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Marasini S, Jia X. Neuroprotective Approaches for Brain Injury After Cardiac Arrest: Current Trends and Prospective Avenues. J Stroke 2024; 26:203-230. [PMID: 38836269 PMCID: PMC11164592 DOI: 10.5853/jos.2023.04329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/26/2024] [Accepted: 02/20/2024] [Indexed: 06/06/2024] Open
Abstract
With the implementation of improved bystander cardiopulmonary resuscitation techniques and public-access defibrillation, survival after out-of-hospital cardiac arrest (OHCA) has increased significantly over the years. Nevertheless, OHCA survivors have residual anoxia/reperfusion brain damage and associated neurological impairment resulting in poor quality of life. Extracorporeal membrane oxygenation or targeted temperature management has proven effective in improving post-cardiac arrest (CA) neurological outcomes, yet considering the substantial healthcare costs and resources involved, there is an urgent need for alternative treatment strategies that are crucial to alleviate brain injury and promote recovery of neurological function after CA. In this review, we searched PubMed for the latest preclinical or clinical studies (2016-2023) utilizing gas-mediated, pharmacological, or stem cell-based neuroprotective approaches after CA. Preclinical studies utilizing various gases (nitric oxide, hydrogen, hydrogen sulfide, carbon monoxide, argon, and xenon), pharmacological agents targeting specific CA-related pathophysiology, and stem cells have shown promising results in rodent and porcine models of CA. Although inhaled gases and several pharmacological agents have entered clinical trials, most have failed to demonstrate therapeutic effects in CA patients. To date, stem cell therapies have not been reported in clinical trials for CA. A relatively small number of preclinical stem-cell studies with subtle therapeutic benefits and unelucidated mechanistic explanations warrant the need for further preclinical studies including the improvement of their therapeutic potential. The current state of the field is discussed and the exciting potential of stem-cell therapy to abate neurological dysfunction following CA is highlighted.
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Affiliation(s)
- Subash Marasini
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wang YP, Lu LC, Li SC, Li L, Jiang Y, Cheng YQ, Ge M, Chen Y, Wang DJ. "Drum Tower Hospital" strategy for acute type A aortic dissection with coma. Perfusion 2023:2676591231210459. [PMID: 37885091 DOI: 10.1177/02676591231210459] [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: 10/28/2023]
Abstract
OVERVIEW Acute type A aortic dissection (ATAAD) with persistent coma is a life-threatening condition associated with high mortality and poor neurological outcomes. The optimal timing for surgical intervention in these patients remains uncertain, and many patients are not eligible for surgery due to their poor prognosis. DESCRIPTION In this case, a 53-year-old man with hypertension presented to the emergency department in a coma that had lasted for 9 hours. The patient was diagnosed with ATAAD and underwent the "Drum Tower Hospital" strategy, which involved preoperative assessments, including computed tomography angiography (CTA) and quantitative electroencephalogram (qEEG) monitoring. Surgical interventions, such as emergency stenting and aortic replacement, were performed to restore blood flow and repair the aorta. Postoperative monitoring, including qEEG, showed improvements in brain function. Despite the patient experiencing hemiplegia and a neurological deficit, the "Drum Tower Hospital" strategy, guided by comprehensive brain assessments, showed promise in managing ATAAD with coma. However, further research is needed to establish effective treatment strategies for these patients. Overall, ATAAD with persistent coma is a critical condition with limited treatment options. The "Drum Tower Hospital" strategy, supported by multimodal brain assessment, offers a potential approach to improve outcomes in these patients.
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Affiliation(s)
- Ya-Peng Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College Graduate School, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
| | - Li-Chong Lu
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing Drum Tower Hospital, Nanjing, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardio- Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
- Nanjing Drum Tower Hospital, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Shu-Chun Li
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing Drum Tower Hospital, Nanjing, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardio- Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
- Nanjing Drum Tower Hospital, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Li Li
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing Drum Tower Hospital, Nanjing, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardio- Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
- Nanjing Drum Tower Hospital, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Yi Jiang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College Graduate School, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
| | - Yong-Qing Cheng
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing Drum Tower Hospital, Nanjing, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardio- Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
- Nanjing Drum Tower Hospital, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Min Ge
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing Drum Tower Hospital, Nanjing, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardio- Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
- Nanjing Drum Tower Hospital, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Yang Chen
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing Drum Tower Hospital, Nanjing, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardio- Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
- Nanjing Drum Tower Hospital, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College Graduate School, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Nanjing University Medical School, Nanjing Drum Tower Hospital, Nanjing, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardio- Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
- Nanjing Drum Tower Hospital, Xuzhou Medical University, Xuzhou, Jiangsu, China
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Kang C, Min JH, Park JS, You Y, Jeong W, Ahn HJ, In YN, Lee IH, Jeong HS, Lee BK, Jeong J. Association of ultra-early diffusion-weighted magnetic resonance imaging with neurological outcomes after out-of-hospital cardiac arrest. Crit Care 2023; 27:16. [PMID: 36639809 PMCID: PMC9837995 DOI: 10.1186/s13054-023-04305-z] [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: 11/21/2022] [Accepted: 01/06/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND This study aimed to investigate the association between ultra-early (within 6 h after return of spontaneous circulation [ROSC]) brain diffusion-weighted magnetic resonance imaging (DW-MRI) and neurological outcomes in comatose survivors after out-of-hospital cardiac arrest. METHODS We conducted a registry-based observational study from May 2018 to February 2022 at a Chungnam national university hospital in Daejeon, Korea. Presence of high-signal intensity (HSI) (PHSI) was defined as a HSI on DW-MRI with corresponding hypoattenuation on the apparent diffusion coefficient map irrespective of volume after hypoxic ischemic brain injury; absence of HSI was defined as AHSI. The primary outcome was the dichotomized cerebral performance category (CPC) at 6 months, defined as good (CPC 1-2) or poor (CPC 3-5). RESULTS Of the 110 patients (30 women [27.3%]; median (interquartile range [IQR]) age, 58 [38-69] years), 48 (43.6%) had a good neurological outcome, time from ROSC to MRI scan was 2.8 h (IQR 2.0-4.0 h), and the PHSI on DW-MRI was observed in 46 (41.8%) patients. No patients in the PHSI group had a good neurological outcome compared with 48 (75%) patients in the AHSI group. In the AHSI group, cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels were significantly lower in the group with good neurological outcome compared to the group with poor neurological outcome (20.1 [14.4-30.7] ng/mL vs. 84.3 [32.4-167.0] ng/mL, P < 0.001). The area under the curve for PHSI on DW-MRI was 0.87 (95% confidence interval [CI] 0.80-0.93), and the specificity and sensitivity for predicting a poor neurological outcome were 100% (95% CI 91.2%-100%) and 74.2% (95% CI 62.0-83.5%), respectively. A higher sensitivity was observed when CSF NSE levels were combined (88.7% [95% CI 77.1-95.1%]; 100% specificity). CONCLUSIONS In this cohort study, PHSI findings on ultra-early DW-MRI were associated with poor neurological outcomes 6 months following the cardiac arrest. The combined CSF NSE levels showed higher sensitivity at 100% specificity than on DW-MRI alone. Prospective multicenter studies are required to confirm these results.
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Affiliation(s)
- Changshin Kang
- grid.411665.10000 0004 0647 2279Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea ,grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - Jin Hong Min
- grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - Jung Soo Park
- grid.411665.10000 0004 0647 2279Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea ,grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - Yeonho You
- grid.411665.10000 0004 0647 2279Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- grid.411665.10000 0004 0647 2279Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea ,grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - Hong Joon Ahn
- grid.411665.10000 0004 0647 2279Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea ,grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - Yong Nam In
- grid.254230.20000 0001 0722 6377Department of Emergency Medicine, College of Medicine, Chungnam National University, 266 Munwha-ro, Jung-gu, Daejeon, 35015 Republic of Korea
| | - In Ho Lee
- grid.254230.20000 0001 0722 6377Department of Radiology, College of Medicine, Chungnam National University, 266, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hye Seon Jeong
- grid.411665.10000 0004 0647 2279Department of Neurology, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Byung Kook Lee
- grid.14005.300000 0001 0356 9399Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Jinwoo Jeong
- grid.255166.30000 0001 2218 7142Department of Emergency Medicine, Dong-A University College of Medicine, Busan, Korea
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Wang Z, Chen S, Smith MF, Jia X. Effect of Graded Targeted Temperature Management on Cerebral Glucose Spatiotemporal Characteristics after Cardiac Arrest. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:182-185. [PMID: 36086320 PMCID: PMC9639334 DOI: 10.1109/embc48229.2022.9871454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Cardiac arrest (CA) is a fatal disease with high rates of neurological impairment. At present, targeted temperature management (TTM) is the only strategy with firm clinical evidence to prove its effectiveness. However, there is still controversy on the implementation of TTM, particularly on its depth, with a lack of elucidated underlying therapeutic mechanisms. Six Wistar rats were subjected to 8 min asphyxia-CA and randomly divided into TTM at 33oC(n=3) or 35° C groups (n=3). The spatiotemporal characteristics of cerebral glucose metabolism after CA were investigated by 18F-FDG microPET/CT. Myelin Basic Protein (MBP) immunofluorescence staining was used to assess acute injury and recovery of oligodendrocytes. Functional recovery was evaluated using the neurological deficit score (NDS). There was a significant improvement in functional recovery by NDS (p < 0.05) in the 33oC group compared with the 35° C group. Glucose metabolism of the 33° C group was higher than that of the 35oC group early after resuscitation (within 10 minutes). Immunofluorescence analysis showed that positive MBP signals in the cortex and hippocampus in the 33oC group were greater than in the 35oC group. In conclusion, compared to 35oC TTM, 33° C TTM changed the spatiotemporal characteristics of brain glucose metabolisms with improved neurological function, which may be through oligodendrocyte participation.
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Cardiac arrest centres: what, who, when, and where? Curr Opin Crit Care 2022; 28:262-269. [PMID: 35653246 DOI: 10.1097/mcc.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions. RECENT FINDINGS CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer. SUMMARY Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.
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