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Atienza-Navarro I, Del Marco A, Alves-Martinez P, Garcia-Perez MDLA, Raya-Marin A, Benavente-Fernandez I, Gil C, Martinez A, Lubian-Lopez S, Garcia-Alloza M. Glycogen Synthase Kinase-3β Inhibitor VP3.15 Ameliorates Neurogenesis, Neuronal Loss and Cognitive Impairment in a Model of Germinal Matrix-intraventricular Hemorrhage of the Preterm Newborn. Transl Stroke Res 2024:10.1007/s12975-023-01229-2. [PMID: 38231413 DOI: 10.1007/s12975-023-01229-2] [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: 10/16/2023] [Revised: 11/24/2023] [Accepted: 12/18/2023] [Indexed: 01/18/2024]
Abstract
Advances in neonatology have significantly reduced mortality rates due to prematurity. However, complications of prematurity have barely changed in recent decades. Germinal matrix-intraventricular hemorrhage (GM-IVH) is one of the most severe complications of prematurity, and these children are prone to suffer short- and long-term sequelae, including cerebral palsy, cognitive and motor impairments, or neuropsychiatric disorders. Nevertheless, GM-IVH has no successful treatment. VP3.15 is a small, heterocyclic molecule of the 5-imino-1,2,4-thiadiazole family with a dual action as a phosphodiesterase 7 and glycogen synthase kinase-3β (GSK-3β) inhibitor. VP3.15 reduces neuroinflammation and neuronal loss in other neurodegenerative disorders and might ameliorate complications associated with GM-IVH. We administered VP3.15 to a mouse model of GM-IVH. VP3.15 reduces the presence of hemorrhages and microglia in the short (P14) and long (P110) term. It ameliorates brain atrophy and ventricle enlargement while limiting tau hyperphosphorylation and neuronal and myelin basic protein loss. VP3.15 also improves proliferation and neurogenesis as well as cognition after the insult. Interestingly, plasma gelsolin levels, a feasible biomarker of brain damage, improved after VP3.15 treatment. Altogether, our data support the beneficial effects of VP3.15 in GM-IVH by ameliorating brain neuroinflammatory, vascular and white matter damage, ultimately improving cognitive impairment associated with GM-IVH.
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Affiliation(s)
- Isabel Atienza-Navarro
- Division of Physiology, School of Medicine, University of Cadiz, C/Dr. Marañon 3, 3rd Floor, 11002, Cadiz, Spain
- Biomedical Research and Innovation Institute of Cadiz (INiBICA) Research Unit, Puerta del Mar University Hospital, Cadiz, Spain
| | - Angel Del Marco
- Division of Physiology, School of Medicine, University of Cadiz, C/Dr. Marañon 3, 3rd Floor, 11002, Cadiz, Spain
- Biomedical Research and Innovation Institute of Cadiz (INiBICA) Research Unit, Puerta del Mar University Hospital, Cadiz, Spain
| | - Pilar Alves-Martinez
- Division of Physiology, School of Medicine, University of Cadiz, C/Dr. Marañon 3, 3rd Floor, 11002, Cadiz, Spain
- Biomedical Research and Innovation Institute of Cadiz (INiBICA) Research Unit, Puerta del Mar University Hospital, Cadiz, Spain
| | | | - Alvaro Raya-Marin
- Biomedical Research and Innovation Institute of Cadiz (INiBICA) Research Unit, Puerta del Mar University Hospital, Cadiz, Spain
| | - Isabel Benavente-Fernandez
- Area of Pediatrics, Department of Child and Mother Health and Radiology, School of Medicine, University of Cadiz, Cadiz, Spain
- Section of Neonatology, Division of Pediatrics, Puerta del Mar University Hospital, Avda. Ana de Viya sn, 11007, Cadiz, Spain
| | - Carmen Gil
- Centro de Investigaciones, Biologicas Margarita Salas-CSIC, Ramiro de Maeztu 9, 28040, Madrid, Spain
| | - Ana Martinez
- Centro de Investigaciones, Biologicas Margarita Salas-CSIC, Ramiro de Maeztu 9, 28040, Madrid, Spain
- Centro de Investigaciones Biomedicas en Red en Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, Avda. Monforte de Lemos 3-5, 28029, Madrid, Spain
| | - Simon Lubian-Lopez
- Area of Pediatrics, Department of Child and Mother Health and Radiology, School of Medicine, University of Cadiz, Cadiz, Spain.
- Section of Neonatology, Division of Pediatrics, Puerta del Mar University Hospital, Avda. Ana de Viya sn, 11007, Cadiz, Spain.
| | - Monica Garcia-Alloza
- Division of Physiology, School of Medicine, University of Cadiz, C/Dr. Marañon 3, 3rd Floor, 11002, Cadiz, Spain.
- Biomedical Research and Innovation Institute of Cadiz (INiBICA) Research Unit, Puerta del Mar University Hospital, Cadiz, Spain.
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Faropoulos K, Tsolaki V, Georgakopoulou VE, Trakas I, Tarantinos K, Papalexis P, Spandidos DA, Aravantinou-Fatorou A, Mathioudakis N, Trakas N, Lavdas E, Fotakopoulos G. Value of sildenafil treatment for the prevention of vasospasm‑related delayed ischemic neurological deficits and delayed brain infarction following aneurysmal subarachnoid hemorrhage. MEDICINE INTERNATIONAL 2023; 3:19. [PMID: 37032716 PMCID: PMC10080186 DOI: 10.3892/mi.2023.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/14/2023] [Indexed: 04/11/2023]
Abstract
Cerebral vasospasm (CV) or delayed cerebral ischemia (DCI) constitutes the main reason for the unfavorable outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). The present retrospective cohort study, through an evaluation with computed tomography (CT) perfusion (CTP), aimed to examine the utility of an intravenous or oral administration of sildenafil in preventing DCI that develops due to vasospasm in these patients. A retrospective cohort study was conducted, which included 34 patients in a tertiary care hospital. Of these patients, 18 were males (52.9%), and the median age was 54.4 years. Of these patients, 18 (52.9%) had undergone surgery, and 16 (47.1%) had an endovascular procedure. CTP was performed on the 3rd to the 6th day. The clinical outcome was documented at 30 days using a CT scan and a complete neurological evaluation, including the Glasgow Coma Scale assessment. There was a statistically significant difference in the number of patients who developed an ischemic event at 1 month between those who did not receive sildenafil compared to those who received sildenafil (P<0.05). In addition, the multivariate analysis revealed that cerebral blood flow was an independent factor for detecting an ischemic event in 1 month (P=0.001). On the whole, the findings of the present study indicate that the intravenous or oral administration of sildenafil may be beneficial for the prevention of DCI.
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Affiliation(s)
| | - Vasiliki Tsolaki
- Department of Pulmonary and Critical Care Medicine, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 11527 Athens, Greece
- Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 17 Agiou Thoma Street, 11527 Athens, Greece
| | - Ilias Trakas
- Department of Infectious Diseases-COVID19 Unit, Laiko General Hospital, 11527 Athens, Greece
| | - Kyriakos Tarantinos
- First Department of Pulmonology, Sismanogleio Hospital, 15126 Athens, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Aikaterini Aravantinou-Fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Eleftherios Lavdas
- Department of Medical Radiological Technologists, Technological Education Institute of Athens, 12243 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Xiong Y, Wintermark P. The Role of Sildenafil in Treating Brain Injuries in Adults and Neonates. Front Cell Neurosci 2022; 16:879649. [PMID: 35620219 PMCID: PMC9127063 DOI: 10.3389/fncel.2022.879649] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/04/2022] [Indexed: 12/02/2022] Open
Abstract
Sildenafil is a recognized treatment for patients suffering from erectile dysfunction and pulmonary hypertension. However, new evidence suggests that it may have a neuroprotective and a neurorestorative role in the central nervous system of both adults and neonates. Phosphodiesterase type 5-the target of sildenafil-is distributed in many cells throughout the body, including neurons and glial cells. This study is a comprehensive review of the demonstrated effects of sildenafil on the brain with respect to its function, extent of injury, neurons, neuroinflammation, myelination, and cerebral vessels.
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Affiliation(s)
- Ying Xiong
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Pia Wintermark
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children’s Hospital, Montreal, QC, Canada
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Solár P, Zamani A, Lakatosová K, Joukal M. The blood-brain barrier and the neurovascular unit in subarachnoid hemorrhage: molecular events and potential treatments. Fluids Barriers CNS 2022; 19:29. [PMID: 35410231 PMCID: PMC8996682 DOI: 10.1186/s12987-022-00312-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/24/2022] [Indexed: 12/12/2022] Open
Abstract
The response of the blood-brain barrier (BBB) following a stroke, including subarachnoid hemorrhage (SAH), has been studied extensively. The main components of this reaction are endothelial cells, pericytes, and astrocytes that affect microglia, neurons, and vascular smooth muscle cells. SAH induces alterations in individual BBB cells, leading to brain homeostasis disruption. Recent experiments have uncovered many pathophysiological cascades affecting the BBB following SAH. Targeting some of these pathways is important for restoring brain function following SAH. BBB injury occurs immediately after SAH and has long-lasting consequences, but most changes in the pathophysiological cascades occur in the first few days following SAH. These changes determine the development of early brain injury as well as delayed cerebral ischemia. SAH-induced neuroprotection also plays an important role and weakens the negative impact of SAH. Supporting some of these beneficial cascades while attenuating the major pathophysiological pathways might be decisive in inhibiting the negative impact of bleeding in the subarachnoid space. In this review, we attempt a comprehensive overview of the current knowledge on the molecular and cellular changes in the BBB following SAH and their possible modulation by various drugs and substances.
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Affiliation(s)
- Peter Solár
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
- Department of Neurosurgery, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Pekařská 53, 656 91, Brno, Czech Republic
| | - Alemeh Zamani
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Klaudia Lakatosová
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Marek Joukal
- Department of Anatomy, Cellular and Molecular Neurobiology Research Group, Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic.
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Regnier-Golanov AS, Gulinello M, Hernandez MS, Golanov EV, Britz GW. Subarachnoid Hemorrhage Induces Sub-acute and Early Chronic Impairment in Learning and Memory in Mice. Transl Stroke Res 2022; 13:625-640. [PMID: 35260988 DOI: 10.1007/s12975-022-00987-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/06/2022] [Accepted: 01/11/2022] [Indexed: 12/20/2022]
Abstract
Subarachnoid hemorrhage (SAH) leads to significant long-term cognitive deficits, so-called the post-SAH syndrome. Existing neurological scales used to assess outcomes of SAH are focused on sensory-motor functions. To better evaluate short-term and chronic consequences of SAH, we explored and validated a battery of neurobehavioral tests to gauge the functional outcomes in mice after the circle of Willis perforation-induced SAH. The 18-point Garcia scale, applied up to 4 days, detected impairment only at 24-h time point and showed no significant difference between the Sham and SAH group. A decrease in locomotion was detected at 4-days post-surgery in the open field test but recovered at 30 days in Sham and SAH groups. However, an anxiety-like behavior undetected at 4 days developed at 30 days in SAH mice. At 4-days post-surgery, Y-maze revealed an impairment in working spatial memory in SAH mice, and dyadic social interactions showed a decrease in the sociability in SAH mice, which spent less time interacting with the stimulus mouse. At 30 days after ictus, SAH mice displayed mild spatial learning and memory deficits in the Barnes maze as they committed significantly more errors and used more time to find the escape box but still were able to learn the task. We also observed cognitive dysfunction in the SAH mice in the novel object recognition test. Taken together, these data suggest dysfunction of the limbic system and hippocampus in particular. We suggest a battery of 5 basic behavioral tests allowing to detect neurocognitive deficits in a sub-acute and chronic phase following the SAH.
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Affiliation(s)
| | - M Gulinello
- Rodent Behavior Core, Department of Neuroscience, Albert Einstein University, Bronx, NY, 10461, USA
| | - M S Hernandez
- Department of Neurosurgery, Houston Methodist Hospital, Houston, USA
| | - E V Golanov
- Department of Neurosurgery, Houston Methodist Hospital, Houston, USA
| | - G W Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, USA.
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Diwan D, Vellimana AK, Aum DJ, Clarke J, Nelson JW, Lawrence M, Han BH, Gidday JM, Zipfel GJ. Sirtuin 1 Mediates Protection Against Delayed Cerebral Ischemia in Subarachnoid Hemorrhage in Response to Hypoxic Postconditioning. J Am Heart Assoc 2021; 10:e021113. [PMID: 34622677 PMCID: PMC8751859 DOI: 10.1161/jaha.121.021113] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Many therapies designed to prevent delayed cerebral ischemia (DCI) and improve neurological outcome in aneurysmal subarachnoid hemorrhage (SAH) have failed, likely because of targeting only one element of what has proven to be a multifactorial disease. We previously demonstrated that initiating hypoxic conditioning before SAH (hypoxic preconditioning) provides powerful protection against DCI. Here, we expanded upon these findings to determine whether hypoxic conditioning delivered at clinically relevant time points after SAH (hypoxic postconditioning) provides similarly robust DCI protection. Methods and Results In this study, we found that hypoxic postconditioning (8% O2 for 2 hours) initiated 3 hours after SAH provides strong protection against cerebral vasospasm, microvessel thrombi, and neurological deficits. By pharmacologic and genetic inhibition of SIRT1 (sirtuin 1) using EX527 and global Sirt1-/- mice, respectively, we demonstrated that this multifaceted DCI protection is SIRT1 mediated. Moreover, genetic overexpression of SIRT1 using Sirt1-Tg mice, mimicked the DCI protection afforded by hypoxic postconditioning. Finally, we found that post-SAH administration of resveratrol attenuated cerebral vasospasm, microvessel thrombi, and neurological deficits, and did so in a SIRT1-dependent fashion. Conclusions The present study indicates that hypoxic postconditioning provides powerful DCI protection when initiated at clinically relevant time points, and that pharmacologic augmentation of SIRT1 activity after SAH can mimic this beneficial effect. We conclude that conditioning-based therapies administered after SAH hold translational promise for patients with SAH and warrant further investigation.
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Affiliation(s)
- Deepti Diwan
- Department of Neurological Surgery Washington University School of Medicine St. Louis MO
| | - Ananth K Vellimana
- Department of Neurological Surgery Washington University School of Medicine St. Louis MO
| | - Diane J Aum
- Department of Neurological Surgery Washington University School of Medicine St. Louis MO
| | - Julian Clarke
- Department of Neurological Surgery Washington University School of Medicine St. Louis MO
| | - James W Nelson
- Department of Neurological Surgery Washington University School of Medicine St. Louis MO
| | - Molly Lawrence
- Department of Neurological Surgery Washington University School of Medicine St. Louis MO
| | - Byung Hee Han
- Department of Pharmacology A.T. Still University of Health SciencesKirksville College of Osteopathic Medicine Kirksville MO
| | - Jeffrey M Gidday
- Departments of Ophthalmology, Physiology, Biochemistry, and Neuroscience Louisiana State University New Orleans LA
| | - Gregory J Zipfel
- Department of Neurological Surgery Washington University School of Medicine St. Louis MO.,Department of Neurology Washington University School of Medicine St. Louis MO
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Dodd WS, Noda I, Martinez M, Hosaka K, Hoh BL. NLRP3 inhibition attenuates early brain injury and delayed cerebral vasospasm after subarachnoid hemorrhage. J Neuroinflammation 2021; 18:163. [PMID: 34284798 PMCID: PMC8293512 DOI: 10.1186/s12974-021-02207-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/25/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The NLRP3 inflammasome is a critical mediator of several vascular diseases through positive regulation of proinflammatory pathways. In this study, we defined the role of NLRP3 in both the acute and delayed phases following subarachnoid hemorrhage (SAH). SAH is associated with devastating early brain injury (EBI) in the acute phase, and those that survive remain at risk for developing delayed cerebral ischemia (DCI) due to cerebral vasospasm. Current therapies are not effective in preventing the morbidity and mortality associated with EBI and DCI. NLRP3 activation is known to drive IL-1β production and stimulate microglia reactivity, both hallmarks of SAH pathology; thus, we hypothesized that inhibition of NLRP3 could alleviate SAH-induced vascular dysfunction and functional deficits. METHODS We studied NLRP3 in an anterior circulation autologous blood injection model of SAH in mice. Mice were randomized to either sham surgery + vehicle, SAH + vehicle, or SAH + MCC950 (a selective NLRP3 inhibitor). The acute phase was studied at 1 day post-SAH and delayed phase at 5 days post-SAH. RESULTS NLRP3 inhibition improved outcomes at both 1 and 5 days post-SAH. In the acute (1 day post-SAH) phase, NLRP3 inhibition attenuated cerebral edema, tight junction disruption, microthrombosis, and microglial reactive morphology shift. Further, we observed a decrease in apoptosis of neurons in mice treated with MCC950. NLRP3 inhibition also prevented middle cerebral artery vasospasm in the delayed (5 days post-SAH) phase and blunted SAH-induced sensorimotor deficits. CONCLUSIONS We demonstrate a novel association between NLRP3-mediated neuroinflammation and cerebrovascular dysfunction in both the early and delayed phases after SAH. MCC950 and other NLRP3 inhibitors could be promising tools in the development of therapeutics for EBI and DCI.
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Affiliation(s)
- William S Dodd
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Imaray Noda
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Melanie Martinez
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Koji Hosaka
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| | - Brian L Hoh
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, 32610, USA.
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Athiraman U, Liu M, Jayaraman K, Yuan J, Mehla J, Zipfel GJ. Anesthetic and subanesthetic doses of isoflurane conditioning provides strong protection against delayed cerebral ischemia in a mouse model of subarachnoid hemorrhage. Brain Res 2020; 1750:147169. [PMID: 33132166 DOI: 10.1016/j.brainres.2020.147169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 12/23/2022]
Abstract
Delayed cerebral ischemia (DCI) is identified as one of the significant contributors to poor patient outcome after aneurysmal subarachnoid hemorrhage (SAH). We previously reported that a supratherapeutic dose of isoflurane conditioning (2%) provided robust protection against SAH-induced DCI. The aim of our current study is to compare the efficacy of the supratherapeutic dose of isoflurane to that typically used to establish general anesthesia or sedation. After IRB approval for animal studies, ten to fourteen-week-old wild-type male mice (C57BL/6) were divided into five groups - sham, SAH alone, or SAH with isoflurane conditioning (0.5%, 1%, and 2%). Conditioning was performed with one-hour of isoflurane initiated one-hour after induction of SAH via endovascular perforation technique. Vasospasm measurement in the middle cerebral artery was assessed 72 h after SAH. Neurological assessment was performed at baseline and for next three days after SAH. It was identified that all tested doses of isoflurane conditioning (0.5%, 1%, and 2%) significantly attenuated large artery vasospasm and markedly improved neurological deficits following SAH. No significant differences in neurovascular outcome were noted between the three doses of isoflurane conditioning. Our data show that isoflurane dosing typically used for general anesthesia (1%) or sedation (0.5%) provide similar levels of DCI protection in SAH as that provided by a supratherapeutic dose (2%). This result has important implications for future translational studies. Additional studies examining the therapeutic potential of anesthetic conditioning for SAH are therefore warranted.
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Affiliation(s)
- Umeshkumar Athiraman
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, United States.
| | - Meizi Liu
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, United States
| | - Keshav Jayaraman
- Department of Neurological Surgery, Washington University, St. Louis, MO 63110, United States
| | - Jane Yuan
- Department of Anesthesiology, Washington University, St. Louis, MO 63110, United States
| | - Jogender Mehla
- Department of Neurological Surgery, Washington University, St. Louis, MO 63110, United States
| | - Gregory J Zipfel
- Departments of Neurological Surgery and Neurology, Washington University, St. Louis, MO 63110, United States
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Vellimana AK, Aum DJ, Diwan D, Clarke JV, Nelson JW, Lawrence M, Han BH, Gidday JM, Zipfel GJ. SIRT1 mediates hypoxic preconditioning induced attenuation of neurovascular dysfunction following subarachnoid hemorrhage. Exp Neurol 2020; 334:113484. [PMID: 33010255 DOI: 10.1016/j.expneurol.2020.113484] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/18/2020] [Accepted: 09/24/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Vasospasm and delayed cerebral ischemia (DCI) contribute significantly to the morbidity/mortality associated with aneurysmal subarachnoid hemorrhage (SAH). While considerable research effort has focused on preventing or reversing vasospasm, SAH-induced brain injury occurs in response to a multitude of concomitantly acting pathophysiologic mechanisms. In this regard, the pleiotropic epigenetic responses to conditioning-based therapeutics may provide an ideal SAH therapeutic strategy. We previously documented the ability of hypoxic preconditioning (PC) to attenuate vasospasm and neurological deficits after SAH, in a manner that depends on the activity of endothelial nitric oxide synthase. The present study was undertaken to elucidate whether the NAD-dependent protein deacetylase sirtuin isoform SIRT1 is an upstream mediator of hypoxic PC-induced protection, and to assess the efficacy of the SIRT1-activating polyphenol Resveratrol as a pharmacologic preconditioning therapy. METHODS Wild-type C57BL/6J mice were utilized in the study and subjected to normoxia or hypoxic PC. Surgical procedures included induction of SAH via endovascular perforation or sham surgery. Multiple endpoints were assessed including cerebral vasospasm, neurobehavioral deficits, SIRT1 expression via quantitative real-time PCR for mRNA, and western blot for protein quantification. Pharmacological agents utilized in the study include EX-527 (SIRT1 inhibitor), and Resveratrol (SIRT1 activator). RESULTS Hypoxic PC leads to rapid and sustained increase in cerebral SIRT1 mRNA and protein expression. SIRT1 inhibition blocks the protective effects of hypoxic PC on vasospasm and neurological deficits. Resveratrol pretreatment dose-dependently abrogates vasospasm and attenuates neurological deficits following SAH - beneficial effects that were similarly blocked by pharmacologic inhibition of SIRT1. CONCLUSION SIRT1 mediates hypoxic preconditioning-induced protection against neurovascular dysfunction after SAH. Resveratrol mimics this neurovascular protection, at least in part, via SIRT1. Activation of SIRT1 is a promising, novel, pleiotropic therapeutic strategy to combat DCI after SAH.
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Affiliation(s)
- Ananth K Vellimana
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Diane J Aum
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Deepti Diwan
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Julian V Clarke
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - James W Nelson
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Molly Lawrence
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Byung Hee Han
- Department of Pharmacology, A.T. Still University of Health Sciences, Kirksville College of Osteopathic Medicine, Kirksville, MO 63501, USA
| | - Jeffrey M Gidday
- Departments of Ophthalmology, Physiology, Biochemistry, and Neuroscience, Louisiana State University, New Orleans, Louisiana, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA.
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Clarke JV, Suggs JM, Diwan D, Lee JV, Lipsey K, Vellimana AK, Zipfel GJ. Microvascular platelet aggregation and thrombosis after subarachnoid hemorrhage: A review and synthesis. J Cereb Blood Flow Metab 2020; 40:1565-1575. [PMID: 32345104 PMCID: PMC7370365 DOI: 10.1177/0271678x20921974] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) has been associated with numerous pathophysiological sequelae, including large artery vasospasm and microvascular thrombosis. The focus of this review is to provide an overview of experimental animal model studies and human autopsy studies that explore the temporal-spatial characterization and mechanism of microvascular platelet aggregation and thrombosis following SAH, as well as to critically assess experimental studies and clinical trials highlighting preventative therapeutic options against this highly morbid pathophysiological process. Upon review of the literature, we discovered that microvascular platelet aggregation and thrombosis occur after experimental SAH across multiple species and SAH induction techniques in a similar time frame to other components of DCI, occurring in the cerebral cortex and hippocampus across both hemispheres. We discuss the relationship of these findings to human autopsy studies. In the final section of this review, we highlight the important therapeutic options for targeting microvascular platelet aggregation and thrombosis, and emphasize why therapeutic targeting of this neurovascular pathology may improve patient care. We encourage ongoing research into the pathophysiology of SAH and DCI, especially in regard to microvascular platelet aggregation and thrombosis and the translation to randomized clinical trials.
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Affiliation(s)
- Julian V Clarke
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Julia M Suggs
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Deepti Diwan
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Jin V Lee
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Kim Lipsey
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Ananth K Vellimana
- Neurological Surgery, Washington University School of Medicine, , Saint Louis, MO, USA
| | - Gregory J Zipfel
- Neurological Surgery, Washington University School of Medicine, , Saint Louis, MO, USA
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Matsumura K, Kumar TP, Guddanti T, Yan Y, Blackburn SL, McBride DW. Neurobehavioral Deficits After Subarachnoid Hemorrhage in Mice: Sensitivity Analysis and Development of a New Composite Score. J Am Heart Assoc 2020; 8:e011699. [PMID: 30971151 PMCID: PMC6507191 DOI: 10.1161/jaha.118.011699] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Because of the failure of numerous clinical trials, various recommendations have been made to improve the usefulness of preclinical studies. Specifically, the STAIR (Stroke Therapy Academic Industry Roundtable) recommendations highlighted functional outcome as a critical measure. Recent reviews of experimental subarachnoid hemorrhage (SAH) studies have brought to light the numerous neurobehavioral scoring systems that are used in preclinical SAH studies. To gain insight into the utility of these scoring systems, as well as to identify a scoring system that best captures the deficits caused by SAH in mice, we designed the current study. Methods and Results Adult male C57BL/6J mice were used. One cohort of mice was randomly allocated to either sham or SAH and had functional testing performed on days 1 to 3 post‐SAH using the modified Bederson Score, Katz Score, Garcia Neuroscore, and Parra Neuroscore, as well as 21 individual subtests. A new composite neuroscore was developed using the 8 most diagnostically accurate subtests. To validate the use of the developed composite neuroscore, another cohort of mice was randomly assigned to either the sham or SAH group and neurobehavior was evaluated on days 1 to 3, 5, and 7 after injury. Receiver operating characteristic curves were used to analyze the diagnostic accuracy of each scoring system, as well as the subtests. Of the 4 published scoring systems, the Parra Neuroscore was diagnostically accurate for SAH injury in mice versus the modified Bederson and Katz Scores, but not the Garcia Neuroscore. However, the newly developed composite neuroscore was found to be statistically more diagnostically accurate than even the Parra Neuroscore. Conclusions The findings of this study promote use of the newly developed composite neuroscore for experimental SAH studies in mice.
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Affiliation(s)
- Kanako Matsumura
- 1 The Vivian L. Smith Department of Neurosurgery McGovern Medical School The University of Texas Health Science Center at Houston Houston TX
| | - T Peeyush Kumar
- 1 The Vivian L. Smith Department of Neurosurgery McGovern Medical School The University of Texas Health Science Center at Houston Houston TX
| | - Tejesh Guddanti
- 1 The Vivian L. Smith Department of Neurosurgery McGovern Medical School The University of Texas Health Science Center at Houston Houston TX
| | - Yuanqing Yan
- 1 The Vivian L. Smith Department of Neurosurgery McGovern Medical School The University of Texas Health Science Center at Houston Houston TX
| | - Spiros L Blackburn
- 1 The Vivian L. Smith Department of Neurosurgery McGovern Medical School The University of Texas Health Science Center at Houston Houston TX
| | - Devin W McBride
- 1 The Vivian L. Smith Department of Neurosurgery McGovern Medical School The University of Texas Health Science Center at Houston Houston TX
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12
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Wagner-Altendorf TA, Boppel T, Herzog R, Münte TF. Sudden headache due to perimesencephalic subarachnoid hemorrhage after self-medication with 200 mg sildenafil: Case report and discussion. Clin Neurol Neurosurg 2020; 194:105844. [DOI: 10.1016/j.clineuro.2020.105844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/02/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
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13
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Pharmacologic Management of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage. Crit Care Nurs Q 2020; 43:138-156. [DOI: 10.1097/cnq.0000000000000299] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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14
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Geraghty JR, Davis JL, Testai FD. Neuroinflammation and Microvascular Dysfunction After Experimental Subarachnoid Hemorrhage: Emerging Components of Early Brain Injury Related to Outcome. Neurocrit Care 2019; 31:373-389. [PMID: 31012056 PMCID: PMC6759381 DOI: 10.1007/s12028-019-00710-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aneurysmal subarachnoid hemorrhage has a high mortality rate and, for those who survive this devastating injury, can lead to lifelong impairment. Clinical trials have demonstrated that cerebral vasospasm of larger extraparenchymal vessels is not the sole contributor to neurological outcome. Recently, the focus of intense investigation has turned to mechanisms of early brain injury that may play a larger role in outcome, including neuroinflammation and microvascular dysfunction. Extravasated blood after aneurysm rupture results in a robust inflammatory response characterized by activation of microglia, upregulation of cellular adhesion molecules, recruitment of peripheral immune cells, as well as impaired neurovascular coupling, disruption of the blood-brain barrier, and imbalances in endogenous vasodilators and vasoconstrictors. Each of these phenomena is either directly or indirectly associated with neuronal death and brain injury. Here, we review recent studies investigating these various mechanisms in experimental models of subarachnoid hemorrhage with special emphasis on neuroinflammation and its effect on microvascular dysfunction. We discuss the various therapeutic targets that have risen from these mechanistic studies and suggest the utility of a multi-targeted approach to preventing delayed injury and improving outcome after subarachnoid hemorrhage.
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Affiliation(s)
- Joseph R Geraghty
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, 912 S. Wood St. Suite 174N, Chicago, IL, 60612, USA.
- Medical Scientist Training Program, University of Illinois at Chicago, Chicago, IL, USA.
| | - Joseph L Davis
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, 912 S. Wood St. Suite 174N, Chicago, IL, 60612, USA
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, College of Medicine, University of Illinois at Chicago, 912 S. Wood St. Suite 174N, Chicago, IL, 60612, USA
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15
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Neulen A, Meyer S, Kramer A, Pantel T, Kosterhon M, Kunzelmann S, Goetz H, Thal SC. Large Vessel Vasospasm Is Not Associated with Cerebral Cortical Hypoperfusion in a Murine Model of Subarachnoid Hemorrhage. Transl Stroke Res 2018; 10:10.1007/s12975-018-0647-6. [PMID: 30003500 PMCID: PMC6526146 DOI: 10.1007/s12975-018-0647-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/27/2018] [Accepted: 07/02/2018] [Indexed: 01/01/2023]
Abstract
Clinical studies on subarachnoid hemorrhage (SAH) have shown discrepancies between large vessel vasospasm, cerebral perfusion, and clinical outcome. We set out to analyze the contribution of large vessel vasospasm to impaired cerebral perfusion and neurological impairment in a murine model of SAH. SAH was induced in C57BL/6 mice by endovascular filament perforation. Vasospasm was analyzed with microcomputed tomography, cortical perfusion by laser SPECKLE contrast imaging, and functional impairment with a quantitative neuroscore. SAH animals developed large vessel vasospasm, as shown by significantly lower vessel volumes of a 2.5-mm segment of the left middle cerebral artery (MCA) (SAH 5.6 ± 0.6 nL, sham 8.3 ± 0.5 nL, p < 0.01). Induction of SAH significantly reduced cerebral perfusion of the corresponding left MCA territory compared to values before SAH, which only recovered partly (SAH vs. sham, 15 min 35.7 ± 3.1 vs. 101.4 ± 10.2%, p < 0.01; 3 h, 85.0 ± 8.6 vs. 121.9 ± 13.4, p < 0.05; 24 h, 75.3 ± 4.6 vs. 110.6 ± 11.4%, p < 0.01; 72 h, 81.8 ± 4.8 vs. 108.5 ± 14.5%, n.s.). MCA vessel volume did not correlate significantly with MCA perfusion after 72 h (r = 0.34, p = 0.25). Perfusion correlated moderately with neuroscore (24 h: r = - 0.58, p < 0.05; 72 h: r = - 0.44, p = 0.14). There was no significant correlation between vessel volume and neuroscore after 72 h (r = - 0.21, p = 0.50). In the murine SAH model, cerebral hypoperfusion occurs independently of large vessel vasospasm. Neurological outcome is associated with cortical hypoperfusion rather than large vessel vasospasm.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Simon Meyer
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Andreas Kramer
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Svenja Kunzelmann
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Hermann Goetz
- Platform for Biomaterial Research, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany.
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16
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Turan N, Miller BA, Heider RA, Nadeem M, Sayeed I, Stein DG, Pradilla G. Neurobehavioral testing in subarachnoid hemorrhage: A review of methods and current findings in rodents. J Cereb Blood Flow Metab 2017; 37:3461-3474. [PMID: 27677672 PMCID: PMC5669338 DOI: 10.1177/0271678x16665623] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The most important aspect of a preclinical study seeking to develop a novel therapy for neurological diseases is whether the therapy produces any clinically relevant functional recovery. For this purpose, neurobehavioral tests are commonly used to evaluate the neuroprotective efficacy of treatments in a wide array of cerebrovascular diseases and neurotrauma. Their use, however, has been limited in experimental subarachnoid hemorrhage studies. After several randomized, double-blinded, controlled clinical trials repeatedly failed to produce a benefit in functional outcome despite some improvement in angiographic vasospasm, more rigorous methods of neurobehavioral testing became critical to provide a more comprehensive evaluation of the functional efficacy of proposed treatments. While several subarachnoid hemorrhage studies have incorporated an array of neurobehavioral assays, a standardized methodology has not been agreed upon. Here, we review neurobehavioral tests for rodents and their potential application to subarachnoid hemorrhage studies. Developing a standardized neurobehavioral testing regimen in rodent studies of subarachnoid hemorrhage would allow for better comparison of results between laboratories and a better prediction of what interventions would produce functional benefits in humans.
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Affiliation(s)
- Nefize Turan
- 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Brandon A Miller
- 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert A Heider
- 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Maheen Nadeem
- 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Iqbal Sayeed
- 2 Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Donald G Stein
- 2 Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Gustavo Pradilla
- 1 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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17
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Vellimana AK, Zhou ML, Singh I, Aum DJ, Nelson JW, Harris GR, Athiraman U, Han BH, Zipfel GJ. Minocycline protects against delayed cerebral ischemia after subarachnoid hemorrhage via matrix metalloproteinase-9 inhibition. Ann Clin Transl Neurol 2017; 4:865-876. [PMID: 29296615 PMCID: PMC5740245 DOI: 10.1002/acn3.492] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/06/2017] [Accepted: 09/25/2017] [Indexed: 12/11/2022] Open
Abstract
Objective Delayed cerebral ischemia (DCI) is an independent risk factor for poor outcome after aneurysmal subarachnoid hemorrhage (SAH) and is multifactorial in etiology. While prior studies have suggested a role for matrix metalloproteinase-9 (MMP-9) in early brain injury after SAH, its contribution to the pathophysiology of DCI is unclear. Methods In the first experiment, wild-type (WT) and MMP-9-/- mice were subjected to sham or endovascular perforation SAH surgery. In separate experiments, WT and MMP-9-/-mice were administered vehicle or minocycline either pre- or post-SAH. All mice underwent assessment of multiple components of DCI including vasospasm, neurobehavioral function, and microvessel thrombosis. In another experiment, rabbits were subjected to sham or cisterna magna injection SAH surgery, and administered vehicle or minocycline followed by vasospasm assessment. Results MMP-9 expression and activity was increased after SAH. Genetic (MMP-9-/- mice) and pharmacological (pre-SAH minocycline administration) inhibition of MMP-9 resulted in decreased vasospasm and neurobehavioral deficits. A therapeutically feasible strategy of post-SAH administration of minocycline resulted in attenuation of multiple components of DCI. Minocycline administration to MMP-9-/- mice did not yield additional protection. Consistent with experiments in mice, both pre- and post-SAH administration of minocycline attenuated SAH-induced vasospasm in rabbits. Interpretation MMP-9 is a key player in the pathogenesis of DCI. The consistent attenuation of multiple components of DCI with both pre- and post-SAH administration of minocycline across different species and experimental models of SAH, combined with the excellent safety profile of minocycline in humans suggest that a clinical trial in SAH patients is warranted.
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Affiliation(s)
- Ananth K Vellimana
- Department of Neurological Surgery Washington University School of Medicine St. Louis Missouri
| | - Meng-Liang Zhou
- Department of Neurosurgery Jinling Hospital School of Medicine Nanjing University Nanjing Jiangsu Province China
| | - Itender Singh
- Department of Neurological Surgery Washington University School of Medicine St. Louis Missouri
| | - Diane J Aum
- Department of Neurological Surgery Washington University School of Medicine St. Louis Missouri
| | - James W Nelson
- Department of Neurological Surgery Washington University School of Medicine St. Louis Missouri
| | - Glenn R Harris
- Department of Neurological Surgery Washington University School of Medicine St. Louis Missouri
| | - Umeshkumar Athiraman
- Department of Anesthesiology Washington University School of Medicine St. Louis Missouri
| | - Byung H Han
- Department of Pharmacology A.T. Still University of Health Sciences Kirksville College of Osteopathic Medicine Kirksville Missouri
| | - Gregory J Zipfel
- Department of Neurological Surgery Washington University School of Medicine St. Louis Missouri
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18
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Dhar R, Washington C, Diringer M, Zazulia A, Jafri H, Derdeyn C, Zipfel G. Acute Effect of Intravenous Sildenafil on Cerebral Blood Flow in Patients with Vasospasm After Subarachnoid Hemorrhage. Neurocrit Care 2017; 25:201-4. [PMID: 26940913 DOI: 10.1007/s12028-016-0243-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The phosphodiesterase-5 inhibitor sildenafil has been shown to attenuate delayed cerebral ischemia (DCI) and improve neurologic function in experimental subarachnoid hemorrhage (SAH). We recently demonstrated that it could improve cerebral vasospasm (CVS) in humans after SAH. However, successful therapies for DCI must also restore cerebral blood flow (CBF) and/or autoregulatory capacity. In this study, we tested the effects of sildenafil on CBF in SAH patients at-risk for DCI. METHODS Six subjects with angiographically confirmed CVS received 30-mg of intravenous sildenafil (mean 9 ± 2 days after aneurysmal SAH). Each underwent (15)O-PET imaging to measure global and regional CBF at baseline and post-sildenafil. RESULTS Mean arterial pressure declined by 10 mm Hg on average post-sildenafil (8 %, p = 0.01), while ICP was unchanged. There was no change in global CBF (mean 34.5 ± 7 ml/100g/min at baseline vs. 33.9 ± 8.0 ml/100g/min post-sildenafil, p = 0.84). The proportion of brain regions with low CBF (<25 ml/100g/min) was also unchanged after sildenafil infusion. CONCLUSIONS Infusion of sildenafil does not lead to a change in global or regional perfusion despite a significant reduction in cerebral perfusion pressure. While this could reflect the ineffectiveness of sildenafil-induced proximal vasodilatation to alter brain perfusion, it also suggests that cerebral autoregulatory function was preserved in this group. Future studies should assess whether sildenafil can restore or enhance autoregulation after SAH.
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Affiliation(s)
- Rajat Dhar
- Division of Neurocritical Care, Department of Neurology, Washington University in St. Louis, 660 S Euclid Avenue, St. Louis, MO, 63110, USA.
| | - Chad Washington
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Michael Diringer
- Division of Neurocritical Care, Department of Neurology, Washington University in St. Louis, 660 S Euclid Avenue, St. Louis, MO, 63110, USA.,Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Allyson Zazulia
- Division of Neurocritical Care, Department of Neurology, Washington University in St. Louis, 660 S Euclid Avenue, St. Louis, MO, 63110, USA.,Department of Radiology, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Hussain Jafri
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Colin Derdeyn
- Division of Neurocritical Care, Department of Neurology, Washington University in St. Louis, 660 S Euclid Avenue, St. Louis, MO, 63110, USA.,Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO, 63110, USA.,Department of Radiology, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Gregory Zipfel
- Division of Neurocritical Care, Department of Neurology, Washington University in St. Louis, 660 S Euclid Avenue, St. Louis, MO, 63110, USA.,Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO, 63110, USA
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19
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Aum DJ, Vellimana AK, Singh I, Milner E, Nelson JW, Han BH, Zipfel GJ. A novel fluorescent imaging technique for assessment of cerebral vasospasm after experimental subarachnoid hemorrhage. Sci Rep 2017; 7:9126. [PMID: 28831103 PMCID: PMC5567362 DOI: 10.1038/s41598-017-09070-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/21/2017] [Indexed: 12/22/2022] Open
Abstract
Various techniques have been developed to study changes in the cerebral vasculature in numerous neuropathological processes including subarachnoid hemorrhage (SAH). One of the most widely employed techniques uses India ink-gelatin casting, which presents numerous challenges due to its high viscosity, rapid solidification, and its impact on immunohistochemical analysis. To overcome these limitations, we developed a novel technique for assessing cerebral vasospasm using cerebrovascular perfusion with ROX, SE (5-Carboxy-X-Rhodamine, Succinimidyl Ester), a fluorescent labeling dye. We found that ROX SE perfusion achieves excellent delineation of the cerebral vasculature, was qualitatively and quantitatively superior to India ink-gelatin casting for the assessment of cerebral vasospasm, permits outstanding immunohistochemical examination of non-vasospasm components of secondary brain injury, and is a more efficient and cost-effective experimental technique. ROX SE perfusion is therefore a novel and highly useful technique for studying cerebrovascular pathology following experimental SAH.
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Affiliation(s)
- Diane J Aum
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Ananth K Vellimana
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Itender Singh
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Eric Milner
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - James W Nelson
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Byung Hee Han
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA.,Department of Pharmacology, A.T. Still University of Health Sciences, Kirksville, MO, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA. .,Department of Neurology, Washington University School of Medicine, St Louis, MO, USA.
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20
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Fanizzi C, Sauerbeck AD, Gangolli M, Zipfel GJ, Brody DL, Kummer TT. Minimal Long-Term Neurobehavioral Impairments after Endovascular Perforation Subarachnoid Hemorrhage in Mice. Sci Rep 2017; 7:7569. [PMID: 28790425 PMCID: PMC5548778 DOI: 10.1038/s41598-017-07701-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/03/2017] [Indexed: 02/06/2023] Open
Abstract
Cognitive deficits are among the most severe and pervasive consequences of aneurysmal subarachnoid hemorrhage (SAH). A critical step in developing therapies targeting such outcomes is the characterization of experimentally-tractable pre-clinical models that exhibit multi-domain neurobehavioral deficits similar to those afflicting humans. We therefore searched for neurobehavioral abnormalities following endovascular perforation induction of SAH in mice, a heavily-utilized model. We instituted a functional screen to manage variability in injury severity, then assessed acute functional deficits, as well as activity, anxiety-related behavior, learning and memory, socialization, and depressive-like behavior at sub-acute and chronic time points (up to 1 month post-injury). Animals in which SAH was induced exhibited reduced acute functional capacity and reduced general activity to 1 month post-injury. Tests of anxiety-related behavior including central area time in the elevated plus maze and thigmotaxis in the open field test revealed increased anxiety-like behavior at subacute and chronic time-points, respectively. Effect sizes for subacute and chronic neurobehavioral endpoints in other domains, however, were small. In combination with persistent variability, this led to non-significant effects of injury on all remaining neurobehavioral outcomes. These results suggest that, with the exception of anxiety-related behavior, alternate mouse models are required to effectively analyze cognitive outcomes after SAH.
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Affiliation(s)
- Claudia Fanizzi
- Department of Neurology, Washington University School of Medicine in St. Louis, Missouri, USA
- Department of Neurosurgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew D Sauerbeck
- Department of Neurology, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Mihika Gangolli
- Department of Neurology, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Gregory J Zipfel
- Department of Neurology, Washington University School of Medicine in St. Louis, Missouri, USA
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri, USA
| | - David L Brody
- Department of Neurology, Washington University School of Medicine in St. Louis, Missouri, USA
| | - Terrance T Kummer
- Department of Neurology, Washington University School of Medicine in St. Louis, Missouri, USA.
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21
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22
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Cumming P. A business of some heat: molecular imaging of phosphodiesterase 5. J Neurochem 2016; 136:220-1. [PMID: 26990291 DOI: 10.1111/jnc.13453] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 11/23/2015] [Accepted: 11/26/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Paul Cumming
- Department of Neuropsychiatry and Psychosomatic Medicine, Oslo University Hospital, Oslo, Norway.,School of Psychology and Counselling, Queensland University of Technology, and QIMR Berghofer Medical Research Institute, Brisbane, Australia
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23
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Abstract
Sildenafil is one of the most commonly used drugs for the treatment of erectile dysfunction. To date, we found five reported cases of intracerebral bleeding and two reported cases of subarachnoid hemorrhage related to sildenafil use. We report a 49-year-old hypertensive and diabetic patient who presented with acute pulmonary edema and loss of consciousness following ingestion of 100 mg of sildenafil prior to sexual intercourse. He was not previously aware of the presence of an aneurysm and had no family history of it. Computed tomography of his head revealed a subarachnoid hemorrhage due to rupture of a saccular aneurysm with subsequent repeat hemorrhage within a few hours of presentation. A sudden increase in blood pressure led to pulmonary edema. Studies have shown that sildenafil acts on phosphodiesterase-1, -2 and -5 receptors and leads to a secondary increase in intracerebral circulation and vasodilatory effects, leading to sympathetic overactivity which increases the risk for intracranial bleeding.
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Affiliation(s)
- Avinash Adiga
- Texas Tech University Health Science Center, Lubbock, Texas
| | - Hawa Edriss
- Texas Tech University Health Science Center, Lubbock, Texas
| | - Kenneth Nugent
- Texas Tech University Health Science Center, Lubbock, Texas
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24
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Yin D, Slavin K. A hypothesis on possible neurochemical mechanisms of action of cervical spinal cord stimulation in prevention and treatment of cerebral arterial vasospasm after aneurysmal subarachnoid hemorrhage. Med Hypotheses 2015; 85:355-8. [DOI: 10.1016/j.mehy.2015.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 06/17/2015] [Indexed: 10/23/2022]
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25
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Washington CW, Derdeyn CP, Dhar R, Arias EJ, Chicoine MR, Cross DT, Dacey RG, Han BH, Moran CJ, Rich KM, Vellimana AK, Zipfel GJ. A Phase I proof-of-concept and safety trial of sildenafil to treat cerebral vasospasm following subarachnoid hemorrhage. J Neurosurg 2015; 124:318-27. [PMID: 26314998 DOI: 10.3171/2015.2.jns142752] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Studies show that phosphodiesterase-V (PDE-V) inhibition reduces cerebral vasospasm (CVS) and improves outcomes after experimental subarachnoid hemorrhage (SAH). This study was performed to investigate the safety and effect of sildenafil (an FDA-approved PDE-V inhibitor) on angiographic CVS in SAH patients. METHODS A2-phase, prospective, nonrandomized, human trial was implemented. Subarachnoid hemorrhage patients underwent angiography on Day 7 to assess for CVS. Those with CVS were given 10 mg of intravenous sildenafil in the first phase of the study and 30 mg in the second phase. In both, angiography was repeated 30 minutes after infusion. Safety was assessed by monitoring neurological examination findings and vital signs and for the development of adverse reactions. For angiographic assessment, in a blinded fashion, pre- and post-sildenafil images were graded as "improvement" or "no improvement" in CVS. Unblinded measurements were made between pre- and post-sildenafil angiograms. RESULTS Twelve patients received sildenafil; 5 patients received 10 mg and 7 received 30 mg. There were no adverse reactions. There was no adverse effect on heart rate or intracranial pressure. Sildenafil resulted in a transient decline in mean arterial pressure, an average of 17% with a return to baseline in an average of 18 minutes. Eight patients (67%) were found to have a positive angiographic response to sildenafil, 3 (60%) in the low-dose group and 5 (71%) in the high-dose group. The largest degree of vessel dilation was an average of 0.8 mm (range 0-2.1 mm). This corresponded to an average percentage increase in vessel diameter of 62% (range 0%-200%). CONCLUSIONS The results from this Phase I safety and proof-of-concept trial assessing the use of intravenous sildenafil in patients with CVS show that sildenafil is safe and well tolerated in the setting of SAH. Furthermore, the angiographic data suggest that sildenafil has a positive impact on human CVS.
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Affiliation(s)
- Chad W Washington
- Departments of 1 Neurological Surgery.,Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Colin P Derdeyn
- Departments of 1 Neurological Surgery.,Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | | | | | | | - DeWitte T Cross
- Departments of 1 Neurological Surgery.,Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | | | | | - Christopher J Moran
- Departments of 1 Neurological Surgery.,Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Keith M Rich
- Departments of 1 Neurological Surgery.,Radiology, Washington University School of Medicine, Saint Louis, Missouri
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Titus DJ, Oliva AA, Wilson NM, Atkins CM. Phosphodiesterase inhibitors as therapeutics for traumatic brain injury. Curr Pharm Des 2015; 21:332-42. [PMID: 25159077 DOI: 10.2174/1381612820666140826113731] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 08/25/2014] [Indexed: 11/22/2022]
Abstract
Developing therapeutics for traumatic brain injury remains a challenge for all stages of recovery. The pathological features of traumatic brain injury are diverse, and it remains an obstacle to be able to target the wide range of pathologies that vary between traumatic brain injured patients and that evolve during recovery. One promising therapeutic avenue is to target the second messengers cAMP and cGMP with phosphodiesterase inhibitors due to their broad effects within the nervous system. Phosphodiesterase inhibitors have the capability to target different injury mechanisms throughout the time course of recovery after brain injury. Inflammation and neuronal death are early targets of phosphodiesterase inhibitors, and synaptic dysfunction and circuitry remodeling are late potential targets of phosphodiesterase inhibitors. This review will discuss how signaling through cyclic nucleotides contributes to the pathology of traumatic brain injury in the acute and chronic stages of recovery. We will review our current knowledge of the successes and challenges of using phosphodiesterase inhibitors for the treatment of traumatic brain injury and conclude with important considerations in developing phosphodiesterase inhibitors as therapeutics for brain trauma.
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Affiliation(s)
| | | | | | - Coleen M Atkins
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida, 33136, USA.
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Muroi C, Fujioka M, Marbacher S, Fandino J, Keller E, Iwasaki K, Mishima K. Mouse model of subarachnoid hemorrhage: technical note on the filament perforation model. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:315-20. [PMID: 25366644 DOI: 10.1007/978-3-319-04981-6_54] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Experiments using genetically engineered mice are regarded as indispensable to gaining a better understanding of the molecular pathophysiology in neuronal injury after subarachnoid hemorrhage (SAH). Therefore, mouse SAH models are becoming increasingly important. The circle of Willis perforation (cWp) model is the most frequently used mouse SAH model. We report and discuss the technical surgical approach, results, and difficulties associated with the cWp model, with reference to the existing literature. Our results largely confirmed previously published results. This model may be the first choice at present, because important pathologies can be reproduced in this model and most findings in the literature are based on it.
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Affiliation(s)
- Carl Muroi
- Department of Neuropharmacology, Faculty of Pharmaceutical Sciences, Fukuoka University, Fukuoka, Japan,
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Milner E, Holtzman JC, Friess S, Hartman RE, Brody DL, Han BH, Zipfel GJ. Endovascular perforation subarachnoid hemorrhage fails to cause Morris water maze deficits in the mouse. J Cereb Blood Flow Metab 2014; 34:jcbfm2014108. [PMID: 24938403 PMCID: PMC4158664 DOI: 10.1038/jcbfm.2014.108] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 05/08/2014] [Accepted: 05/23/2014] [Indexed: 11/09/2022]
Abstract
Cognitive dysfunction is the primary driver of poor long-term outcome in aneurysmal subarachnoid hemorrhage (SAH) survivors; modeling such deficits preclinically is thus key for mechanistic and translational investigation. Although rat SAH causes long-term deficits in learning and memory, it remains unknown whether similar deficits are seen in the mouse, a species particularly amenable to powerful, targeted genetic manipulation. We thus subjected mice to endovascular perforation SAH and assessed long-term cognitive outcome via the Morris water maze (MWM), the most commonly used metric for rodent neurocognition. No significant differences in MWM performance (by either of two protocols) were seen in SAH versus sham mice. Moreover, SAH caused negligible hippocampal CA1 injury. These results undercut the potential of commonly used methods (of SAH induction and assessment of long-term neurocognitive outcome) for use in targeted molecular studies of SAH-induced cognitive deficits in the mouse.
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Affiliation(s)
- Eric Milner
- 1] Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA [2] Program in Neuroscience, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jacob C Holtzman
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Stuart Friess
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Richard E Hartman
- Department of Psychology, Loma Linda University, Loma Linda, California, USA
| | - David L Brody
- 1] Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA [2] Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, Missouri, USA
| | - Byung H Han
- 1] Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA [2] Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, Missouri, USA
| | - Gregory J Zipfel
- 1] Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA [2] Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA [3] Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, Missouri, USA
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Inflammation, vasospasm, and brain injury after subarachnoid hemorrhage. BIOMED RESEARCH INTERNATIONAL 2014; 2014:384342. [PMID: 25105123 PMCID: PMC4106062 DOI: 10.1155/2014/384342] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/14/2014] [Accepted: 05/26/2014] [Indexed: 12/15/2022]
Abstract
Subarachnoid hemorrhage (SAH) can lead to devastating neurological outcomes, and there are few pharmacologic treatments available for treating this condition. Both animal and human studies provide evidence of inflammation being a driving force behind the pathology of SAH, leading to both direct brain injury and vasospasm, which in turn leads to ischemic brain injury. Several inflammatory mediators that are elevated after SAH have been studied in detail. While there is promising data indicating that blocking these factors might benefit patients after SAH, there has been little success in clinical trials. One of the key factors that complicates clinical trials of SAH is the variability of the initial injury and subsequent inflammatory response. It is likely that both genetic and environmental factors contribute to the variability of patients' post-SAH inflammatory response and that this confounds trials of anti-inflammatory therapies. Additionally, systemic inflammation from other conditions that affect patients with SAH could contribute to brain injury and vasospasm after SAH. Continuing work on biomarkers of inflammation after SAH may lead to development of patient-specific anti-inflammatory therapies to improve outcome after SAH.
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Muroi C, Fujioka M, Okuchi K, Fandino J, Keller E, Sakamoto Y, Mishima K, Iwasaki K, Fujiwara M. Filament perforation model for mouse subarachnoid hemorrhage: Surgical-technical considerations. Br J Neurosurg 2014; 28:722-32. [DOI: 10.3109/02688697.2014.918579] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Li T, Wang H, Ding Y, Zhou M, Zhou X, Zhang X, Ding K, He J, Lu X, Xu J, Wei W. Genetic elimination of Nrf2 aggravates secondary complications except for vasospasm after experimental subarachnoid hemorrhage in mice. Brain Res 2014; 1558:90-9. [PMID: 24576487 DOI: 10.1016/j.brainres.2014.02.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 02/18/2014] [Indexed: 01/27/2023]
Abstract
Nuclear factor erythroid 2-related factor 2 (Nrf2) is a key endogenous protective regulator in the body. This study aimed to explore the role of Nrf2 in subarachnoid hemorrhage (SAH)-induced secondary complications. Wild type (WT) and Nrf2 knockout (KO) mice were subjected to experimental SAH by injecting fresh autologous blood into pre-chiasmatic cistern. The absence of Nrf2 function in mice resulted in exacerbated brain injury with increased brain edema, blood-brain barrier (BBB) disruption, neural apoptosis, and severe neurological deficits at 24h after SAH. Moreover, cerebral vasospasm was severe at 24h after SAH, but not significantly different between WT and Nrf2 KO mice after SAH. Meanwhile, Molondialdehyde (MDA) was increased and GSH/GSSG ratio was decreased in Nrf2 KO mice after SAH. Furthermore, higher expression of TNF-α and IL-1β was also found after SAH in Nrf2 KO mice. In conclusion, our results revealed that Nrf2 plays an important role in attenuating SAH-induced secondary complications by regulating excessive oxidative stress and inflammatory response.
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Affiliation(s)
- Tao Li
- Department of Neurosurgery, Jinling Hospital Affiliated to Nanjing University School of Medicine, Nanjing, Jiangsu 210089, PR China; Department of Neurosurgery, Jinling Hospital, Neurosurgical Institution of People's Liberation Army of China, PR China
| | - Handong Wang
- Department of Neurosurgery, Jinling Hospital, Neurosurgical Institution of People's Liberation Army of China, PR China.
| | - Yu Ding
- Department of Neurosurgery, Jinling Hospital Affiliated to Nanjing University School of Medicine, Nanjing, Jiangsu 210089, PR China
| | - Mengliang Zhou
- Department of Neurosurgery, Jinling Hospital, Neurosurgical Institution of People's Liberation Army of China, PR China
| | - Xiaoming Zhou
- Department of Neurosurgery, Jinling Hospital, Neurosurgical Institution of People's Liberation Army of China, PR China
| | - Xiangshen Zhang
- Department of Neurosurgery, Jinling Hospital, Neurosurgical Institution of People's Liberation Army of China, PR China
| | - Ke Ding
- Department of Neurosurgery, Jinling Hospital, Neurosurgical Institution of People's Liberation Army of China, PR China
| | - Jin He
- Department of Neurosurgery, Jinling Hospital, Neurosurgical Institution of People's Liberation Army of China, PR China
| | - Xinyu Lu
- Department of Neurosurgery, Jinling Hospital Affiliated to Nanjing University School of Medicine, Nanjing, Jiangsu 210089, PR China
| | - Jianguo Xu
- Department of Neurosurgery, Jinling Hospital Affiliated to Nanjing University School of Medicine, Nanjing, Jiangsu 210089, PR China
| | - Wuting Wei
- Neurosurgery Department of Southern Medical University, Guangzhou, Guangdong 510515, PR China
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Nitric oxide in cerebral vasospasm: theories, measurement, and treatment. Neurol Res Int 2013; 2013:972417. [PMID: 23878735 PMCID: PMC3708422 DOI: 10.1155/2013/972417] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 05/23/2013] [Accepted: 05/28/2013] [Indexed: 12/22/2022] Open
Abstract
In recent decades, a large body of research has focused on the role of nitric oxide (NO) in the development of cerebral vasospasm (CV) following subarachnoid hemorrhage (SAH). Literature searches were therefore conducted regarding the role of NO in cerebral vasospasm, specifically focusing on NO donors, reactive nitrogen species, and peroxynitrite in manifestation of vasospasm. Based off the assessment of available evidence, two competing theories are reviewed regarding the role of NO in vasospasm. One school of thought describes a deficiency in NO due to scavenging by hemoglobin in the cisternal space, leading to an NO signaling deficit and vasospastic collapse. A second hypothesis focuses on the dysfunction of nitric oxide synthase, an enzyme that synthesizes NO, and subsequent generation of reactive nitrogen species. Both theories have strong experimental evidence behind them and hold promise for translation into clinical practice. Furthermore, NO donors show definitive promise for preventing vasospasm at the angiographic and clinical level. However, NO augmentation may also cause systemic hypotension and worsen vasospasm due to oxidative distress. Recent evidence indicates that targeting NOS dysfunction, for example, through erythropoietin or statin administration, also shows promise at preventing vasospasm and neurotoxicity. Ultimately, the role of NO in neurovascular disease is complex. Neither of these theories is mutually exclusive, and both should be considered for future research directions and treatment strategies.
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Abstract
PURPOSE OF REVIEW Cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage remains a considerable challenge in neurocritical care medicine. This review aims to cover the recent novel aspects and results in CVS treatment. RECENT FINDINGS On the basis of the recent literature, treatment focusing on CVS alone is outdated. A considerable amount of evidence suggests CVS not to be the sole cause of delayed cerebral ischemia (DCI) and poor outcome. Early brain injury, cortical spreading depolarization, inflammation and microthrombosis have recently been discussed as additional factors. The results of a well designed phase III trial, using an endothelin-1 antagonist, indicated a decrease in the occurrence of CVS but did not change the clinical outcome significantly. Induced hypertension is currently recommended for treating suspected DCI, whereas hemodilution and hypervolemia are not. Endovascular intervention is only recommended in case of refractory symptomatic CVS. A couple of newer treatment strategies are under evaluation. Phase III trials are underway for magnesium sulfate and statins. Clinical trials aiming specifically at recently discussed factors other than CVS have not been reported. SUMMARY Reviewing the recent literature, there have been some updates on recommendations and newer treatment modalities are under evaluation. However, a novel treatment with convincing evidence has not been reported so far.
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Barry C, Turner RJ, Corrigan F, Vink R. New therapeutic approaches to subarachnoid hemorrhage. Expert Opin Investig Drugs 2012; 21:845-59. [DOI: 10.1517/13543784.2012.683113] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mukherjee KK, Singh SK, Khosla VK, Mohindra S, Salunke P. Safety and efficacy of sildenafil citrate in reversal of cerebral vasospasm: A feasibility study. Surg Neurol Int 2012; 3:3. [PMID: 22347673 PMCID: PMC3280003 DOI: 10.4103/2152-7806.92164] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 12/13/2011] [Indexed: 12/28/2022] Open
Abstract
Objective: Cerebral vasospasm is the commonest cause for mortality and morbidity in patients following clipping of a ruptured aneurysm. Selective phosphodiesterase (PDE) inhibitor like sildenafil acts as a vasodilator. The objective of this study was to evaluate the safety and feasibility of oral sildenafil citrate in patients with symptomatic refractory vasospasm. Methods: A total of 832 patients with aneurysmal subarachnoid bleed were operated in 4 years. Two hundred and seventy-three patients had vasospasm. Of these, 72 patients had refractory cerebral vasospasm. Vasospasm was defined as refractory when institution of “HHH” failed to reverse the transcranial Doppler (TCD) values even after 24 hours. Computed tomography (CT) scan showed no infarct, hematoma, or hydrocephalus, and the serum electrolytes were within normal limits. They received 100–150 mg of sildenafil every 4 hours. Response was evaluated by 2-hourly TCD. Results: Eight patients had sustained (TCD values normal for >48 hours) and four had temporary relief in vasospasm, as suggested. Four patients developed complications significant enough to terminate the therapy. Conclusions: Sildenafil citrate may be effective in patients with refractory symptomatic vasospasm. It calls upon the pharmacologists and scientists to discover newer supraselective PDE inhibitors, specific to PDE receptors in brain vessels.
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