573-0.949) to 0.949 (0.779-1.120). The overall quality score of the studies was modest. Conclusions: We demonstrated a significant, beneficial effect of t-PBM on cognitive performance of young, healthy individuals; however, the heterogeneity of the data was high. This could be due to the modest quality or to the low number of included studies, or to the differences between the various subdomains assessed. These shortcomings should be meticulously addressed before concluding that t-PBM is a cognitive-enhancing intervention in healthy individuals.
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Affiliation(s)
- Farzad Salehpour
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
- Niraxx Light Therapeutics, Inc., Irvine, California
- ProNeuroLIGHT LLC, Phoenix, Arizona
| | - Alireza Majdi
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Faranak Ghasemi
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahsa Khademi
- Neurosciences Research Center (NSRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fariba Pashazadeh
- Research Center for Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Iranian EBM Center: A Joanna Briggs Institute Affiliated Group, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Michael R. Hamblin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Dermatology, Harvard Medical School, Boston, Massachusetts
- Harvard-MIT Division of Health Sciences and Technology, Cambridge, Massachusetts
| | - Paolo Cassano
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
- Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
- Department of Psychiatry, Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital, Boston, Massachusetts
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30
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Lyden PD, Lamb J, Kothari S, Toossi S, Boitano P, Rajput PS. Differential effects of hypothermia on neurovascular unit determine protective or toxic results: Toward optimized therapeutic hypothermia. J Cereb Blood Flow Metab 2019; 39:1693-1709. [PMID: 30461327 PMCID: PMC6727141 DOI: 10.1177/0271678x18814614] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Therapeutic hypothermia (TH) benefits survivors of cardiac arrest and neonatal hypoxic-ischemic injury and may benefit stroke patients. Large TH clinical trials, however, have shown mixed results. Given the substantial pre-clinical literature supporting TH, we explored possible mechanisms for clinical trial variability. Using a standard rodent stroke model (n = 20 per group), we found smaller infarctions after 2 h pre- or post-reperfusion TH compared to 4 h. To explore the mechanism of this discrepancy, we used primary cell cultures of rodent neurons, astrocytes, or endothelial cells subjected to oxygen-glucose deprivation (OGD). Then, cells were randomly assigned to 33℃, 35℃ or 37℃ for varying durations after varying delay times. Both 33 and 35℃ TH effectively preserved all cell types, although 33℃ was superior. Longer cooling durations overcame moderate delays to cooling initiation. In contrast, TH interfered with astrocyte paracrine protection of neurons in a temperature-dependent manner. These findings suggest that longer TH is needed to overcome delays to TH onset, but shorter TH durations may be superior to longer, perhaps due to suppression of astrocytic paracrine support of neurons during injury. We propose a scheme for optimizing TH after cerebral injury to stimulate further studies of cardiac arrest and stroke.
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Affiliation(s)
- Patrick D Lyden
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jessica Lamb
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shweta Kothari
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shahed Toossi
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,2 Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Paul Boitano
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Padmesh S Rajput
- 1 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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31
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Baron JC. Protecting the ischaemic penumbra as an adjunct to thrombectomy for acute stroke. Nat Rev Neurol 2019; 14:325-337. [PMID: 29674752 DOI: 10.1038/s41582-018-0002-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
After ischaemic stroke, brain damage can be curtailed by rescuing the 'ischaemic penumbra' - that is, the severely hypoperfused, at-risk but not yet infarcted tissue. Current evidence-based treatments involve restoration of blood flow so as to salvage the penumbra before it evolves into irreversibly damaged tissue, termed the 'core'. Intravenous thrombolysis (IVT) can salvage the penumbra if given within 4.5 h after stroke onset; however, the early recanalization rate is only ~30%. Direct removal of the occluding clot by mechanical thrombectomy considerably improves outcomes over IVT alone, but despite early recanalization in > 80% of cases, ~50% of patients who receive this treatment do not enjoy functional independence, usually because the core is already too large at the time of recanalization. Novel therapies aiming to 'freeze' the penumbra - that is, prevent core growth until recanalization is complete - hold potential as adjuncts to mechanical thrombectomy. This Review focuses on nonpharmacological approaches that aim to restore the physiological balance between oxygen delivery to and oxygen demand of the penumbra. Particular emphasis is placed on normobaric oxygen therapy, hypothermia and sensory stimulation. Preclinical evidence and early pilot clinical trials are critically reviewed, and future directions, including clinical translation and trial design issues, are discussed.
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Affiliation(s)
- Jean-Claude Baron
- Department of Neurology, Hôpital Sainte-Anne, Université Paris 5, INSERM U894, Paris, France.
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32
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Caroff J, King RM, Mitchell JE, Marosfoi M, Licwinko JR, Gray-Edwards HL, Puri AS, Merrill TL, Gounis MJ. Focal cooling of brain parenchyma in a transient large vessel occlusion model: proof-of-concept. J Neurointerv Surg 2019; 12:209-213. [PMID: 31363042 DOI: 10.1136/neurintsurg-2019-015179] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The neuroprotective benefit of therapeutic hypothermia (TH) has been demonstrated, but systemic side effects and time required to achieve effective TH in acute ischemic stroke (AIS) care limits clinical use. We investigate rapid and localized cooling using a novel insulated catheter in an ischemia-reperfusion model. METHODS In phase I (n=4), cold saline was delivered to the canine internal carotid artery via an insulated catheter. Temperature was measured using intracerebral thermocouples. The coolant flow rate was varied to meet a target temperature of 31-32°C in the hemisphere infused. In phase II (n=8), a temporary middle cerebral artery occlusion was created. Five dogs underwent localized TH at the optimal flow rate from phase I, and the remaining animals were untreated controls. Cooling was initiated 5 min before recanalization and continued for an additional 20 min following 45 min of occlusion duration. The outcome was infarct volume and neurological function. RESULTS Ipsilateral tissue cooling rates were 2.2±2.5°C/min at a flow rate of 20-40 mL/min with an observed minimum of 23.8°C. Tissue cooling was localized to the ipsilateral side of the infusion with little impact on temperatures of the core or contralateral hemisphere of the brain. In phase II, animals tolerated TH with minimal systemic impact. Infarct volume in treated animals was 0.2±0.2 cm3, which was smaller than in sham animals (3.8±1.0 cm3) as well as six untreated historical control animals (4.0±2.8 cm3) (p=0.013). CONCLUSIONS Proof-of-concept data show that localised brain TH can be quickly and safely achieved through a novel insulated catheter. The small infarct volumes suggest potential benefit for this approach.
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Affiliation(s)
- Jildaz Caroff
- Interventional Neuroradiology, NEURI Center, Bicêtre Hospital, Le Kremlin- Bicêtre, France
| | - Robert M King
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | | | - Miklos Marosfoi
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | | | - Heather L Gray-Edwards
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ajit S Puri
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Thomas L Merrill
- FocalCool, Mullica Hill, New Jersey, USA.,Department of Mechanical Engineering, Rowan University, Glassboro, NJ, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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33
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Lutz Y, Loewe A, Meckel S, Dössel O, Cattaneo G. Combined local hypothermia and recanalization therapy for acute ischemic stroke: Estimation of brain and systemic temperature using an energetic numerical model. J Therm Biol 2019; 84:316-322. [PMID: 31466769 DOI: 10.1016/j.jtherbio.2019.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 10/26/2022]
Abstract
Local brain hypothermia is an attractive method for providing cerebral neuroprotection for ischemic stroke patients and at the same time reducing systemic side effects of cooling. In acute ischemic stroke patients with large vessel occlusion, combination with endovascular mechanical recanalization treatment could potentially allow for an alleviation of inflammatory and apoptotic pathways in the critical phase of reperfusion. The direct cooling of arterial blood by means of an intra-carotid heat exchange catheter compatible with recanalization systems is a novel promising approach. Focusing on the concept of "cold reperfusion", we developed an energetic model to calculate the rate of temperature decrease during intra-carotid cooling in case of physiological as well as decreased perfusion. Additionally, we discussed and considered the effect and biological significance of temperature decrease on resulting brain perfusion. Our model predicted a 2 °C brain temperature decrease in 8.3, 11.8 and 26.2 min at perfusion rates of 50, 30 and 10ml100g⋅min, respectively. The systemic temperature decrease - caused by the venous blood return to the main circulation - was limited to 0.5 °C in 60 min. Our results underline the potential of catheter-assisted, intracarotid blood cooling to provide a fast and selective brain temperature decrease in the phase of vessel recanalization. This method can potentially allow for a tissue hypothermia during the restoration of the physiological flow and thus a "cold reperfusion" in the setting of mechanical recanalization.
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Affiliation(s)
- Yannick Lutz
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany.
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Stephan Meckel
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Olaf Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
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34
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Zhao J, Mu H, Liu L, Jiang X, Wu D, Shi Y, Leak RK, Ji X. Transient selective brain cooling confers neurovascular and functional protection from acute to chronic stages of ischemia/reperfusion brain injury. J Cereb Blood Flow Metab 2019; 39:1215-1231. [PMID: 30334662 PMCID: PMC6668511 DOI: 10.1177/0271678x18808174] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Ischemic injury can be alleviated by the judicious use of hypothermia. However, the optimal regimens and the temporal kinetics of post-stroke neurovascular responses to hypothermic intervention have not been systematically studied. These gaps slow the clinical translation of hypothermia as an anti-stroke therapy. Here, we characterized the effects of transient selective brain hypothermia (TSBH) from the hyperacute to chronic stages of focal ischemia/reperfusion brain injury induced by transient middle cerebral artery occlusion in mice. A simple cooling device was used to induce TSBH during cerebral ischemia. This treatment reduced mortality from 31.8% to 0% and improved neurological outcomes for at least 35 days post-injury. TSBH mitigated blood-brain barrier leakage during the hyperacute and acute injury stages (1-23 h post-reperfusion). This early protection of the blood-brain barrier was associated with anti-inflammatory phenotypic polarization of microglia/macrophages, reduced production of pro-inflammatory cytokines, and less brain infiltration of neutrophils and macrophages during the subacute injury stage (three days post-reperfusion). TSBH elicited enduring protective effects on both grey and white matter for at least 35 days post-injury and preserved the long-term electrophysiological function of fiber tracts. In conclusion, TSBH ameliorates ischemia/reperfusion injury in the neurovascular unit from hyperacute to chronic injury stages after experimental stroke.
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Affiliation(s)
- Jingyan Zhao
- 1 Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,2 Stroke Center, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,3 Pittsburgh Institute of Brain Disorders & Recovery and Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hongfeng Mu
- 3 Pittsburgh Institute of Brain Disorders & Recovery and Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Liqiang Liu
- 2 Stroke Center, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,3 Pittsburgh Institute of Brain Disorders & Recovery and Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Xiaoyan Jiang
- 3 Pittsburgh Institute of Brain Disorders & Recovery and Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Di Wu
- 1 Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yejie Shi
- 3 Pittsburgh Institute of Brain Disorders & Recovery and Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rehana K Leak
- 4 Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, USA
| | - Xunming Ji
- 1 Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,2 Stroke Center, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,5 Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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35
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van der Worp HB, Macleod MR, Bath PM, Bathula R, Christensen H, Colam B, Cordonnier C, Demotes-Mainard J, Durand-Zaleski I, Gluud C, Jakobsen JC, Kallmünzer B, Kollmar R, Krieger DW, Lees KR, Michalski D, Molina C, Montaner J, Roine RO, Petersson J, Perry R, Sprigg N, Staykov D, Szabo I, Vanhooren G, Wardlaw JM, Winkel P, Schwab S. Therapeutic hypothermia for acute ischaemic stroke. Results of a European multicentre, randomised, phase III clinical trial. Eur Stroke J 2019; 4:254-262. [PMID: 31984233 PMCID: PMC6960691 DOI: 10.1177/2396987319844690] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/27/2019] [Indexed: 01/24/2023] Open
Abstract
Introduction We assessed whether modest systemic cooling started within 6 hours of symptom
onset improves functional outcome at three months in awake patients with
acute ischaemic stroke. Patients and methods In this European randomised open-label clinical trial with blinded outcome
assessment, adult patients with acute ischaemic stroke were randomised to
cooling to a target body temperature of 34.0–35.0°C, started within 6 h
after stroke onset and maintained for 12 or 24 h , versus standard
treatment. The primary outcome was the score on the modified Rankin Scale at
91 days, as analysed with ordinal logistic regression. Results The trial was stopped after inclusion of 98 of the originally intended 1500
patients because of slow recruitment and cessation of funding. Forty-nine
patients were randomised to hypothermia versus 49 to standard treatment.
Four patients were lost to follow-up. Of patients randomised to hypothermia,
15 (31%) achieved the predefined cooling targets. The primary outcome did
not differ between the groups (odds ratio for good outcome, 1.01; 95%
confidence interval, 0.48–2.13; p = 0.97). The number of
patients with one or more serious adverse events did not differ between
groups (relative risk, 1.22; 95% confidence interval, 0.65–1.94;
p = 0.52). Discussion In this trial, cooling to a target of 34.0–35.0°C and maintaining this for 12
or 24 h was not feasible in the majority of patients. The final sample was
underpowered to detect clinically relevant differences in outcomes. Conclusion Before new trials are launched, the feasibility of cooling needs to be
improved.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Malcolm R Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, UK
| | - Philip Mw Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Raj Bathula
- Stroke Department, Northwick Park Hospital, London, UK
| | - Hanne Christensen
- Department of Neurology, Bispebjerg og Frederiksberg Hospitaler, University of Copenhagen, Copenhagen, Denmark
| | - Bridget Colam
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, Scotland, UK
| | - Charlotte Cordonnier
- University of Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, Centre Hospitalier Universitaire Lille, Lille, France
| | | | | | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Copenhagen, Denmark
| | - Bernd Kallmünzer
- Department of Neurology, University Medical Centre Erlangen, Erlangen, Germany
| | - Rainer Kollmar
- Klinik für Neurologie und Neurointensivmedizin, Klinikum Darmstadt, Darmstadt, Germany
| | | | - Kennedy R Lees
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | | | - Carlos Molina
- Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Risto O Roine
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Jesper Petersson
- Department of Neurology, Skane University Hospital, Malmö, Sweden
| | - Richard Perry
- Stroke Service, National Hospital for Neurology & Neurosurgery, Queen Square, London, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Dimitre Staykov
- Department of Neurology, University Medical Centre Erlangen, Erlangen, Germany.,Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria
| | - Istvan Szabo
- European Stroke Research Network for Hypothermia, Brussels, Belgium
| | | | - Joanna M Wardlaw
- Edinburgh Imaging, Centre for Clinical Brain Sciences and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Per Winkel
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stefan Schwab
- Department of Neurology, University Medical Centre Erlangen, Erlangen, Germany
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Abdul-Rahim AH, Dickie DA, Selvarajah JR, Lees KR, Quinn TJ. Stroke aetiological classification reliability and effect on trial sample size: systematic review, meta-analysis and statistical modelling. Trials 2019; 20:107. [PMID: 30736833 PMCID: PMC6368715 DOI: 10.1186/s13063-019-3222-x] [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] [Received: 11/08/2018] [Accepted: 01/25/2019] [Indexed: 12/15/2022] Open
Abstract
Background Inter-observer variability in stroke aetiological classification may have an effect on trial power and estimation of treatment effect. We modelled the effect of misclassification on required sample size in a hypothetical cardioembolic (CE) stroke trial. Methods We performed a systematic review to quantify the reliability (inter-observer variability) of various stroke aetiological classification systems. We then modelled the effect of this misclassification in a hypothetical trial of anticoagulant in CE stroke contaminated by patients with non-cardioembolic (non-CE) stroke aetiology. Rates of misclassification were based on the summary reliability estimates from our systematic review. We randomly sampled data from previous acute trials in CE and non-CE participants, using the Virtual International Stroke Trials Archive. We used bootstrapping to model the effect of varying misclassification rates on sample size required to detect a between-group treatment effect across 5000 permutations. We described outcomes in terms of survival and stroke recurrence censored at 90 days. Results From 4655 titles, we found 14 articles describing three stroke classification systems. The inter-observer reliability of the classification systems varied from ‘fair’ to ‘very good’ and suggested misclassification rates of 5% and 20% for our modelling. The hypothetical trial, with 80% power and alpha 0.05, was able to show a difference in survival between anticoagulant and antiplatelet in CE with a sample size of 198 in both trial arms. Contamination of both arms with 5% misclassified participants inflated the required sample size to 237 and with 20% misclassification inflated the required sample size to 352, for equivalent trial power. For an outcome of stroke recurrence using the same data, base-case estimated sample size for 80% power and alpha 0.05 was n = 502 in each arm, increasing to 605 at 5% contamination and 973 at 20% contamination. Conclusions Stroke aetiological classification systems suffer from inter-observer variability, and the resulting misclassification may limit trial power. Trial registration Protocol available at reviewregistry540. Electronic supplementary material The online version of this article (10.1186/s13063-019-3222-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Azmil H Abdul-Rahim
- Institute of Neuroscience and Psychology, University of Glasgow, Room 0.07, Office Block, Queen Elizabeth University Hospital, G51 4TF, Glasgow, UK.
| | | | - Johann R Selvarajah
- Institute of Neuroscience and Psychology, University of Glasgow, Room 0.07, Office Block, Queen Elizabeth University Hospital, G51 4TF, Glasgow, UK.,Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Kennedy R Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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37
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Pallesen LP, Barlinn K, Puetz V. Role of Decompressive Craniectomy in Ischemic Stroke. Front Neurol 2019; 9:1119. [PMID: 30687210 PMCID: PMC6333741 DOI: 10.3389/fneur.2018.01119] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/06/2018] [Indexed: 12/12/2022] Open
Abstract
Ischemic stroke is one of the leading causes for death and disability worldwide. In patients with large space-occupying infarction, the subsequent edema complicated by transtentorial herniation poses a lethal threat. Especially in patients with malignant middle cerebral artery infarction, brain swelling secondary to the vessel occlusion is associated with high mortality. By decompressive craniectomy, a significant proportion of the skull is surgically removed, allowing the ischemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. Several studies have shown that decompressive craniectomy reduces the mortality rate in patients with malignant cerebral artery infarction. However, this is done for the cost of a higher proportion of patients who survive with severe disability. In this review, we will describe the clinical and radiological features of malignant middle cerebral artery infarction and the role of decompressive craniectomy and additional therapies in this condition. We will also discuss large cerebellar stroke and the possibilities of suboccipital craniectomy.
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Affiliation(s)
- Lars-Peder Pallesen
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
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38
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Kurisu K, Kim JY, You J, Yenari MA. Therapeutic Hypothermia and Neuroprotection in Acute Neurological Disease. Curr Med Chem 2019; 26:5430-5455. [PMID: 31057103 PMCID: PMC6913523 DOI: 10.2174/0929867326666190506124836] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/24/2018] [Accepted: 04/11/2019] [Indexed: 01/07/2023]
Abstract
Therapeutic hypothermia has consistently been shown to be a robust neuroprotectant in many labs studying different models of neurological disease. Although this therapy has shown great promise, there are still challenges at the clinical level that limit the ability to apply this routinely to each pathological condition. In order to overcome issues involved in hypothermia therapy, understanding of this attractive therapy is needed. We review methodological concerns surrounding therapeutic hypothermia, introduce the current status of therapeutic cooling in various acute brain insults, and review the literature surrounding the many underlying molecular mechanisms of hypothermic neuroprotection. Because recent work has shown that body temperature can be safely lowered using pharmacological approaches, this method may be an especially attractive option for many clinical applications. Since hypothermia can affect multiple aspects of brain pathophysiology, therapeutic hypothermia could also be considered a neuroprotection model in basic research, which would be used to identify potential therapeutic targets. We discuss how research in this area carries the potential to improve outcome from various acute neurological disorders.
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Affiliation(s)
- Kota Kurisu
- Department of Neurology, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, California 94121, USA
| | - Jong Youl Kim
- Department of Neurology, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, California 94121, USA
- Departments of Anatomy, Yonsei University College of Medicine, Seoul, South Korea
| | - Jesung You
- Department of Neurology, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, California 94121, USA
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Midori A. Yenari
- Department of Neurology, University of California, San Francisco and Veterans Affairs Medical Center, San Francisco, California 94121, USA
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39
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Liska MG, Crowley MG, Tuazon JP, Borlongan CV. Neuroprotective and neuroregenerative potential of pharmacologically-induced hypothermia with D-alanine D-leucine enkephalin in brain injury. Neural Regen Res 2018; 13:2029-2037. [PMID: 30323116 PMCID: PMC6199924 DOI: 10.4103/1673-5374.241427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 10/27/2017] [Indexed: 12/21/2022] Open
Abstract
Neurovascular disorders, such as traumatic brain injury and stroke, persist as leading causes of death and disability - thus, the search for novel therapeutic approaches for these disorders continues. Many hurdles have hindered the translation of effective therapies for traumatic brain injury and stroke primarily because of the inherent complexity of neuropathologies and an inability of current treatment approaches to adapt to the unique cell death pathways that accompany the disorder symptoms. Indeed, developing potent treatments for brain injury that incorporate dynamic and multiple disorder-engaging therapeutic targets are likely to produce more effective outcomes than traditional drugs. The therapeutic use of hypothermia presents a promising option which may fit these criteria. While regulated temperature reduction has displayed great promise in preclinical studies of brain injury, clinical trials have been far less consistent and associated with adverse effects, especially when hypothermia is pursued via systemic cooling. Accordingly, devising better methods of inducing hypothermia may facilitate the entry of this treatment modality into the clinic. The use of the delta opioid peptide D-alanine D-leucine enkephalin (DADLE) to pharmacologically induce temperature reduction may offer a potent alternative, as DADLE displays both the ability to cause temperature reduction and to confer a broad profile of other neuroprotective and neuroregenerative processes. This review explores the prospect of DADLE-mediated hypothermia to treat neurovascular brain injuries, emphasizing the translational steps necessary for its clinical translation.
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Affiliation(s)
- M. Grant Liska
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Marci G. Crowley
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Julian P. Tuazon
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Cesar V. Borlongan
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
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40
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Bobinger T, Burkardt P, B Huttner H, Manaenko A. Programmed Cell Death after Intracerebral Hemorrhage. Curr Neuropharmacol 2018; 16:1267-1281. [PMID: 28571544 PMCID: PMC6251052 DOI: 10.2174/1570159x15666170602112851] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/26/2017] [Accepted: 06/01/2017] [Indexed: 01/01/2023] Open
Abstract
Background: Intracerebral hemorrhage (ICH) accounts for up to 15% of all strokes and is characterized by high rates of mortality and morbidity. The post-ICH brain injury can be distinguished in 1) primary, which are caused by disrup-tion and mechanical deformation of brain tissue due to hematoma growth and 2) secondary, which are induced by microglia activation, mitochondrial dysfunction, neurotransmitter and inflammatory mediator release. Although these events typically lead to necrosis, the occurrence of programmed cell death has also been reported after ICH. Methods: We reviewed recent publications describing advance in pre- and clinic ICH research. Results: At present, treatment of ICH patients is based on oral anticoagulant reversal, management of blood pressure and other medical complications. Several pre-clinical studies showed promising results and demonstrated that anti-oxidative and anti-inflammatory treatments reduced neuronal cell death, however, to date, all of these attempts have failed in randomized controlled clinical trials. Yet, the time frame of administration may be crucial in translation from animal to clinical studies. Furthermore, the latest pre-clinical research points toward the existence of other, apoptosis-unrelated forms kinds of pro-grammed cell death. Conclusion: Our review summarizes current knowledge of pathways leading to programmed cell death after ICH in addition to data from clinical trials. Some of the pre-clinical results have not yet demonstrated clinical confirmation, however they sig-nificantly contribute to our understanding of post-ICH pathology and can contribute to development of new therapeutic ap-proaches, decreasing mortality and improving ICH patients’ quality of life.
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Affiliation(s)
- Tobias Bobinger
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Petra Burkardt
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
| | - Anatol Manaenko
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, Erlangen 91054, Germany
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41
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Meadows KL. Experimental models of focal and multifocal cerebral ischemia: a review. Rev Neurosci 2018; 29:661-674. [PMID: 29397392 DOI: 10.1515/revneuro-2017-0076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/26/2017] [Indexed: 02/07/2023]
Abstract
Rodent and rabbit stroke models have been instrumental in our current understanding of stroke pathophysiology; however, translational failure is a significant problem in preclinical ischemic stroke research today. There are a number of different focal cerebral ischemia models that vary in their utility, pathophysiology of causing disease, and their response to treatments. Unfortunately, despite active preclinical research using these models, treatment options for ischemic stroke have not significantly advanced since the food and drug administration approval of tissue plasminogen activator in 1996. This review aims to summarize current stroke therapies, the preclinical experimental models used to help develop stroke therapies, as well as their advantages and limitations. In addition, this review discusses the potential for naturally occurring canine ischemic stroke models to compliment current preclinical models and to help bridge the translational gap between small mammal models and human clinical trials.
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Affiliation(s)
- Kristy L Meadows
- Cummings School of Veterinary Medicine, Tufts University, 200 Westboro Road, Grafton, MA 01536, USA
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Park J, Kim JH, Suk K, Han HS, Ohk B, Kim DG. Selective Brain Hypothermia Augmenting Neuroprotective Effects of Decompressive Craniectomy for Permanent Middle Cerebral Artery Infarction in a Rat Model. World Neurosurg 2018; 121:e181-e190. [PMID: 30261392 DOI: 10.1016/j.wneu.2018.09.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the combined effects of a decompressive craniectomy and prolonged selective brain hypothermia on large hemispheric infarction in a rat model. METHODS Permanent middle cerebral artery infarction using an endovascular occlusion technique was created in rats assigned to 4 groups. Normothermia was maintained without a craniectomy in group A (n = 20) as the control, prolonged (>44 hours), selective brain hypothermic treatment was performed on group B (n = 20), a craniectomy was performed on group C (n = 18), and prolonged, selective brain hypothermic treatment using a cooling coil implanted in the craniectomy site was combined with a craniectomy for group D (n = 18). RESULTS Group B and C exhibited a significantly reduced infarct volume when compared with the control. Furthermore, group D showed a significantly reduced infarct volume when compared with group C, plus a significantly improved neurologic score. These results for group D were associated with an increased neuronal cell count and reduced hyperactive microglia and hypertrophic astrocytes in the cortical penumbra (P < 0.01). Moreover, a greater preservation of normal-appearing axonal bundles and the blood-brain barrier was observed in the core infarct region at the caudoputamen. CONCLUSIONS A decompressive craniectomy reduced the infarct volume and improved the neurologic outcomes in a rat model of middle cerebral artery infarction. Furthermore, when combined with prolonged selective brain hypothermia, significant additional benefits were observed for the neurologic outcomes, infarct volume, and degree of neuroinflammation.
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Affiliation(s)
- Jaechan Park
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.
| | - Jong-Heon Kim
- Department of Pharmacology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Kyoungho Suk
- Department of Pharmacology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hyung Soo Han
- Department of Physiology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Boram Ohk
- Clinical Trial Center, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Abstract
Evidence from animal models indicates that lowering temperature by a few degrees can produce substantial neuroprotection. In humans, hypothermia has been found to be neuroprotective with a significant impact on mortality and long-term functional outcome only in cardiac arrest and neonatal hypoxic-ischemic encephalopathy. Clinical trials have explored the potential role of maintaining normothermia and treating fever in critically ill brain injured patients. This review concentrates on basic concepts to understand the physiologic interactions of thermoregulation, effects of thermal modulation in critically ill patients, proposed mechanisms of action of temperature modulation, and practical aspects of targeted temperature management.
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44
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Nutritional and Bioenergetic Considerations in Critically Ill Patients with Acute Neurological Injury. Neurocrit Care 2018; 27:276-286. [PMID: 28004327 DOI: 10.1007/s12028-016-0336-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The brain, due to intensive cellular processes and maintenance of electrochemical gradients, is heavily dependent on a constant supply of energy. Brain injury, and critical illness in general, induces a state of increased metabolism and catabolism, which has been proven to lead to poor outcomes. Of all the biochemical interventions undertaken in the ICU, providing nutritional support is perhaps one of the most undervalued, but potentially among the safest, and most effective interventions. Adequate provisions of calories and protein have been shown to improve patient outcomes, and guidelines for the nutritional support of the critically ill patient are reviewed. However, there are no such specific guidelines for the critically ill patient with neurological injury. Patients with primary or secondary neurological disorders are frequently undernourished, while data suggest this population would benefit from early and adequate nutritional support, although comprehensive clinical evidence is lacking. We review the joint recommendations from the Society for Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition, as they pertain to neurocritical care, and assess the recommendations for addressing nutrition in this patient population.
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45
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Drieu A, Levard D, Vivien D, Rubio M. Anti-inflammatory treatments for stroke: from bench to bedside. Ther Adv Neurol Disord 2018; 11:1756286418789854. [PMID: 30083232 PMCID: PMC6066814 DOI: 10.1177/1756286418789854] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/19/2018] [Indexed: 12/11/2022] Open
Abstract
So far, intravenous tissue-type plasminogen activator (tPA) and mechanical
removal of arterial blood clot (thrombectomy) are the only available treatments
for acute ischemic stroke. However, the short therapeutic window and the lack of
specialized stroke unit care make the overall availability of both treatments
limited. Additional agents to combine with tPA administration or thrombectomy to
enhance efficacy and improve outcomes associated with stroke are needed.
Stroke-induced inflammatory processes are a response to the tissue damage due to
the absence of blood supply but have been proposed also as key contributors to
all the stages of the ischemic stroke pathophysiology. Despite promising results
in experimental studies, inflammation-modulating treatments have not yet been
translated successfully into the clinical setting. This review will (a) describe
the timing of the stroke immune pathophysiology; (b) detail the immune responses
to stroke sift-through cell type; and (c) discuss the pitfalls on the
translation from experimental studies to clinical trials testing the therapeutic
pertinence of immune modulators.
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Affiliation(s)
- Antoine Drieu
- Pathophysiology and Imaging of Neurological Disorders, Normandy University, Caen, France
| | - Damien Levard
- Pathophysiology and Imaging of Neurological Disorders, Normandy University, Caen, France
| | - Denis Vivien
- Pathophysiology and Imaging of Neurological Disorders, Normandy University, Caen, France Pathophysiology and Imaging of Neurological Disorders, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Marina Rubio
- Pathophysiology and Imaging of Neurological Disorders, Normandy University, Boulevard Henri Becquerel BP 5229, Caen Cedex, 14000, France
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46
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Abstract
Evidence from animal models indicates that lowering temperature by a few degrees can produce substantial neuroprotection. In humans, hypothermia has been found to be neuroprotective with a significant impact on mortality and long-term functional outcome only in cardiac arrest and neonatal hypoxic-ischemic encephalopathy. Clinical trials have explored the potential role of maintaining normothermia and treating fever in critically ill brain injured patients. This review concentrates on basic concepts to understand the physiologic interactions of thermoregulation, effects of thermal modulation in critically ill patients, proposed mechanisms of action of temperature modulation, and practical aspects of targeted temperature management.
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Affiliation(s)
- Fred Rincon
- Division of Critical Care and Neurotrauma, Department of Neurology, Sidney-Kimmel College of Medicine, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA; Division of Critical Care and Neurotrauma, Department of Neurological Surgery, Sidney-Kimmel College of Medicine, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA.
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47
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Andrews PJD, Verma V, Healy M, Lavinio A, Curtis C, Reddy U, Andrzejowski J, Foulkes A, Canestrini S. Targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke: consensus recommendations. Br J Anaesth 2018; 121:768-775. [PMID: 30236239 DOI: 10.1016/j.bja.2018.06.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/30/2018] [Accepted: 07/02/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND A modified Delphi approach was used to identify a consensus on practical recommendations for the use of non-pharmacological targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke with non-infectious fever (assumed neurogenic fever). METHODS Nine experts in the management of neurogenic fever participated in the process, involving the completion of online questionnaires, face-to-face discussions, and summary reviews, to consolidate a consensus on targeted temperature management. RESULTS The panel's recommendations are based on a balance of existing evidence and practical considerations. With this in mind, they highlight the importance of managing neurogenic fever using a single protocol for targeted temperature management. Targeted temperature management should be initiated if the patient temperature increases above 37.5°C, once an appropriate workup for infection has been undertaken. This helps prevent prophylactic targeted temperature management use and ensures infection is addressed appropriately. When neurogenic fever is detected, targeted temperature management should be initiated rapidly if antipyretic agents fail to control the temperature within 1 h, and should then be maintained for as long as there is potential for secondary brain damage. The recommended target temperature for targeted temperature management is 36.5-37.5°C. The use of advanced targeted temperature management methods that enable continuous, or near continuous, temperature measurement and precise temperature control is recommended. CONCLUSIONS Given the limited heterogeneous evidence currently available on targeted temperature management use in patients with neurogenic fever and intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke, a Delphi approach was appropriate to gather an expert consensus. To aid in the development of future investigations, the panel provides recommendations for data gathering.
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Affiliation(s)
- P J D Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - V Verma
- Royal London Hospital, London, UK
| | - M Healy
- Royal London Hospital, London, UK
| | - A Lavinio
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge, UK
| | - C Curtis
- University College London Hospital, London, UK
| | - U Reddy
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - J Andrzejowski
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - A Foulkes
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - S Canestrini
- King's College Hospital NHS Foundation Trust, London, UK
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48
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Reuß CJ, Bernhard M, Beynon C, Hecker A, Jungk C, Michalski D, Nusshag C, Weigand MA, Brenner T. [Intensive care studies from 2016/2017]. Anaesthesist 2018; 66:690-713. [PMID: 28667421 PMCID: PMC7095915 DOI: 10.1007/s00101-017-0339-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- C J Reuß
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - A Hecker
- Klinik für Allgemein- Viszeral‑, Thorax- Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Neurologische Intensivstation und Stroke Unit, Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - C Nusshag
- Klinik für Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - T Brenner
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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49
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Contrôle cible de la température en réanimation (hors nouveau-nés). MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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50
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Abstract
Selective brain hypothermia is a powerful concept for neuroprotection that has been successfully investigated in a variety of animal models of global and focal ischemia. Its major advantages over systemic hypothermia include rapid induction of cooling, ability to achieve profound target brain temperatures, organ-selective cooling, and temperature control. Clinical systems and devices are available or are currently under development that utilize conductive (surface-cooling pads, closed-loop catheters), convective (transnasal coolant delivery), or mass and energy transport (cold intra-arterial infusion) methods to achieve and maintain selective brain hypothermia. The "ideal" brain-cooling system that is characterized by rapid cooling to profound hypothermia, its ability to maintain selective cooling over several days, and is noninvasive in nature, remains unrealistic. Instead, systems may be identified by their distinct advantages to meet a specific need in the care of a patient. This involves the consideration of the timing of ischemic injury (preischemic, intraischemic, postischemic), extent of ischemic damage (excitotoxicity, inflammation, necrosis, edema), and type and setting of therapeutic intervention (intensive care, interventional therapy, surgery). The successful translation of these systems into clinical practice will depend on smart engineering, safety and efficacy, and usability in current clinical work flow.
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Affiliation(s)
- Jae H Choi
- Neurological Surgery PC, Lake Success, NY, United States.
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