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Bömers JP, Holm A, Kazantzi S, Edvinsson L, Mathiesen TI, Haanes KA. Protein kinase C-inhibition reduces critical weight loss and improves functional outcome after experimental subarachnoid haemorrhage. J Stroke Cerebrovasc Dis 2024; 33:107728. [PMID: 38643942 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 04/23/2024] Open
Abstract
OBJECTIVES Subarachnoid haemorrhage (SAH) carries a high burden of morbidity and mortality. One in three patients develop vasospasm, which is associated with Delayed Cerebral Ischemia. The pathophysiology includes vasoconstrictor receptor upregulation in cerebral arteries. The protein kinase C - inhibitor RO-31-7549 reduces the expression of several vasoconstrictor receptors and normalizes cerebral blood flow in experimental SAH but functional and behavioural effects are unknown. This study was undertaken to analyse functional outcomes up to 14 days after experimental SAH. MATERIALS AND METHODS 54 male rats were randomised to experimental SAH or sham, using the pre-chiasmatic, single injection model, and subsequent treatment or vehicle. 42 remained for final analysis. The animals were euthanized on day 14 or when reaching a humane endpoint. The primary endpoint was overall survival, defined as either spontaneous mortality or when reaching a predefined humane endpoint. The secondary outcomes were differences in the rotating pole test, weight, open field test, novel object recognition and qPCR of selected inflammatory markers. RESULTS In the vehicle group 6/15 rats reached the humane endpoint of >20 % weight loss compared to 1/14 in the treatment group. This resulted in a significant reduced risk of early euthanasia due to >20 % weight loss of HR 0.15 (0.03-0.66, p = 0.04). Furthermore, the treatment group did significantly better on the rotating pole test, RR 0.64 (0.47-0.91, p = 0.02). CONCLUSION RO-31-7549 improved outcomes in terms >20 % weight loss and rotating pole performance after experimental SAH and could be investigated.
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Affiliation(s)
- Jesper P Bömers
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark.
| | - Anja Holm
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Center for RNA Medicine, Aalborg University, Copenhagen, Denmark
| | - Spyridoula Kazantzi
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark
| | - Lars Edvinsson
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Tiit I Mathiesen
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kristian A Haanes
- Clinical Experimental Research Unit, Translational Research Centre, Copenhagen University Hospital - Rigshospitalet, Glostrup, Denmark; Department of Biology, University of Copenhagen, Copenhagen, Denmark
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Dreier JP, Joerk A, Uchikawa H, Horst V, Lemale CL, Radbruch H, McBride DW, Vajkoczy P, Schneider UC, Xu R. All Three Supersystems-Nervous, Vascular, and Immune-Contribute to the Cortical Infarcts After Subarachnoid Hemorrhage. Transl Stroke Res 2024:10.1007/s12975-024-01242-z. [PMID: 38689162 DOI: 10.1007/s12975-024-01242-z] [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: 02/06/2024] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 05/02/2024]
Abstract
The recently published DISCHARGE-1 trial supports the observations of earlier autopsy and neuroimaging studies that almost 70% of all focal brain damage after aneurysmal subarachnoid hemorrhage are anemic infarcts of the cortex, often also affecting the white matter immediately below. The infarcts are not limited by the usual vascular territories. About two-fifths of the ischemic damage occurs within ~ 48 h; the remaining three-fifths are delayed (within ~ 3 weeks). Using neuromonitoring technology in combination with longitudinal neuroimaging, the entire sequence of both early and delayed cortical infarct development after subarachnoid hemorrhage has recently been recorded in patients. Characteristically, cortical infarcts are caused by acute severe vasospastic events, so-called spreading ischemia, triggered by spontaneously occurring spreading depolarization. In locations where a spreading depolarization passes through, cerebral blood flow can drastically drop within a few seconds and remain suppressed for minutes or even hours, often followed by high-amplitude, sustained hyperemia. In spreading depolarization, neurons lead the event, and the other cells of the neurovascular unit (endothelium, vascular smooth muscle, pericytes, astrocytes, microglia, oligodendrocytes) follow. However, dysregulation in cells of all three supersystems-nervous, vascular, and immune-is very likely involved in the dysfunction of the neurovascular unit underlying spreading ischemia. It is assumed that subarachnoid blood, which lies directly on the cortex and enters the parenchyma via glymphatic channels, triggers these dysregulations. This review discusses the neuroglial, neurovascular, and neuroimmunological dysregulations in the context of spreading depolarization and spreading ischemia as critical elements in the pathogenesis of cortical infarcts after subarachnoid hemorrhage.
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Affiliation(s)
- Jens P Dreier
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.
- Einstein Center for Neurosciences Berlin, Berlin, Germany.
| | - Alexander Joerk
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Hiroki Uchikawa
- Barrow Aneurysm & AVM Research Center, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Viktor Horst
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Coline L Lemale
- Center for Stroke Research Berlin, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
- Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Helena Radbruch
- Institute of Neuropathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Devin W McBride
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulf C Schneider
- Department of Neurosurgery, Cantonal Hospital of Lucerne and University of Lucerne, Lucerne, Switzerland
| | - Ran Xu
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK, German Centre for Cardiovascular Research, Berlin, Germany
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Magid-Bernstein J, Yan J, Herman AL, He Z, Johnson CW, Beatty H, Choi R, Velazquez S, Neeman E, Falcone G, Kim J, Petersen N, Gilmore EJ, Matouk C, Sheth K, Sansing L. Characterization of CSF inflammatory markers after hemorrhagic stroke and their relationship to disease severity. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.05.23299566. [PMID: 38106157 PMCID: PMC10723522 DOI: 10.1101/2023.12.05.23299566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Background The inflammatory response within the central nervous system is a key driver of secondary brain injury after hemorrhagic stroke, both in patients with intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (aSAH). In this study, we aimed to characterize inflammatory molecules in the blood and cerebrospinal fluid (CSF) of patients within 72 hours of hemorrhage to understand how such molecules vary across disease types and disease severity. Methods Biological samples were collected from patients admitted to a single-center Neurosciences Intensive Care Unit with a diagnosis of ICH or aSAH between 2014 and 2022. Control CSF samples were collected from patients undergoing CSF diversion for normal pressure hydrocephalus. A panel of immune molecules in the plasma and CSF samples was analyzed using Cytometric Bead Array assays. Clinical variables, including demographics, disease severity, and intensive care unit length of stay were collected. Results Plasma and/or CSF samples were collected from 260 patients (188 ICH patients, 54 aSAH patients, 18 controls). C-C motif chemokine ligand-2 (CCL2), interleukin-6 (IL-6), granulocyte-colony stimulating factor (G-CSF), interleukin-8 (IL-8), and vascular endothelial growth factor (VEGF), were detectable in the CSF within the first 3 days after hemorrhage, and all were elevated compared to plasma. Compared with controls, CCL2, IL-6, IL-8, G-CSF, and VEGF were elevated in the CSF of both ICH and aSAH patients (p<0.01 for all comparisons). VEGF was increased in ICH patients compared to aSAH patients (p<0.01). CCL2, G-CSF, and VEGF in the CSF were associated with more severe disease in aSAH patients only. Conclusions Within 3 days of hemorrhagic stroke, proinflammatory molecules can be detected in the CSF at higher concentrations than in the plasma. Early concentrations of some pro-inflammatory molecules may be associated with markers of disease severity.
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Koopman I, Tack RWP, Wunderink HF, Bruns AHW, van der Schaaf IC, Cianci D, Gelderman KA, van de Ridder IM, Hol EM, Rinkel GJE, Vergouwen MDI. Safety and pharmacodynamic efficacy of eculizumab in aneurysmal subarachnoid hemorrhage (CLASH): A phase 2a randomized clinical trial. Eur Stroke J 2023; 8:1097-1106. [PMID: 37606053 PMCID: PMC10683736 DOI: 10.1177/23969873231194123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/25/2023] [Indexed: 08/23/2023] Open
Abstract
INTRODUCTION Complement C5 antibodies reduce brain injury after experimental subarachnoid hemorrhage. PATIENTS AND METHODS In this randomized, controlled, open-label, phase 2a clinical trial with blinded-outcome assessment, we included adult aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to a tertiary referral center ⩽11 h after ictus. Patients were randomized (1:1) to eculizumab plus care as usual or to care as usual. Eculizumab (1200 mg) was administered <12 h, and on days 3 and 7 after ictus. In the intervention group, all patients received prophylactic antibiotics and, after a protocol amendment, fluconazole if indicated. Primary outcome was C5a concentration in cerebrospinal fluid (CSF) on day 3 after ictus. Safety was monitored during 4 weeks. In each group, 13 patients with CSF assessments were needed to detect a 55% reduction in CSF C5a concentration. RESULTS From October 2018 to May 2021, we enrolled 31 patients of whom 26 with CSF samples, 13 per group. Median C5a concentration in CSF on day 3 was 251 pg/ml [IQR: 103-402] in the intervention group and 371 pg/ml [IQR: 131-534] in the control group (p = 0.29). Infections occurred in two patients in the intervention group and four patients in the control group. One patient in the intervention group developed a C. albicans meningitis prior to the protocol amendment. DISCUSSION AND CONCLUSION One dose of eculizumab did not result in a ⩾ 55% decrease in C5a concentration in CSF on day 3 after aSAH. The study did not reveal new safety concerns, except for a C. albicans drain-related infection prior to antifungal monitoring and treatment. TRIAL REGISTRATION EudraCT 2017-004307-51, https://www.clinicaltrialsregister.eu/.
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Affiliation(s)
- Inez Koopman
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Reinier WP Tack
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Herman F Wunderink
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anke HW Bruns
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Irene C van der Schaaf
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daniela Cianci
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Inge M van de Ridder
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elly M Hol
- Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gabriel JE Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mervyn DI Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Chen T, Xu YP, Chen Y, Sun S, Yan ZZ, Wang YH. Arc regulates brain damage and neuroinflammation via Sirt1 signaling following subarachnoid hemorrhage. Brain Res Bull 2023; 203:110780. [PMID: 37820952 DOI: 10.1016/j.brainresbull.2023.110780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 10/13/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) accounts for only 5 % of all stroke cases, but carries a heavy burden of morbidity and mortality. Activity regulated cytoskeleton associated protein (Arc) is an immediate early gene (IEG)-coded postsynaptic protein that is involved in synaptic plasticity. Increasing evidence and our previous studies have shown that Arc might be involved in the pathological mechanism of various neurological diseases, such as traumatic brain injury (TBI). In this study, we investigated the level of Arc in cerebrospinal fluids (CSF) of aSAH patients and its potential role in brain damage following experimental SAH model. We found that the levels of Arc in aSAH patients' CSF positively correlated with Hunt-Hess (H&H) grades. Knockdown of endogenous Arc expression by small interfere RNA (siRNA) significantly increased brain edema and oxidative stress following SAH. The results of immunostaining in brain sections showed that knockdown of Arc enhanced activation of microglia and astrocytes. In congruent, generation of inflammatory cytokines following SAH was increased by Si-Arc transfection. The results of western blot analysis showed that knockdown of Arc inhibited the expression of Sirt1 and Nrf2, which was accompanied by decreased enzymatic activities of superoxide dismutase (SOD) and glutathione peroxidase (GSH-px). In addition, activation of sirtuin 1 (Sirt1) via agonist SRT2104 markedly decreased the brain damage and neuroinflammation induced by Arc knockdown. In conclusion, knockdown of endogenous Arc could aggravate brain damage and neuroinflammation following experimental SAH, and Arc levels in aSAH patients' CSF might be a potential indicator of brain damage and prognosis.
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Affiliation(s)
- Tao Chen
- Department of Neurosurgery, Wuxi Taihu Hospital, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, China
| | - Ye-Ping Xu
- Department of Neurosurgery, Wuxi Taihu Hospital, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, China
| | - Yang Chen
- Department of Neurology, Wuxi Taihu Hospital, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, China
| | - Shu Sun
- Department of Pharmacy, Wuxi Taihu Hospital, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, China
| | - Zhi-Zhong Yan
- Department of Neurosurgery, Wuxi Taihu Hospital, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, China
| | - Yu-Hai Wang
- Department of Neurosurgery, Wuxi Taihu Hospital, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, China.
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Burzyńska M, Uryga A, Woźniak J, Załuski R, Robba C, Goździk W. The Role of Early Serum Biomarkers and Clinical Rating Scales in the Prediction of Delayed Cerebral Ischaemia and Short-Term Outcome after Aneurysmal Subarachnoid Haemorrhage: Single Centre Experience. J Clin Med 2023; 12:5614. [PMID: 37685681 PMCID: PMC10488375 DOI: 10.3390/jcm12175614] [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: 07/17/2023] [Revised: 08/16/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
Considering the variety of complications that arise after aneurysmal subarachnoid haemorrhage (aSAH) and the complex pathomechanism of delayed cerebral ischaemia (DCI), the task of predicting the outcome assumes a profound complexity. Therefore, there is a need to develop early predictive and decision-making models. This study explores the effect of serum biomarkers and clinical scales on patients' outcomes and their interrelationship with DCI and systemic complications in aSAH. This was a retrospective analysis including aSAH patients admitted to the Wroclaw University Hospital (Wrocław, Poland) from 2011 to 2020. A good outcome was defined as a modified Rankin Scale (mRS) score of 0-2. The prediction of the development of DCI and poor outcome was conducted using logistic regression as a standard model (SM) and random forest as a machine learning method (ML). A cohort of 174 aSAH patients were included in the analysis. DCI was diagnosed in 79 (45%) patients. Significant differences between patients with poor vs. good outcome were determined from their levels of albumin (31 ± 7 vs. 35 ± 5 (g/L); p < 0.001), D-dimer (3.0 ± 4.5 vs. 1.5 ± 2.8 (ng/mL); p < 0.001), procalcitonin (0.2 ± 0.4 vs. 0.1 ± 0.1 (ng/mL); p < 0.001), and glucose (169 ± 69 vs. 137 ± 48 (nmol/L); p < 0.001). SM for DCI prediction included the Apache II scale (odds ratio [OD] 1.05; 95% confidence interval [CI] 1.00-1.09) and albumin level (OD 0.88; CI 0.82-0.95). ML demonstrated that low albumin level, high Apache II scale, increased D-dimer and procalcitonin levels had the highest predictive values for DCI. The integration of clinical parameters and scales with a panel of biomarkers may effectively facilitate the stratification of aSAH patients, identifying those at high risk of secondary complications and poor outcome.
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Affiliation(s)
- Małgorzata Burzyńska
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, 50-370 Wroclaw, Poland
| | - Jowita Woźniak
- Department of Neurosurgery, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.W.); (R.Z.)
| | - Rafał Załuski
- Department of Neurosurgery, Wroclaw Medical University, 50-367 Wroclaw, Poland; (J.W.); (R.Z.)
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy;
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16145 Genoa, Italy
| | - Waldemar Goździk
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, 50-367 Wroclaw, Poland; (M.B.); (W.G.)
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Chai CZ, Ho UC, Kuo LT. Systemic Inflammation after Aneurysmal Subarachnoid Hemorrhage. Int J Mol Sci 2023; 24:10943. [PMID: 37446118 DOI: 10.3390/ijms241310943] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/16/2023] [Accepted: 06/18/2023] [Indexed: 07/15/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is one of the most severe neurological disorders, with a high mortality rate and severe disabling functional sequelae. Systemic inflammation following hemorrhagic stroke may play an important role in mediating intracranial and extracranial tissue damage. Previous studies showed that various systemic inflammatory biomarkers might be useful in predicting clinical outcomes. Anti-inflammatory treatment might be a promising therapeutic approach for improving the prognosis of patients with aSAH. This review summarizes the complicated interactions between the nervous system and the immune system.
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Affiliation(s)
- Chang-Zhang Chai
- Department of Medical Education, National Taiwan University, School of Medicine, Taipei 100, Taiwan
| | - Ue-Cheung Ho
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin 640, Taiwan
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin 640, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei 100, Taiwan
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Vlachogiannis P, Hillered L, Enblad P, Ronne-Engström E. Temporal patterns of inflammation-related proteins measured in the cerebrospinal fluid of patients with aneurysmal subarachnoid hemorrhage using multiplex Proximity Extension Assay technology. PLoS One 2022; 17:e0263460. [PMID: 35324941 PMCID: PMC8947082 DOI: 10.1371/journal.pone.0263460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/19/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The complexity of the inflammatory response post subarachnoid hemorrhage (SAH) may require temporal analysis of multiple protein biomarkers simultaneously to be more accurately described. METHODS Ventricular cerebrospinal fluid was collected at days 1, 4 and 10 after SAH in 29 patients. Levels of 92 inflammation-related proteins were simultaneously measured using Target 96 Inflammation ® assay (Olink Proteomics, Uppsala, Sweden) based on Proximity Extension Assay (PEA) technology. Twenty-eight proteins were excluded from further analysis due to lack of >50% of measurable values. Temporal patterns of the remaining 64 proteins were analyzed. Repeated measures ANOVA and its nonparametric equivalent Friedman's ANOVA were used for comparisons of means between time points. RESULTS Four different patterns (Groups A-D) were visually observed with an early peak and gradually decreasing trend (11 proteins), a middle peak (10 proteins), a late peak after a gradually increasing trend (30 proteins) and no specific pattern (13 proteins). Statistically significant early peaks defined as Day 1 > Day 4 values were noticed in 4 proteins; no significant decreasing trends defined as Day 1 > Day 4 > Day 10 values were observed. Two proteins showed significant middle peaks (i.e. Day 1 < Day 4 > Day 10 values). Statistically significant late peaks (i.e. Day 4 < Day 10 values) and increasing trends (i.e. Day 1 < Day 4 < Day 10 values) were observed in 14 and 10 proteins, respectively. Four of Group D proteins showed biphasic peaks and the rest showed stable levels during the observation period. CONCLUSION The comprehensive data set provided in this explorative study may act as an illustration of an inflammatory profile of the acute phase of SAH showing groups of potential protein biomarkers with similar temporal patterns of activation, thus facilitating further research on their role in the pathophysiology of the disease.
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Affiliation(s)
- Pavlos Vlachogiannis
- Department of Neurosciences, Neurosurgery, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Lars Hillered
- Department of Neurosciences, Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neurosciences, Neurosurgery, Uppsala University, Uppsala, Sweden
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Wu CH, Tsai HP, Su YF, Tsai CY, Lu YY, Lin CL. 2-PMAP Ameliorates Cerebral Vasospasm and Brain Injury after Subarachnoid Hemorrhage by Regulating Neuro-Inflammation in Rats. Cells 2022; 11:242. [PMID: 35053358 PMCID: PMC8773560 DOI: 10.3390/cells11020242] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/27/2021] [Accepted: 01/07/2022] [Indexed: 02/01/2023] Open
Abstract
A subarachnoid hemorrhage (SAH), leading to severe disability and high fatality in survivors, is a devastating disease. Neuro-inflammation, a critical mechanism of cerebral vasospasm and brain injury from SAH, is tightly related to prognoses. Interestingly, studies indicate that 2-[(pyridine-2-ylmethyl)-amino]-phenol (2-PMAP) crosses the blood-brain barrier easily. Here, we investigated whether the vasodilatory and neuroprotective roles of 2-PMAP were observed in SAH rats. Rats were assigned to three groups: sham, SAH and SAH+2-PMAP. SAHs were induced by a cisterna magna injection. In the SAH+2-PMAP group, 5 mg/kg 2-PMAP was injected into the subarachnoid space before SAH induction. The administration of 2-PMAP markedly ameliorated cerebral vasospasm and decreased endothelial apoptosis 48 h after SAH. Meanwhile, 2-PMAP decreased the severity of neurological impairments and neuronal apoptosis after SAH. Furthermore, 2-PMAP decreased the activation of microglia and astrocytes, expressions of TLR-4 and p-NF-κB, inflammatory markers (TNF-α, IL-1β and IL-6) and reactive oxygen species. This study is the first to confirm that 2-PMAP has vasodilatory and neuroprotective effects in a rat model of SAH. Taken together, the experimental results indicate that 2-PMAP treatment attenuates neuro-inflammation, oxidative stress and cerebral vasospasm, in addition to ameliorating neurological deficits, and that these attenuating and ameliorating effects are conferred through the TLR-4/NF-κB pathway.
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Affiliation(s)
- Chieh-Hsin Wu
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (C.-H.W.); (H.-P.T.); (Y.-F.S.); (C.-Y.T.)
- Department of Surgery, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80756, Taiwan
| | - Hung-Pei Tsai
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (C.-H.W.); (H.-P.T.); (Y.-F.S.); (C.-Y.T.)
| | - Yu-Feng Su
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (C.-H.W.); (H.-P.T.); (Y.-F.S.); (C.-Y.T.)
- Department of Surgery, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80756, Taiwan
| | - Cheng-Yu Tsai
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (C.-H.W.); (H.-P.T.); (Y.-F.S.); (C.-Y.T.)
- Department of Surgery, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80756, Taiwan
| | - Ying-Yi Lu
- Department of Dermatology, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
- Department of Health and Beauty, Shu-Zen Junior College of Medicine and Management, Kaohsiung 821, Taiwan
| | - Chih-Lung Lin
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (C.-H.W.); (H.-P.T.); (Y.-F.S.); (C.-Y.T.)
- Department of Surgery, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80756, Taiwan
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Früh A, Tielking K, Schoknecht F, Liu S, Schneider UC, Fischer S, Vajkoczy P, Xu R. RNase A Inhibits Formation of Neutrophil Extracellular Traps in Subarachnoid Hemorrhage. Front Physiol 2021; 12:724611. [PMID: 34603082 PMCID: PMC8481772 DOI: 10.3389/fphys.2021.724611] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/10/2021] [Indexed: 01/21/2023] Open
Abstract
Background: Subarachnoid hemorrhage (SAH) caused by rupture of an intracranial aneurysm, is a life-threatening emergency that is associated with substantial morbidity and mortality. Emerging evidence suggests involvement of the innate immune response in secondary brain injury, and a potential role of neutrophil extracellular traps (NETs) for SAH-associated neuroinflammation. In this study, we investigated the spatiotemporal patterns of NETs in SAH and the potential role of the RNase A (the bovine equivalent to human RNase 1) application on NET burden. Methods: A total number of n=81 male C57Bl/6 mice were operated utilizing a filament perforation model to induce SAH, and Sham operation was performed for the corresponding control groups. To confirm the bleeding and exclude stroke and intracerebral hemorrhage, the animals received MRI after 24h. Mice were treated with intravenous injection of RNase A (42μg/kg body weight) or saline solution for the control groups, respectively. Quadruple-immunofluorescence (IF) staining for cell nuclei (DAPI), F-actin (phalloidin), citrullinated H3, and neurons (NeuN) was analyzed by confocal imaging and used to quantify NET abundance in the subarachnoid space (SAS) and brain parenchyma. To quantify NETs in human SAH patients, cerebrospinal spinal fluid (CSF) and blood samples from day 1, 2, 7, and 14 after bleeding onset were analyzed for double-stranded DNA (dsDNA) via Sytox Green. Results: Neutrophil extracellular traps are released upon subarachnoid hemorrhage in the SAS on the ipsilateral bleeding site 24h after ictus. Over time, NETs showed progressive increase in the parenchyma on both ipsi- and contralateral site, peaking on day 14 in periventricular localization. In CSF and blood samples of patients with aneurysmal SAH, NETs also increased gradually over time with a peak on day 7. RNase application significantly reduced NET accumulation in basal, cortical, and periventricular areas. Conclusion: Neutrophil extracellular trap formation following SAH originates in the ipsilateral SAS of the bleeding site and spreads gradually over time to basal, cortical, and periventricular areas in the parenchyma within 14days. Intravenous RNase application abrogates NET burden significantly in the brain parenchyma, underpinning a potential role in modulation of the innate immune activation after SAH.
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Affiliation(s)
- Anton Früh
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Katharina Tielking
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Schoknecht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Shuheng Liu
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ulf C Schneider
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Silvia Fischer
- Department of Biochemistry, Giessen University, Giessen, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ran Xu
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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11
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Croci DM, Sivanrupan S, Wanderer S, Agnoletto GJ, Chiappini A, Grüter BE, Andereggen L, Mariani L, Taussky P, Marbacher S. Preclinical and clinical role of interleukin-6 in the development of delayed cerebral vasospasm and neuronal cell death after subarachnoid hemorrhage: towards a potential target therapy? Neurosurg Rev 2021; 45:395-403. [PMID: 34448990 PMCID: PMC8391870 DOI: 10.1007/s10143-021-01628-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/13/2021] [Accepted: 08/16/2021] [Indexed: 12/28/2022]
Abstract
Delayed cerebral vasospasm (DCVS), early brain injury (EBI), and delayed cerebral ischemia (DCI) are devastating complications after aneurysmal subarachnoid hemorrhage (SAH). Interleukin (IL)-6 seems to be an important interleukin in the inflammatory response after SAH, and many studies describe a strong correlation between IL-6 and worse outcome. The aim of this study was to systematically review preclinical and clinical studies that evaluated systemic and cerebral IL-6 levels after SAH and their relation to DCVS, neuronal cell death, and DCI. We conducted two systematic literature searches using PubMed to identify preclinical and clinical studies evaluating the role of IL-6 after SAH. Suitable articles were selected based on predefined eligibility criteria following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 61 and 30 preclinical and clinical articles, respectively, were included in the systematic reviews. Of the preclinical studies in which IL-6 was measured in cerebrospinal fluid (CSF), parenchyma, and systemically, 100%, 94.4%, and 81.3%, respectively, showed increased expression of IL-6 after SAH. Preclinical results were mirrored by clinical findings in which elevated levels of IL-6 in CSF and plasma were found after SAH, correlating with DCVS, DCI, and worse outcome. Only two preclinical studies analyzed the direct inhibition of IL-6, which resulted in reduced DCVS and neuronal cell death. IL-6 is a marker of intracranial inflammation and plays a role in the pathophysiology of DCVS and DCI after SAH in preclinical animal models and clinical studies. Its inhibition might have therapeutic potential to improve the outcome of SAH patients.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT, 84132, USA. .,Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland. .,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland.
| | - Sivani Sivanrupan
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - Stefan Wanderer
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
| | - Guilherme J Agnoletto
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Alessio Chiappini
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Basil E Grüter
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
| | - Lukas Andereggen
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Serge Marbacher
- Cerebrovascular Research Group, Department of BioMedical Research, University of Bern, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital Aarau, c/o NeuroResearch Office, Tellstrasse 1, 5001, Aarau, Switzerland
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12
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Lidington D, Wan H, Bolz SS. Cerebral Autoregulation in Subarachnoid Hemorrhage. Front Neurol 2021; 12:688362. [PMID: 34367053 PMCID: PMC8342764 DOI: 10.3389/fneur.2021.688362] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/25/2021] [Indexed: 12/28/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a devastating stroke subtype with a high rate of mortality and morbidity. The poor clinical outcome can be attributed to the biphasic course of the disease: even if the patient survives the initial bleeding emergency, delayed cerebral ischemia (DCI) frequently follows within 2 weeks time and levies additional serious brain injury. Current therapeutic interventions do not specifically target the microvascular dysfunction underlying the ischemic event and as a consequence, provide only modest improvement in clinical outcome. SAH perturbs an extensive number of microvascular processes, including the “automated” control of cerebral perfusion, termed “cerebral autoregulation.” Recent evidence suggests that disrupted cerebral autoregulation is an important aspect of SAH-induced brain injury. This review presents the key clinical aspects of cerebral autoregulation and its disruption in SAH: it provides a mechanistic overview of cerebral autoregulation, describes current clinical methods for measuring autoregulation in SAH patients and reviews current and emerging therapeutic options for SAH patients. Recent advancements should fuel optimism that microvascular dysfunction and cerebral autoregulation can be rectified in SAH patients.
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Affiliation(s)
- Darcy Lidington
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Hoyee Wan
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Steffen-Sebastian Bolz
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada.,Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, ON, Canada
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13
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Bodnar CN, Watson JB, Higgins EK, Quan N, Bachstetter AD. Inflammatory Regulation of CNS Barriers After Traumatic Brain Injury: A Tale Directed by Interleukin-1. Front Immunol 2021; 12:688254. [PMID: 34093593 PMCID: PMC8176952 DOI: 10.3389/fimmu.2021.688254] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/05/2021] [Indexed: 01/13/2023] Open
Abstract
Several barriers separate the central nervous system (CNS) from the rest of the body. These barriers are essential for regulating the movement of fluid, ions, molecules, and immune cells into and out of the brain parenchyma. Each CNS barrier is unique and highly dynamic. Endothelial cells, epithelial cells, pericytes, astrocytes, and other cellular constituents each have intricate functions that are essential to sustain the brain's health. Along with damaging neurons, a traumatic brain injury (TBI) also directly insults the CNS barrier-forming cells. Disruption to the barriers first occurs by physical damage to the cells, called the primary injury. Subsequently, during the secondary injury cascade, a further array of molecular and biochemical changes occurs at the barriers. These changes are focused on rebuilding and remodeling, as well as movement of immune cells and waste into and out of the brain. Secondary injury cascades further damage the CNS barriers. Inflammation is central to healthy remodeling of CNS barriers. However, inflammation, as a secondary pathology, also plays a role in the chronic disruption of the barriers' functions after TBI. The goal of this paper is to review the different barriers of the brain, including (1) the blood-brain barrier, (2) the blood-cerebrospinal fluid barrier, (3) the meningeal barrier, (4) the blood-retina barrier, and (5) the brain-lesion border. We then detail the changes at these barriers due to both primary and secondary injury following TBI and indicate areas open for future research and discoveries. Finally, we describe the unique function of the pro-inflammatory cytokine interleukin-1 as a central actor in the inflammatory regulation of CNS barrier function and dysfunction after a TBI.
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Affiliation(s)
- Colleen N. Bodnar
- Department of Neuroscience, University of Kentucky, Lexington, KY, United States
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY, United States
| | - James B. Watson
- Department of Neuroscience, University of Kentucky, Lexington, KY, United States
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY, United States
| | - Emma K. Higgins
- Department of Neuroscience, University of Kentucky, Lexington, KY, United States
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY, United States
| | - Ning Quan
- Department of Biomedical Science, Charles E. Schmidt College of Medicine and Brain Institute, Florida Atlantic University, Jupiter, FL, United States
| | - Adam D. Bachstetter
- Department of Neuroscience, University of Kentucky, Lexington, KY, United States
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY, United States
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14
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Moteki Y, Kobayashi T, Kawamata T. Clinical Significance of Cytotoxic Lesions of the Corpus Callosum in Subarachnoid Hemorrhage Patients: A Retrospective Analysis. Cerebrovasc Dis 2021; 50:405-411. [PMID: 33774621 DOI: 10.1159/000514383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/07/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Cytotoxic lesions of the corpus callosum are secondary lesions induced by significant increases in cytokine levels in the brain and are associated with subarachnoid hemorrhage (SAH). However, their clinical significance in SAH patients remains unclear. METHODS We retrospectively analyzed SAH patients who were treated in our hospital and evaluated between-group differences in the backgrounds, clinical findings, and outcomes between SAH patients who developed cytotoxic lesions of the corpus callosum and those who did not. We further compared patients who achieved good outcomes with those who had poor outcomes. Multivariate logistic regression analysis was used to identify risk factors for poor clinical outcomes. RESULTS We analyzed 159 SAH patients; 17 patients (10.7%) had cytotoxic lesions of the corpus callosum. Patients with cytotoxic lesions of the corpus callosum were more likely to be in a severe condition (World Federation of Neurosurgical Societies grading IV-V: odds ratio [OR], 4.53; 95% confidence interval [95% CI]: 1.60-12.84; p = 0.0042) and have an intraventricular (OR, 5.98; 95% CI: 1.32-27.13; p = 0.0054) or an intraparenchymal hematoma (OR, 3.62; 95% CI: 1.25-10.45; p = 0.023). Patients with cytotoxic lesions of the corpus callosum had a greater propensity of a poor outcome 3 months after onset (modified Rankin Scale score 0-2: OR, 0.22; 95% CI: 0.07-0.66; p = 0.0043). Multivariate analysis confirmed that cytotoxic lesions of the corpus callosum increased the risk of a poor outcome (OR, 4.39; 95% CI: 1.06-18.1; p = 0.037). DISCUSSION/CONCLUSIONS The development of cytotoxic lesions of the corpus callosum may be related to the extent of hematomas in SAH patients. Although they are usually reversible lesions, the development of cytotoxic lesions of the corpus callosum may be a predictor of poor outcomes in SAH patients.
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Affiliation(s)
- Yosuke Moteki
- Department of Neurosurgery, Ebina General Hospital, Kanagawa, Japan
| | | | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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15
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Toi H, Yagi K, Matsubara S, Hara K, Uno M. Clinical Features of Cytotoxic Lesions of the Corpus Callosum Associated with Aneurysmal Subarachnoid Hemorrhage. AJNR Am J Neuroradiol 2021; 42:1046-1051. [PMID: 33664118 DOI: 10.3174/ajnr.a7055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/01/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Patients with SAH due to a ruptured intracranial aneurysm occasionally show reversible high-signal lesions in the splenium of the corpus callosum on DWI. These lesions are called cytotoxic lesions of the corpus callosum. This study retrospectively reviewed cases of aneurysmal SAH and investigated clinical features of cytotoxic lesions of the corpus callosum associated with SAH. MATERIALS AND METHODS Participants comprised 259 patients with aneurysmal SAH who had undergone curative treatment at our hospital. We examined the following items related to cytotoxic lesions of the corpus callosum: occurrence rate, timing of appearance and disappearance of the lesions, lesion size, aneurysm location, severity of SAH, treatment method, clinical course, and outcome. RESULTS Among the 259 cases, DWI detected cytotoxic lesions of the corpus callosum in 33 patients (12.7%). The mean periods from the onset of SAH to detection and disappearance of cytotoxic lesions of the corpus callosum were 6.3 days (range, 0-25 days) and 35.7 days (range, 9-78 days), respectively. Cytotoxic lesions of the corpus callosum were classified into 2 types: a small type localized in the splenium in 26 cases (78.9%) and a large type spread along the ventricle in 7 cases (21.2%). The severity of SAH, coiling, hydrocephalus, and poor mRS score at discharge were significantly higher in the group with cytotoxic lesions of the corpus callosum. However, multivariate analysis did not identify cytotoxic lesions of the corpus callosum as a risk factor for poor outcome. CONCLUSIONS Cytotoxic lesions of the corpus callosum appear at a frequency of 12.7% in patients with aneurysmal SAH. Cytotoxic lesions of the corpus callosum associated with SAH take several days to appear and subsequently resolve within about a month. Cytotoxic lesions of the corpus callosum were likely to occur in patients with high-grade SAH but did not represent a predictor of poor outcome.
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Affiliation(s)
- H Toi
- From the Department Neurosurgery (H.T., K.Y., S.M., K.H., M.U.), Kawasaki Medical School, Kurashiki, Okayama, Japan .,Department Neurosurgery (H.T.), Oita Oka Hospital, Oita, Japan
| | - K Yagi
- From the Department Neurosurgery (H.T., K.Y., S.M., K.H., M.U.), Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - S Matsubara
- From the Department Neurosurgery (H.T., K.Y., S.M., K.H., M.U.), Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - K Hara
- From the Department Neurosurgery (H.T., K.Y., S.M., K.H., M.U.), Kawasaki Medical School, Kurashiki, Okayama, Japan
| | - M Uno
- From the Department Neurosurgery (H.T., K.Y., S.M., K.H., M.U.), Kawasaki Medical School, Kurashiki, Okayama, Japan
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16
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Cytokines associated with hemorrhage in proliferative diabetic retinopathy. Int Ophthalmol 2021; 41:1845-1853. [PMID: 33609201 DOI: 10.1007/s10792-021-01746-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To investigate aqueous cytokine levels in association with hemorrhage in proliferative diabetic retinopathy (PDR) in patients with type 2 diabetes mellitus. METHODS Sixty-six eyes with treatment-naïve PDR, including 26 hemorrhagic and 40 nonhemorrhagic eyes were included in this institutional study. Aqueous humor levels of interleukin (IL)-1b, IL-6, IL-8, IL-10, monocyte chemoattractant protein (MCP)-1, tumor necrosis factor (TNF)-α, vascular endothelial growth factor (VEGF), and soluble VEGF receptor-1 were obtained by multiplex bead assay. Visual acuity and hemorrhage area measurements were obtained, and correlations between cytokine levels and hemorrhage were identified. RESULTS Levels of MCP-1, TNF-α, and VEGF were higher in hemorrhagic eyes (1506.77 vs. 2131.31 pg/mL, 0.43 vs. 0.63 pg/mL, and 103.96 vs. 206.96 pg/mL; P = 0.050, 0.022, and 0.027, respectively). The levels of IL-8, MCP-1, TNF-α, and VEGF showed positive correlation with visual acuity (P = 0.019, 0.015, 0.001, and 0.014, respectively). The hemorrhage area revealed positive correlation with TNF-α and VEGF levels (P = 0.001 and < 0.001, respectively). CONCLUSION The presence and amount of hemorrhage in PDR were associated not only with VEGF concentration, but also with the levels of certain inflammatory cytokines, suggesting a role of both VEGF and inflammation in hemorrhagic eyes.
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17
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Bjerkne Wenneberg S, Odenstedt Hergès H, Svedin P, Mallard C, Karlsson T, Adiels M, Naredi S, Block L. Association between inflammatory response and outcome after subarachnoid haemorrhage. Acta Neurol Scand 2021; 143:195-205. [PMID: 32990943 PMCID: PMC7821330 DOI: 10.1111/ane.13353] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/03/2020] [Accepted: 09/21/2020] [Indexed: 12/17/2022]
Abstract
Objectives Recent reports suggest an association between the inflammatory response after aneurysmal subarachnoid haemorrhage (aSAH) and patients' outcome. The primary aim of this study was to identify a potential association between the inflammatory response after aSAH and 1‐year outcome. The secondary aim was to investigate whether the inflammatory response after aSAH could predict the development of delayed cerebral ischaemia (DCI). Materials and methods This prospective observational pilot study included patients with an aSAH admitted to Sahlgrenska University Hospital, Gothenburg, Sweden, between May 2015 and October 2016. The patients were stratified according to the extended Glasgow Outcome Scale (GOSE) as having an unfavourable (score: 1–4) or favourable outcome (score: 5–8). Furthermore, patients were stratified depending on development of DCI or not. Patient data and blood samples were collected and analysed at admission and after 10 days. Results Elevated serum concentrations of inflammatory markers such as tumour necrosis factor‐α and interleukin (IL)‐6, IL‐1Ra, C‐reactive protein and intercellular adhesion molecule‐1 were detected in patients with unfavourable outcome. When adjustments for Glasgow coma scale were made, only IL‐1Ra remained significantly associated with poor outcome (p = 0.012). The inflammatory response after aSAH was not predictive of the development of DCI. Conclusion Elevated serum concentrations of inflammatory markers were associated with poor neurological outcome 1‐year after aSAH. However, inflammatory markers are affected by many clinical events, and when adjustments were made, only IL‐1Ra remained significantly associated with poor outcome. The robustness of these results needs to be tested in a larger trial.
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Affiliation(s)
- Sandra Bjerkne Wenneberg
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden
| | - Helena Odenstedt Hergès
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden
| | - Pernilla Svedin
- Department of Physiology Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Carina Mallard
- Department of Physiology Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Thomas Karlsson
- Biostatistics School of Public Health and Community Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Martin Adiels
- Biostatistics School of Public Health and Community Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Silvana Naredi
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden
| | - Linda Block
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden
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18
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Okada T, Suzuki H. The Role of Tenascin-C in Tissue Injury and Repair After Stroke. Front Immunol 2021; 11:607587. [PMID: 33552066 PMCID: PMC7859104 DOI: 10.3389/fimmu.2020.607587] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022] Open
Abstract
Stroke is still one of the most common causes for mortality and morbidity worldwide. Following acute stroke onset, biochemical and cellular changes induce further brain injury such as neuroinflammation, cell death, and blood-brain barrier disruption. Matricellular proteins are non-structural proteins induced by many stimuli and tissue damage including stroke induction, while its levels are generally low in a normal physiological condition in adult tissues. Currently, a matricellular protein tenascin-C (TNC) is considered to be an important inducer to promote neuroinflammatory cascades and the resultant pathology in stroke. TNC is upregulated in cerebral arteries and brain tissues including astrocytes, neurons, and brain capillary endothelial cells following subarachnoid hemorrhage (SAH). TNC may be involved in blood-brain barrier disruption, neuronal apoptosis, and cerebral vasospasm via the activation of mitogen-activated protein kinases and nuclear factor-kappa B following SAH. In addition, post-SAH TNC levels in cerebrospinal fluid predicted the development of delayed cerebral ischemia and angiographic vasospasm in clinical settings. On the other hand, TNC is reported to promote fibrosis and exert repair effects for an experimental aneurysm via macrophages-induced migration and proliferation of smooth muscle cells. The authors review TNC-induced inflammatory signal cascades and the relationships with other matricellular proteins in stroke-related pathology.
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Affiliation(s)
- Takeshi Okada
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Neurosurgery, Kuwana City Medical Center, Kuwana, Japan
| | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
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19
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Sharma A, Muresanu DF, Sahib S, Tian ZR, Castellani RJ, Nozari A, Lafuente JV, Buzoianu AD, Bryukhovetskiy I, Manzhulo I, Patnaik R, Wiklund L, Sharma HS. Concussive head injury exacerbates neuropathology of sleep deprivation: Superior neuroprotection by co-administration of TiO 2-nanowired cerebrolysin, alpha-melanocyte-stimulating hormone, and mesenchymal stem cells. PROGRESS IN BRAIN RESEARCH 2020; 258:1-77. [PMID: 33223033 DOI: 10.1016/bs.pbr.2020.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sleep deprivation (SD) is common in military personnel engaged in combat operations leading to brain dysfunction. Military personnel during acute or chronic SD often prone to traumatic brain injury (TBI) indicating the possibility of further exacerbating brain pathology. Several lines of evidence suggest that in both TBI and SD alpha-melanocyte-stimulating hormone (α-MSH) and brain-derived neurotrophic factor (BDNF) levels decreases in plasma and brain. Thus, a possibility exists that exogenous supplement of α-MSH and/or BDNF induces neuroprotection in SD compounded with TBI. In addition, mesenchymal stem cells (MSCs) are very portent in inducing neuroprotection in TBI. We examined the effects of concussive head injury (CHI) in SD on brain pathology. Furthermore, possible neuroprotective effects of α-MSH, MSCs and neurotrophic factors treatment were explored in a rat model of SD and CHI. Rats subjected to 48h SD with CHI exhibited higher leakage of BBB to Evans blue and radioiodine compared to identical SD or CHI alone. Brain pathology was also exacerbated in SD with CHI group as compared to SD or CHI alone together with a significant reduction in α-MSH and BDNF levels in plasma and brain and enhanced level of tumor necrosis factor-alpha (TNF-α). Exogenous administration of α-MSH (250μg/kg) together with MSCs (1×106) and cerebrolysin (a balanced composition of several neurotrophic factors and active peptide fragments) (5mL/kg) significantly induced neuroprotection in SD with CHI. Interestingly, TiO2 nanowired delivery of α-MSH (100μg), MSCs, and cerebrolysin (2.5mL/kg) induced enhanced neuroprotection with higher levels of α-MSH and BDNF and decreased the TNF-α in SD with CHI. These observations are the first to show that TiO2 nanowired administration of α-MSH, MSCs and cerebrolysin induces superior neuroprotection following SD in CHI, not reported earlier. The clinical significance of our findings in light of the current literature is discussed.
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Affiliation(s)
- Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
| | - Dafin F Muresanu
- Department of Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania; "RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Seaab Sahib
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Z Ryan Tian
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Rudy J Castellani
- Department of Pathology, University of Maryland, Baltimore, MD, United States
| | - Ala Nozari
- Anesthesiology & Intensive Care, Massachusetts General Hospital, Boston, MA, United States
| | - José Vicente Lafuente
- LaNCE, Department of Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Bizkaia, Spain
| | - Anca D Buzoianu
- Department of Clinical Pharmacology and Toxicology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Igor Bryukhovetskiy
- Department of Fundamental Medicine, School of Biomedicine, Far Eastern Federal University, Vladivostok, Russia; Laboratory of Pharmacology, National Scientific Center of Marine Biology, Far East Branch of the Russian Academy of Sciences, Vladivostok, Russia
| | - Igor Manzhulo
- Department of Fundamental Medicine, School of Biomedicine, Far Eastern Federal University, Vladivostok, Russia; Laboratory of Pharmacology, National Scientific Center of Marine Biology, Far East Branch of the Russian Academy of Sciences, Vladivostok, Russia
| | - Ranjana Patnaik
- Department of Biomaterials, School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, India
| | - Lars Wiklund
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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Zhang P, Guan C, Li C, Zhu Z, Zhang W, Luan H, Zhou B, Man X, Che L, Wang Y, Zhao L, Zhang H, Luo C, Xu Y. A visual risk assessment tool for acute kidney injury after intracranial aneurysm clipping surgery. Ren Fail 2020; 42:1093-1099. [PMID: 33115300 PMCID: PMC7599021 DOI: 10.1080/0886022x.2020.1838299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective The aim of the study was to establish a predictive postoperative nomogram for acute kidney injury (AKI) after intracranial aneurysm clipping surgery, in order to early identify patients with high postoperative AKI risk. Methods This is a retrospective study, which included patients who underwent intracranial aneurysm clipping surgery. Multivariate logistic regression was employed to select confound factors that associated with AKI, then incorporated into the nomogram. The predictive accuracy of the model was assessed by concordance index (C-Index). Results A total of 365 patients after intracranial aneurysm clipping surgery were enrolled in the study eventually, of which 68 (18.63%) suffered postoperative AKI, and the incidence of stage 1, stage 2 and stage 3 were 92.65% (63/68), 5.88% (4/68), and 1.47% (1/68), respectively. Univariate logistic regression revealed that high density lipoprotein (HDL), prothrombin time (PT), estimated glomerular filtration rate (eGFR), size of aneurysm ≥10 mm, and aneurysm ruptured before surgery were associated with AKI after surgery, while multivariate logistic regression showed same results as the size of aneurysm ≥10 mm and aneurysm ruptured were independent AKI risk factors. In addition, the nomogram demonstrated a good accuracy in estimating intracranial aneurysm clipping associated AKI, as a C-Index and a bootstrap-corrected one of 0.772 and 0.737, respectively. Moreover, calibration plots showed consistency with the actual presence of AKI. Conclusion The novel nomogram model can serve as a promising predictive tool to improve the identification of AKI among those who underwent intracranial aneurysm clipping surgery.
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Affiliation(s)
- Pei Zhang
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chen Guan
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chenyu Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhihui Zhu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wei Zhang
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hong Luan
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bin Zhou
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaofei Man
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lin Che
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yanfei Wang
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Long Zhao
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hui Zhang
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Congjuan Luo
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yan Xu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
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21
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Commentary on TNF-R1 Correlates with Cerebral Perfusion and Acute Ischemia Following Subarachnoid Hemorrhage. Neurocrit Care 2020; 33:650-651. [PMID: 32929596 DOI: 10.1007/s12028-020-01093-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 08/28/2020] [Indexed: 10/23/2022]
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22
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Fragata I, Bustamante A, Penalba A, Ferreira P, Nunes AP, Canhão P, Montaner J. TNF-R1 Correlates with Cerebral Perfusion and Acute Ischemia Following Subarachnoid Hemorrhage. Neurocrit Care 2020; 33:679-687. [PMID: 32820384 DOI: 10.1007/s12028-020-01082-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/10/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early cerebral hypoperfusion and ischemia occur after subarachnoid hemorrhage (SAH) and influence clinical prognosis. Pathophysiological mechanisms possibly involve inflammatory mediators. TNF-α has been associated with complications and prognosis after SAH. We investigated the relation of perfusion parameters and ischemic lesions, with levels of TNF-α main receptor, TNF-R1, after SAH, and their association with prognosis. METHODS We included consecutive SAH patients admitted within the first 72 h of SAH onset. Blood samples were simultaneously collected from a peripheral vein and from the parent artery of the aneurysm. Levels of TNF-R1 were measured using ELISA (R&D Systems Inc., USA). CT perfusion and MRI studies were performed in the first 72 h. Correlation and logistic regression analysis were used to identify outcome predictors. RESULTS We analyzed 41 patients. Increased levels of TNF-R1 correlated with increased Tmax (arterial: r = -0.37, p = 0.01) and prolonged MTT (arterial: r = 0.355, p = 0.012; venous: r = 0.306, p = 0.026). Increased levels of both arterial and venous TNF-R1 were associated with increased number of lesions on DWI (p = 0.006). In multivariate analysis, venous TNFR1 levels > 1742.2 pg/mL (OR 1.78; 95%CI 1.18-2.67; p = 0.006) and DWI lesions (OR 14.01; 95%CI 1.19-165.3; p = 0.036) were both independent predictors of poor outcome (mRS ≥ 3) at 6 months. CONCLUSION Increased levels of TNF-R1 in arterial and venous blood correlate with worse cerebral perfusion and with increased burden of acute ischemic lesions in the first 72 h after SAH. Venous levels of TNF-R1 and DWI lesions were associated with poor outcome at 6 months. These results highlight the pathophysiological role of TNF-α pathways in SAH and suggest a possible role of combined imaging and laboratorial markers in determining prognosis in acute SAH.
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Affiliation(s)
- Isabel Fragata
- Neuroradiology Department, Centro Hospitalar Lisboa Central, Rua Jose Antonio Serrano, 1150-099, Lisbon, Portugal.
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Ana Penalba
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Patrícia Ferreira
- Unidade Cérebro-Vascular, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Ana Paiva Nunes
- Unidade Cérebro-Vascular, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Patrícia Canhão
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria, Lisbon, Portugal.,Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain.,Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Seville, Spain.,Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain
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23
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Nadkarni NA, Maas MB, Batra A, Kim M, Manno EM, Sorond FA, Prabhakaran S, Naidech AM, Liotta EM. Elevated Cerebrospinal Fluid Protein Is Associated with Unfavorable Functional Outcome in Spontaneous Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104605. [PMID: 31932209 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104605] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 12/10/2019] [Accepted: 12/13/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND/OBJECTIVE Subarachnoid hemorrhage (SAH) is a devastating neurologic event for which markers to assess poor outcome are needed. Elevated cerebrospinal fluid (CSF) protein may result from inflammation and blood-brain barrier (BBB) disruption that occurs during SAH. We sought to determine if CSF protein level is associated with functional outcome after SAH. METHODS We prospectively collected single-center demographic and clinical data for consecutive patients admitted with spontaneous SAH. Inclusion required an external ventricular drain and daily CSF protein and cellular counts starting within 48 hours of symptom onset and extending through 7 days after onset. Seven-day average CSF protein was determined from daily measured values after correcting for contemporaneous CSF red blood cell (RBC) count. Three-month functional outcome was assessed by telephone interview with good outcome defined as modified Rankin score 0-3. Variables univariately associated with outcome at P less than .25 and measures of hemorrhage volume were included for binary logistic regression model development. RESULTS The study included 130 patients (88% aneurysmal SAH, 69% female, 54.8 ± 14.8 years, Glasgow Coma Scale [GCS] 14 [7-15]). Three-month outcome assessment was complete in 112 (86%) patients with good functional outcome in 74 (66%). CSF protein was lower in good outcome (35.3 [20.4-49.7] versus 80.5 [40.5-115.5] mg/dL; P < .001). CSF protein was not associated with cerebral vasospasm, but delayed radiographic infarction on 3 to 12-month neuroimaging was associated with higher CSF protein (46.3 [32.0-75.0] versus 30.2 [20.4-47.8] mg/dL; P = .023). Good 3-month outcome was independently associated with lower CSF protein (odds ratios [OR] .39 [.23-.70] for 75th versus 25th percentile of protein; P = .001) and higher admission GCS (OR 1.23 [1.10-1.37] for good outcome per GCS point increase; P < .001). Parenchymal hematoma predicted worse outcome (OR 6.31 [1.58-25.25]; P = .009). Results were similar after excluding nonaneurysmal SAH and after including CSF RBC count, CT score, and intraventricular hemorrhage volume in models. CONCLUSIONS Elevated average CSF protein is associated with poor outcome after spontaneous SAH. Further research should investigate if elevated CSF protein identifies patients in whom mechanisms such as BBB disruption contribute to poor outcome.
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Affiliation(s)
- Neil A Nadkarni
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Matthew B Maas
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Ayush Batra
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Minjee Kim
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Edward M Manno
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Farzaneh A Sorond
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Shyam Prabhakaran
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Andrew M Naidech
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois
| | - Eric M Liotta
- Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Chicago, Illinois.
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Chou SHY, Macdonald RL, Keller E. Biospecimens and Molecular and Cellular Biomarkers in Aneurysmal Subarachnoid Hemorrhage Studies: Common Data Elements and Standard Reporting Recommendations. Neurocrit Care 2020; 30:46-59. [PMID: 31144274 DOI: 10.1007/s12028-019-00725-4] [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] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Development of clinical biomarkers to guide therapy is an important unmet need in aneurysmal subarachnoid hemorrhage (SAH). A wide spectrum of plausible biomarkers has been reported for SAH, but none have been validated due to significant variabilities in study design, methodology, laboratory techniques, and outcome endpoints. METHODS A systematic review of SAH biomarkers was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The panel's recommendations focused on harmonization of (1) target cellular and molecular biomarkers for future investigation in SAH, (2) standardization of best-practice procedures in biospecimen and biomarker studies, and (3) experimental method reporting requirements to facilitate meta-analyses and future validation of putative biomarkers. RESULTS No cellular or molecular biomarker has been validated for inclusion as "core" recommendation. Fifty-four studies met inclusion criteria and generated 33 supplemental and emerging biomarker targets. Core recommendations include best-practice protocols for biospecimen collection and handling as well as standardized reporting guidelines to capture the heterogeneity and variabilities in experimental methodologies and biomarker analyses platforms. CONCLUSION Significant variabilities in study design, methodology, laboratory techniques, and outcome endpoints exist in SAH biomarker studies and present significant barriers toward validation and translation of putative biomarkers to clinical use. Adaptation of common data elements, recommended biospecimen protocols, and reporting guidelines will reduce heterogeneity and facilitate future meta-analyses and development of validated clinical biomarkers in SAH.
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Affiliation(s)
- Sherry H-Y Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, 3550 Terrace Street Suite 646, Pittsburgh, PA, 15261, USA.
| | - R Loch Macdonald
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada.,Departments of Physiology and Surgery, University of Toronto, Toronto, Canada
| | - Emanuela Keller
- Neurocritical Care Unit, Department of Neurosurgery, UniversitätsSpital Zürich, Zurich, Switzerland
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25
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Chen J, Jin H, Xu H, Peng Y, Jie L, Xu D, Chen L, Li T, Fan L, He P, Ying G, Gu C, Wang C, Wang L, Chen G. The Neuroprotective Effects of Necrostatin-1 on Subarachnoid Hemorrhage in Rats Are Possibly Mediated by Preventing Blood-Brain Barrier Disruption and RIP3-Mediated Necroptosis. Cell Transplant 2019; 28:1358-1372. [PMID: 31370690 PMCID: PMC6802141 DOI: 10.1177/0963689719867285] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 06/29/2019] [Accepted: 07/11/2019] [Indexed: 12/17/2022] Open
Abstract
Despite the substantial efforts to elucidate the role of early brain injury in subarachnoid hemorrhage (SAH), an effective pharmaceutical therapy for patients with SAH continues to be unavailable. This study aims to reveal the role of necroptosis after SAH, and explore whether the disruption of the blood-brain barrier (BBB) and RIP3-mediated necroptosis following SAH in a rat SAH model are altered by necrostatin-1 via its selective inhibition of receptor-interacting protein kinase 1 (RIP1). Sixty-five rats were used in the experiments. The SAH model was established using endovascular perforation. Necrostatin-1 was intracerebroventricularly injected 1 h before SAH induction. The neuroprotective effects of necrostatin-1 were evaluated with multiple methods such as magnetic resonance imaging (MRI) scanning, immunohistochemistry, propidium iodide (PI) labeling, and western blotting. Pretreatment with necrostatin-1 attenuated brain swelling and reduced the lesion volume on T2 sequence and ventricular volume on MRI 72 h after SAH induction. Albumin leakage and the degradation of tight junction proteins were also ameliorated by necrostatin-1 administration. In addition, necrostatin-1 decreased the number of PI-positive cells in the basal cortex, reduced the levels of the RIP3 and MLKL proteins, and inhibited the production of the pro-inflammatory cytokines IL-1β, IL-6, and TNF-α. Based on the findings from the present study, the selective RIP1 inhibitor necrostatin-1 functioned as a neuroprotective agent after SAH by attenuating brain swelling and BBB disruption. Moreover, the necrostatin-1 pretreatment prevented SAH-induced necroptosis by suppressing the activity of the RIP3/MLKL signaling pathway. These results will provide insights into new drugs and pharmacological targets to manage SAH, which are worth further study.
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Affiliation(s)
- Jingsen Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
- All the authors contributed equally to this article
| | - Hanghuang Jin
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
- Department of Neurosurgery, Affiliated Taizhou Municipal Hospital, Taizhou
University, Taizhou, China
- All the authors contributed equally to this article
| | - Hangzhe Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
- All the authors contributed equally to this article
| | - Yucong Peng
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
| | - Liyong Jie
- Department of Radiology, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
| | - Demin Xu
- Department of Radiology, Peking University Shenzhen Hospital, Shenzhen,
China
| | - Lili Chen
- Department of Neurology, Xiasha Campus, Sir Run Run Shaw Hospital, School of
Medicine, Zhejiang University, Hangzhou, China
| | - Tao Li
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
| | - Linfeng Fan
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
| | - Pingyou He
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
| | - Guangyu Ying
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
| | - Chi Gu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
| | - Chun Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
| | - Lin Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
| | - Gao Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine,
Zhejiang University, Hangzhou, China
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26
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Bach A, Conzen C, Schubert GA, Bleilevens C, Lindauer U. Acute changes of pro-inflammatory markers and corticosterone in experimental subarachnoid haemorrhage: A prerequisite for severity assessment. PLoS One 2019; 14:e0220467. [PMID: 31361786 PMCID: PMC6667150 DOI: 10.1371/journal.pone.0220467] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/16/2019] [Indexed: 12/27/2022] Open
Abstract
Many details of the pathophysiology of subarachnoid haemorrhage (SAH) still remain unknown, making animal experiments an indispensable tool for assessment of diagnostics and therapy. For animal protection and project authorization, one needs objective measures to evaluate the severity and burden in each model. Corticosterone is described as a sensitive stress parameter reflecting the acute burden, and inflammatory markers can be used for assessment of the extent of the brain lesion. However, the brain lesion itself may activate the hypothalamic-pituitary-adrenal-axis early after SAH, as shown for ischemic stroke, probably interfering with early inflammatory processes, thus complicating the assessment of severity and burden on the basis of corticosterone and inflammation. To assess the suitability of these markers in SAH, we evaluated the courses of corticosterone, IL-6 and TNF-α up to 6h in an acute model simulating SAH in continuously anaesthetized rats, lacking the pain and stress induced impact on these parameters. Animals were randomly allocated to sham or SAH. SAH was induced by cisterna magna blood-injection, and intracranial pressure and cerebral blood flow were measured under continuous isoflurane/fentanyl anaesthesia. Withdrawn at predetermined time points, blood was analysed by commercial ELISA kits. After 6h the brain was removed for western blot analysis of IL-6 and TNF-α. Serum corticosterone levels were low with no significant difference between sham and SAH. No activation of the HPA-axis was detectable, rendering corticosterone a potentially useful parameter for stress assessment in future chronic studies. Blood IL-6 and TNF-α increased in both groups over time, with IL-6 increasing significantly more in SAH compared to sham towards the end of the observation period. In the basal cortex, IL-6 and TNF-α increased only in SAH. The pro-inflammatory response seems to start locally in the brain, reflected by an increase in peripheral blood. An additional surgery-induced systemic inflammatory response should be considered.
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Affiliation(s)
- Annika Bach
- Translational Neurosurgery and Neurobiology, University Hospital Aachen, RWTH Aachen, Aachen, Germany
| | - Catharina Conzen
- Translational Neurosurgery and Neurobiology, University Hospital Aachen, RWTH Aachen, Aachen, Germany.,Department of Neurosurgery, University Hospital Aachen, RWTH Aachen, Aachen, Germany
| | | | - Christian Bleilevens
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen, Aachen, Germany
| | - Ute Lindauer
- Translational Neurosurgery and Neurobiology, University Hospital Aachen, RWTH Aachen, Aachen, Germany.,Department of Neurosurgery, University Hospital Aachen, RWTH Aachen, Aachen, Germany
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27
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Al-Tamimi YZ, Bhargava D, Orsi NM, Teraifi A, Cummings M, Ekbote UV, Quinn AC, Homer-Vanniasinkam S, Ross S. Compartmentalisation of the inflammatory response following aneurysmal subarachnoid haemorrhage. Cytokine 2019; 123:154778. [PMID: 31323526 DOI: 10.1016/j.cyto.2019.154778] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/30/2019] [Accepted: 07/09/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION There is some evidence to suggest that a systemic and central nervous system (CNS) inflammatory response occurs following aneurysmal subarachnoid haemorrhage (aSAH) which may be related to the pathophysiology of early brain injury and delayed ischaemic neurological deficit (DIND). The aim of this study was to measure inflammatory mediator levels in plasma and cerebrospinal fluid (CSF) in the days following aSAH and to determine their association with aSAH, DIND and clinical outcome. MATERIAL AND METHODS Plasma and CSF samples were obtained prospectively from patients with aSAH on days 1-3, 5, 7 and 9 and profiled for interleukin (IL)-1α, IL-1β, IL-4, IL-6, IL-8, IL-10, IL-15, IL-17, IL-18, macrophage chemotactic protein (MCP)-1, vascular endothelial growth factor (VEGF) and tumour necrosis factor (TNF)-α. Plasma and CSF samples from non-aSAH patients undergoing spinal anaesthesia were used as controls. RESULTS The CSF levels of all cytokines investigated except for IL-1α were significantly higher in aSAH compared to controls in the first seven days of ictus. CSF levels of IL-1α (p = 0.014), IL-18 (p = 0.016), IL-6 (p = 0.0006) and IL-8 (p = 0.006) showed significant increases in the days following aSAH. Conversely IL-17 demonstrated a decrease. In particular, IL-4 was higher in the CSF of patients who had DIND at all time-points (p = 0.032). Plasma IL-6 and IL-8 levels were higher, and IL-1α levels lower, than controls at most time-points. All mediators demonstrated persistent elevation in the CSF compared to plasma apart from IL-1α and IL-18 which followed the opposite trend. Day 3 plasma IL-6 levels predicted poor outcome at six months (Exp(B) 1.12 1.03-1.22, P = 0.012), although this association was lost in the second analysis incorporating Fisher grade, WFNS grade and age. CONCLUSION The post aSAH inflammatory response peaks on days 5-7 post ictus and remains largely compartmentalised within the CNS. IL-4 may have a particular association with DIND although its precise role in the pathophysiology of the disorder remains unclear. IL-6 predicted poor outcome but not independently of clinical grade, suggesting that it may be a surrogate marker of early brain injury.
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Affiliation(s)
- Yahia Z Al-Tamimi
- Department of Neurosurgery, Sheffield Teaching Hospital NHS Foundation Trust, Glossop Road, Sheffield S10 2JF, United Kingdom; Department of Neurosurgery, Level G Jubilee Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, United Kingdom.
| | - Deepti Bhargava
- Department of Neurosurgery, Level G Jubilee Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Nicolas M Orsi
- Leeds Institute of Cancer & Pathology, Wellcome Trust Brenner Building, St James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - Anmar Teraifi
- University of Liverpool School of Medicine, Cedar House, Ashton Street, Liverpool L69 3GE, United Kingdom
| | - Michele Cummings
- Leeds Institute of Cancer & Pathology, Wellcome Trust Brenner Building, St James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - Uma V Ekbote
- Leeds Institute of Cancer & Pathology, Wellcome Trust Brenner Building, St James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - Audrey C Quinn
- Department of Anaesthesia, Level C Brotherton Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Shervanthi Homer-Vanniasinkam
- Department of Vascular Surgery, Level B Brotherton Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, United Kingdom
| | - Stuart Ross
- Department of Neurosurgery, Level G Jubilee Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, United Kingdom
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Saand AR, Yu F, Chen J, Chou SHY. Systemic inflammation in hemorrhagic strokes - A novel neurological sign and therapeutic target? J Cereb Blood Flow Metab 2019; 39:959-988. [PMID: 30961425 PMCID: PMC6547186 DOI: 10.1177/0271678x19841443] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Growing evidences suggest that stroke is a systemic disease affecting many organ systems beyond the brain. Stroke-related systemic inflammatory response and immune dysregulations may play an important role in brain injury, recovery, and stroke outcome. The two main phenomena in stroke-related peripheral immune dysregulations are systemic inflammation and post-stroke immunosuppression. There is emerging evidence suggesting that the spleen contracts following ischemic stroke, activates peripheral immune response and this may further potentiate brain injury. Whether similar brain-immune crosstalk occurs in hemorrhagic strokes such as intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is not established. In this review, we systematically examined animal and human evidence to date on peripheral immune responses associated with hemorrhagic strokes. Specifically, we reviewed the impact of clinical systemic inflammatory response syndrome (SIRS), inflammation- and immune-associated biomarkers, the brain-spleen interaction, and cellular mediators of peripheral immune responses to ICH and SAH including regulatory T cells (Tregs). While there is growing data suggesting that peripheral immune dysregulation following hemorrhagic strokes may be important in brain injury pathogenesis and outcome, details of this brain-immune system cross-talk remain insufficiently understood. This is an important unmet scientific need that may lead to novel therapeutic strategies in this highly morbid condition.
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Affiliation(s)
- Aisha R Saand
- 1 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Fang Yu
- 2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jun Chen
- 2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sherry H-Y Chou
- 1 Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,2 Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,3 Department of Neurosurgery, School of Medicine, University of Pittsburgh, PA, USA
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Neuroprotective Role of the Nrf2 Pathway in Subarachnoid Haemorrhage and Its Therapeutic Potential. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:6218239. [PMID: 31191800 PMCID: PMC6525854 DOI: 10.1155/2019/6218239] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/17/2019] [Accepted: 03/20/2019] [Indexed: 12/11/2022]
Abstract
The mechanisms underlying poor outcome following subarachnoid haemorrhage (SAH) are complex and multifactorial. They include early brain injury, spreading depolarisation, inflammation, oxidative stress, macroscopic cerebral vasospasm, and microcirculatory disturbances. Nrf2 is a global promoter of the antioxidant and anti-inflammatory response and has potential protective effects against all of these mechanisms. It has been shown to be upregulated after SAH, and Nrf2 knockout animals have poorer functional and behavioural outcomes after SAH. There are many agents known to activate the Nrf2 pathway. Of these, the actions of sulforaphane, curcumin, astaxanthin, lycopene, tert-butylhydroquinone, dimethyl fumarate, melatonin, and erythropoietin have been studied in SAH models. This review details the different mechanisms of injury after SAH including the contribution of haemoglobin (Hb) and its breakdown products. It then summarises the evidence that the Nrf2 pathway is active and protective after SAH and finally examines the evidence supporting Nrf2 upregulation as a therapy after SAH.
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Venous and arterial TNF-R1 predicts outcome and complications in acute subarachnoid hemorrhage. Neurocrit Care 2019; 31:107-115. [DOI: 10.1007/s12028-019-00669-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Ma C, Liu S, Zhang S, Xu T, Yu X, Gao Y, Zhai C, Li C, Lei C, Fan S, Chen Y, Tian H, Wang Q, Cheng F, Wang X. Evidence and perspective for the role of the NLRP3 inflammasome signaling pathway in ischemic stroke and its therapeutic potential (Review). Int J Mol Med 2018; 42:2979-2990. [PMID: 30280193 DOI: 10.3892/ijmm.2018.3911] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 09/26/2018] [Indexed: 11/06/2022] Open
Abstract
Ischemic stroke is one of the main causes of death and disablement globally. The NLR family pyrin domain containing 3 (NLRP3) inflammasome is established as a sensor of detecting cellular damage and modulating inflammatory responses to injury during the progress of ischemic stroke. Inhibiting or blocking the NLRP3 inflammasome at different stages, including expression, assembly, and secretion, may have great promise to improve the neurological deficits during ischemic stroke. The current review provides a comprehensive summary of the current understanding in the literature of the molecular structure, expression, and assembly of the NLRP3 inflammasome, and highlights its potential as a novel therapeutic target for ischemic stroke.
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Affiliation(s)
- Chongyang Ma
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Shuling Liu
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Shuang Zhang
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Tian Xu
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Xue Yu
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Yushan Gao
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Changming Zhai
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Changxiang Li
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Chaofang Lei
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Shuning Fan
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Yuxi Chen
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Huiling Tian
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Qingguo Wang
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Fafeng Cheng
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
| | - Xueqian Wang
- School of Basic Medical Sciences, Beijing University of Chinese Medicine, Beijing 100029, P.R. China
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Watson E, Ding D, Khattar NK, Everhart DE, James RF. Neurocognitive outcomes after aneurysmal subarachnoid hemorrhage: Identifying inflammatory biomarkers. J Neurol Sci 2018; 394:84-93. [PMID: 30240942 DOI: 10.1016/j.jns.2018.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 06/21/2018] [Accepted: 06/24/2018] [Indexed: 12/19/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe type of stroke which carries a high case-fatality rate. Those who survive the ictus of aneurysm rupture harbor substantial risks of neurological morbidity, functional disability, and cognitive dysfunction. Although the pervasiveness of cognitive impairment is widely acknowledged as a long-term sequela of aSAH, the mechanisms underlying its development are poorly understood. The onset of aSAH elicits activation of the inflammatory cascade, and ongoing neuroinflammation is suspected to contribute to secondary complications, such as vasospasm and delayed cerebral ischemia. In this review, we analyze the extant literature regarding the relationship between neuroinflammation and cognitive dysfunction after aSAH. Pro-inflammatory cytokines appear to play a role in maintaining normal cognitive function in adults unaffected by aSAH. However, in the setting of aSAH, elevated cytokine levels may correlate with worse neuropsychological outcomes. This seemingly dichotomous relationship between neuroinflammation and cognition suggests that the action of cytokines varies, depending on their physiologic environment. Experimental therapies which suppress the immune response to aSAH appear to have a beneficial effect on cognitive outcomes. However, further studies are necessary to determine the utility of inflammatory mediators as biomarkers of neurocognitive outcomes, as well as their role in the management of aSAH.
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Affiliation(s)
- Eric Watson
- Icahn School of Medicine at Mount Sinai, Department of Rehabilitation Medicine, 1 Gustave L. Levy Place, New York, NY 10029, United States
| | - Dale Ding
- Department of Neurosurgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, Suite 1500, Louisville, KY 40202, United States
| | - Nicolas K Khattar
- Department of Neurosurgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, Suite 1500, Louisville, KY 40202, United States
| | - D Erik Everhart
- Department of Psychology, East Carolina University, 104 Rawl Building, Greenville, NC 27858, United States
| | - Robert F James
- Department of Neurosurgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, Suite 1500, Louisville, KY 40202, United States.
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Blackburn SL, Kumar PT, McBride D, Zeineddine HA, Leclerc J, Choi HA, Dash PK, Grotta J, Aronowski J, Cardenas JC, Doré S. Unique Contribution of Haptoglobin and Haptoglobin Genotype in Aneurysmal Subarachnoid Hemorrhage. Front Physiol 2018; 9:592. [PMID: 29904350 PMCID: PMC5991135 DOI: 10.3389/fphys.2018.00592] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/02/2018] [Indexed: 01/12/2023] Open
Abstract
Survivors of cerebral aneurysm rupture are at risk for significant morbidity and neurological deficits. Much of this is related to the effects of blood in the subarachnoid space which induces an inflammatory cascade with numerous downstream consequences. Recent clinical trials have not been able to reduce the toxic effects of free hemoglobin or improve clinical outcome. One reason for this may be the inability to identify patients at high risk for neurologic decline. Recently, haptoglobin genotype has been identified as a pertinent factor in diabetes, sickle cell, and cardiovascular disease, with the Hp 2-2 genotype contributing to increased complications. Haptoglobin is a protein synthesized by the liver that binds free hemoglobin following red blood cell lysis, and in doing so, prevents hemoglobin induced toxicity and facilitates clearance. Clinical studies in patients with subarachnoid hemorrhage indicate that Hp 2-2 patients may be a high-risk group for hemorrhage related complications and poor outcome. We review the relevance of haptoglobin in subarachnoid hemorrhage and discuss the effects of genotype and expression levels on the known mechanisms of early brain injury (EBI) and cerebral ischemia after aneurysm rupture. A better understanding of haptoglobin and its role in preventing hemoglobin related toxicity should lead to novel therapeutic avenues.
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Affiliation(s)
- Spiros L Blackburn
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - Peeyush T Kumar
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - Devin McBride
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - Hussein A Zeineddine
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - Jenna Leclerc
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, FL, United States
| | - H Alex Choi
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - Pramod K Dash
- Department of Neurosurgery, The University of Texas Houston Health Sciences Center, Houston, TX, United States
| | - James Grotta
- Department of Neurology, The University of Texas Health Sciences Center, Houston, TX, United States
| | - Jaroslaw Aronowski
- Department of Neurology, The University of Texas Health Sciences Center, Houston, TX, United States
| | - Jessica C Cardenas
- Department of Surgery, Division of Acute Care Surgery and Center for Translational Injury Research, The University of Texas Health Science Center, Houston, TX, United States
| | - Sylvain Doré
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, FL, United States.,Departments of Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience, University of Florida, McKnight Brain Institute, Gainesville, FL, United States
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Al-Mufti F, Witsch J, Manning N, Crimmins M, Amuluru K, Agarwal S, Park S, Willey JZ, Kamel H, Connolly ES, Meyers PM, Claassen J. Severity of cerebral vasospasm associated with development of collaterals following aneurysmal subarachnoid hemorrhage. J Neurointerv Surg 2018; 10:638-643. [DOI: 10.1136/neurintsurg-2017-013410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 01/17/2018] [Accepted: 01/24/2018] [Indexed: 11/03/2022]
Abstract
IntroductionCerebral collateral circulation has been studied extensively in ischemic stroke where it has been shown to be a predictor of reperfusion, final infarct size, and outcome. Little is known about the significance of the collaterals in the setting of aneurysmal subarachnoid hemorrhage (aSAH). We sought to evaluate the effect of cerebral vasospasm on the development of cerebral collaterals following aneurysmal subarachnoid hemorrhage and the effects of the latter on delayed cerebral ischemia (DCI).MethodsWe retrospectively evaluated 64 aSAH patients with evidence of DCI between day 5 and 7, enrolled in a prospectively maintained observational cohort study. Angiograms were evaluated by four blinded neurointerventionalists. We compared good collateral grades to poor collateral grades, additionally we compared enrolled individuals with any collaterals versus patients who had no collaterals.ResultsInter-rater reliability for collateral grades was substantial (weighted kappa 0.632). Mild vasospasm was more frequent in patients with poor collateral grades compared with patients with good collateral grades (32% vs 4% P=0.012). There was no difference between the collateral groups with regards to DCI, functional, or cognitive outcome. Patients adjudicated to have any collaterals were more likely to have severe vasospasm (62% vs 33% P=0.023) and less likely to have mild vasospasm (37% vs 9% P=0.007). In a multivariable model, vasospasm severity remained associated with collateral status, while aneurysm location was not.ConclusionsThe severity of vasospasm following aSAH was associated with the development of collaterals. There was no difference between collateral grades with regards to DCI or outcome.
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de Oliveira Manoel AL, Macdonald RL. Neuroinflammation as a Target for Intervention in Subarachnoid Hemorrhage. Front Neurol 2018; 9:292. [PMID: 29770118 PMCID: PMC5941982 DOI: 10.3389/fneur.2018.00292] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/16/2018] [Indexed: 01/09/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a sub-type of hemorrhagic stroke associated with the highest rates of mortality and long-term neurological disabilities. Despite the improvement in the management of SAH patients and the reduction in case fatality in the last decades, disability and mortality remain high in this population. Brain injury can occur immediately and in the first days after SAH. This early brain injury can be due to physical effects on the brain such as increased intracranial pressure, herniations, intracerebral, intraventricular hemorrhage, and hydrocephalus. After the first 3 days, angiographic cerebral vasospasm (ACV) is a common neurological complication that in severe cases can lead to delayed cerebral ischemia and cerebral infarction. Consequently, the prevention and treatment of ACV continue to be a major goal. However, most treatments for ACV are vasodilators since ACV is due to arterial vasoconstriction. Other targets also have included those directed at the underlying biochemical mechanisms of brain injury such as inflammation and either independently or as a consequence, cerebral microthrombosis, cortical spreading ischemia, blood–brain barrier breakdown, and cerebral ischemia. Unfortunately, no pharmacologic treatment directed at these processes has yet shown efficacy in SAH. Enteral nimodipine and the endovascular treatment of the culprit aneurysm, remain the only treatment options supported by evidence from randomized clinical trials to improve patients’ outcome. Currently, there is no intervention directly developed and approved to target neuroinflammation after SAH. The goal of this review is to provide an overview on anti-inflammatory drugs tested after aneurysmal SAH.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- Adult Critical Care Unit, Hospital Paulistano - United Health Group, São Paulo, Brazil.,Keenan Research Center for Biomedical Science, Department of Surgery, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science, Department of Surgery, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
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Golanov EV, Bovshik EI, Wong KK, Pautler RG, Foster CH, Federley RG, Zhang JY, Mancuso J, Wong ST, Britz GW. Subarachnoid hemorrhage - Induced block of cerebrospinal fluid flow: Role of brain coagulation factor III (tissue factor). J Cereb Blood Flow Metab 2018; 38:793-808. [PMID: 28350198 PMCID: PMC5987942 DOI: 10.1177/0271678x17701157] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Subarachnoid hemorrhage (SAH) in 95% of cases results in long-term disabilities due to brain damage, pathogenesis of which remains uncertain. Hindrance of cerebrospinal fluid (CSF) circulation along glymphatic pathways is a possible mechanism interrupting drainage of damaging substances from subarachnoid space and parenchyma. We explored changes in CSF circulation at different time following SAH and possible role of brain tissue factor (TF). Fluorescent solute and fluorescent microspheres injected into cisterna magna were used to track CSF flow in mice. SAH induced by perforation of circle of Willis interrupted CSF flow for up to 30 days. Block of CSF flow did not correlate with the size of hemorrhage. Following SAH, fibrin deposits were observed on the brain surface including areas without visible blood. Block of astroglia-associated TF by intracerebroventricular administration of specific antibodies increased size of hemorrhage, decreased fibrin deposition and facilitated spread of fluorophores in sham/naïve animals. We conclude that brain TF plays an important role in localization of hemorrhage and also regulates CSF flow under normal conditions. Targeting of the TF system will allow developing of new therapeutic approaches to the treatment of SAH and pathologies related to CSF flow such as hydrocephalus.
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Affiliation(s)
- Eugene V Golanov
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Evgeniy I Bovshik
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Kelvin K Wong
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA.,2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Robia G Pautler
- 3 Departments of Molecular Physiology and Biophysics and Neuroscience and Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Chase H Foster
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - Richard G Federley
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA.,2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Jonathan Y Zhang
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
| | - James Mancuso
- 2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Stephen Tc Wong
- 2 Department of Systems Medicine & Bioengineering, Houston Methodist Research Institute, Houston, TX, USA
| | - Gavin W Britz
- 1 Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
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Roflumilast Reduces Cerebral Inflammation in a Rat Model of Experimental Subarachnoid Hemorrhage. Inflammation 2018; 40:1245-1253. [PMID: 28451841 DOI: 10.1007/s10753-017-0567-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Roflumilast, a selective inhibitor for PDE4, is approved by FDA as an anti-inflammation drug for treatment of chronic obstructive pulmonary disease (COPD). This study investigates the effects of roflumilast on cerebral inflammation in the rat SAH model. Here, we show that subcutaneous administration of roflumilast (3 mg/kg) significantly improved the neurological deficits. Measurement of evans blue extravasation and brain water content revealed a significant reduction of blood-brain barrier permeability and brain edema. Importantly, roflumilast treatment remarkably decreased levels of IL-1β, IL-6, and TNF-α and the number of apoptotic neurons in the brain after SAH. These results indicate that roflumilast is effective in treating cerebral inflammation following SAH.
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Kilic TY, Aksay E, Atilla OD, Sezik S, Camlar M. The diagnostic value of complete blood count parameters in patients with subarachnoid hemorrhage. Turk J Emerg Med 2018; 17:128-131. [PMID: 29464214 PMCID: PMC5812913 DOI: 10.1016/j.tjem.2017.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/21/2017] [Accepted: 07/18/2017] [Indexed: 11/17/2022] Open
Abstract
Objectives Diagnosis of subarachnoid hemorrhage (SAH) in patients presenting with headache is challenging and there has been any biomarker studied for excluding of SAH in those patients. We aim to determine the sensitivity of leukocytosis or left shift to exclude the diagnosis of SAH in ED patients presenting with headache. Method Adult patients with headache who received a computed tomography (CT) with the diagnosis of SAH and had a complete blood count (CBC) represent the case group, headache patients with normal CT and had a CBC represent the control group. The white blood cell (WBC) count and percentage of polymorphonuclear cells (PMNs%) taken during admission and within the first 6 and 12 h of admission were recorded. Results A hundred ninety seven patients with SAH and 197 patients without SAH were enrolled in to study. Sensitivity, specificity, NPV and PPV of leukocytosis or increase in PMNs% (left shift) in the diagnosis of SAH was 89.8% (84.5-93.5, 95% CI), 46.7% (39.6-53.9, 95% CI), 82.1% (73.5-88.4, 95% CI) and 62.8% (56.8-68.4, 95% CI) respectively on initial emergency department (ED) admission. Conclusion CBC should be considered as a noninvasive test for the exclusion of SAH in ED patients with 6 h observation.
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Affiliation(s)
- Turgay Yılmaz Kilic
- Izmir Tepecik Research and Educational Hospital, Department of Emergency Medicine, Izmir, Turkey
- Corresponding author. Department of Emergency Medicine, Tepecik Training and Research Hospital, Gaziler Caddesi, Yenisehir, 35120, Izmir, Turkey.Department of Emergency MedicineTepecik Training and Research HospitalGaziler CaddesiYenisehirIzmir35120Turkey
| | - Ersin Aksay
- Dokuz Eylul University Hospital, Department of Emergency Medicine, Izmir, Turkey
| | - Ozge Duman Atilla
- Izmir Tepecik Research and Educational Hospital, Department of Emergency Medicine, Izmir, Turkey
| | - Savas Sezik
- Izmir Tepecik Research and Educational Hospital, Department of Emergency Medicine, Izmir, Turkey
| | - Mahmut Camlar
- Izmir Tepecik Research and Educational Hospital, Department of Neurosurgery, Izmir, Turkey
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Abstract
Diseases of the central nervous system that are caused by an underlying vascular pathology typically result in either hemorrhage or ischemia. Most prominent entities include spontaneous subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, and ischemic stroke. For anatomic reasons, cerebrospinal fluid (CSF) qualifies as body fluid for the exploration of biomarkers in these disorders. Even though in subarachnoid hemorrhage a few CSF parameters have been established for routine diagnostic purposes, there is still an unmet need and broad interest in the identification of molecules that would allow further insight into disease mechanisms and supplement patients' medical care. This chapter provides an overview on what is presently known about CSF biomarkers in spontaneous subarachnoid hemorrhage, spontaneous intracerebral hemorrhage, and ischemic stroke. We recapitulate current evidence on established diagnostic tests, discuss the role of various CSF molecules in the pathophysiology of these diseases, and illuminate their potential use in future clinical practice. Furthermore, we address methodologic aspects as well as shortcomings of research in this field.
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Affiliation(s)
- Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Michael Auer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Schneider U, Xu R, Vajkoczy P. Inflammatory Events Following Subarachnoid Hemorrhage (SAH). Curr Neuropharmacol 2018; 16:1385-1395. [PMID: 29651951 PMCID: PMC6251050 DOI: 10.2174/1570159x16666180412110919] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/17/2017] [Accepted: 02/28/2018] [Indexed: 11/22/2022] Open
Abstract
Acute SAH from a ruptured intracranial aneurysm contributes for 30% of all hemorrhagic strokes. The bleeding itself occurs in the subarachnoid space. Nevertheless, injury to the brain parenchyma occurs as a consequence of the bleeding, directly, via several well-defined mechanisms and pathways, but also indirectly, or secondarily. This secondary brain injury following SAH has a variety of causes and possible mechanisms. Amongst others, inflammatory events have been shown to occur in parallel to, contribute to, or even to initiate programmed cell death (PCD) within the central nervous system (CNS) in human and animal studies alike. Mechanisms of secondary brain injury are of utmost interest not only to scientists, but also to clinicians, as they often provide possibilities for translational approaches as well as distinct time windows for tailored treatment options. In this article, we review secondary brain injury due to inflammatory changes, that occur on cellular, as well as on molecular level in the various different compartments of the CNS: the brain vessels, the subarachnoid space, and the brain parenchyma itself and hypothesize about possible signaling mechanisms between these compartments.
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Affiliation(s)
- U.C. Schneider
- Dept. Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - R. Xu
- Dept. Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - P. Vajkoczy
- Dept. Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Lidington D, Kroetsch JT, Bolz SS. Cerebral artery myogenic reactivity: The next frontier in developing effective interventions for subarachnoid hemorrhage. J Cereb Blood Flow Metab 2018; 38:17-37. [PMID: 29135346 PMCID: PMC5757446 DOI: 10.1177/0271678x17742548] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a devastating cerebral event that kills or debilitates the majority of those afflicted. The blood that spills into the subarachnoid space stimulates profound cerebral artery vasoconstriction and consequently, cerebral ischemia. Thus, once the initial bleeding in SAH is appropriately managed, the clinical focus shifts to maintaining/improving cerebral perfusion. However, current therapeutic interventions largely fail to improve clinical outcome, because they do not effectively restore normal cerebral artery function. This review discusses emerging evidence that perturbed cerebrovascular "myogenic reactivity," a crucial microvascular process that potently dictates cerebral perfusion, is the critical element underlying cerebral ischemia in SAH. In fact, the myogenic mechanism could be the reason why many therapeutic interventions, including "Triple H" therapy, fail to deliver benefit to patients. Understanding the molecular basis for myogenic reactivity changes in SAH holds the key to develop more effective therapeutic interventions; indeed, promising recent advancements fuel optimism that vascular dysfunction in SAH can be corrected to improve outcome.
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Affiliation(s)
- Darcy Lidington
- 1 Department of Physiology, University of Toronto, Toronto, Canada.,2 Toronto Centre for Microvascular Medicine at TBEP, University of Toronto, Toronto, Canada
| | - Jeffrey T Kroetsch
- 1 Department of Physiology, University of Toronto, Toronto, Canada.,2 Toronto Centre for Microvascular Medicine at TBEP, University of Toronto, Toronto, Canada
| | - Steffen-Sebastian Bolz
- 1 Department of Physiology, University of Toronto, Toronto, Canada.,2 Toronto Centre for Microvascular Medicine at TBEP, University of Toronto, Toronto, Canada.,3 Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, Canada
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Lv SY, Wu Q, Liu JP, Shao J, Wen LL, Xue J, Zhang XS, Zhang QR, Zhang X. Levels of Interleukin-1β, Interleukin-18, and Tumor Necrosis Factor-α in Cerebrospinal Fluid of Aneurysmal Subarachnoid Hemorrhage Patients May Be Predictors of Early Brain Injury and Clinical Prognosis. World Neurosurg 2017; 111:e362-e373. [PMID: 29277532 DOI: 10.1016/j.wneu.2017.12.076] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/10/2017] [Accepted: 12/11/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a severe cerebrovascular accident with high morbidity and mortality. The aim of this study is to investigate the relationship between level of inflammatory cytokines in cerebrospinal fluid (CSF) of aSAH patients, the severity of aSAH, and the outcome of aSAH patients. METHODS aSAH patients were prospectively included and followed-up for 6 months. CSF samples were collected at 1-3, 4-6, and 7-9 days after aSAH onset. Levels of interleukin (IL)-1β, IL-18, and tumor necrosis factor-α (TNF-α) in the CSF of aSAH patients were measured by enzyme-linked immunosorbent assay. RESULTS Eighty-one aSAH patients were enrolled. The levels of IL-1β, IL-18 and TNF-α in the CSF were especially higher in the group of aSAH patients with cerebral edema, cerebral vasospasm, and a high grade on Hunt-Hess scale, the high World Federation of Neurological Surgeons grades, and Fisher grade (P < 0.01). Higher levels of plasma C-reactive protein in the blood were correlated with poor outcome. The areas under the receiver operating characteristic curves for the levels of inflammatory cytokines in CSF were 0.85, 0.84, and 0.95, respectively. Clinical features (age, Hunt-Hess grade, etc.) were positively correlated with poor outcomes (P < 0.05). CONCLUSIONS The levels of IL-1β, IL-18, and TNF-α in CSF were elevated in aSAH patients and were positively associated with cerebral edema and acute hydrocephalus. Our findings suggest that CSF inflammatory cytokines might be biomarkers to assess severity and predict outcomes.
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Affiliation(s)
- Sheng-Yin Lv
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Southern Medical University (Guangzhou), Nanjing, Jiangsu Province, China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jing-Peng Liu
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Southern Medical University (Guangzhou), Nanjing, Jiangsu Province, China
| | - Jiang Shao
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Southern Medical University (Guangzhou), Nanjing, Jiangsu Province, China
| | - Li-Li Wen
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jin Xue
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiang-Sheng Zhang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu Province, China
| | - Qing-Rong Zhang
- Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Southern Medical University (Guangzhou), Nanjing, Jiangsu Province, China; Department of Neurosurgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
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Nagahama Y, Allan L, Nakagawa D, Zanaty M, Starke RM, Chalouhi N, Jabbour P, Brown RD, Derdeyn CP, Leira EC, Broderick J, Chimowitz M, Torner JC, Hasan D. Dual antiplatelet therapy in aneurysmal subarachnoid hemorrhage: association with reduced risk of clinical vasospasm and delayed cerebral ischemia. J Neurosurg 2017; 129:702-710. [PMID: 29099296 DOI: 10.3171/2017.5.jns17831] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clinical vasospasm and delayed cerebral ischemia (DCI) are devastating complications of aneurysmal subarachnoid hemorrhage (aSAH). Several theories involving platelet activation have been postulated as potential explanations of the development of clinical vasospasm and DCI. However, the effects of dual antiplatelet therapy (DAPT; aspirin and clopidogrel) on clinical vasospasm and DCI have not been previously investigated. The objective of this study was to evaluate the effects of DAPT on clinical vasospasm and DCI in aSAH patients. METHODS Analysis of patients treated for aSAH during the period from July 2009 to April 2014 was performed in a single-institution retrospective study. Patients were divided into 2 groups: patients who underwent stent-assisted coiling or placement of flow diverters requiring DAPT (DAPT group) and patients who underwent coiling only without DAPT (control group). The frequency of symptomatic clinical vasospasm and DCI and of hemorrhagic complications was compared between the 2 groups, utilizing univariate and multivariate logistic regression. RESULTS Of 312 aSAH patients considered for this study, 161 met the criteria for inclusion and were included in the analysis (85 patients in the DAPT group and 76 patients in the control group). The risks of clinical vasospasm (OR 0.244, CI 95% 0.097-0.615, p = 0.003) and DCI (OR 0.056, CI 95% 0.01-0.318, p = 0.001) were significantly lower in patients receiving DAPT. The rates of hemorrhagic complications associated with placement of external ventricular drains and ventriculoperitoneal shunts were similar in both groups (4% vs 2%, p = 0.9). CONCLUSIONS The use of DAPT was associated with a lower risk of clinical vasospasm and DCI in patients treated for aSAH, without an increased risk of hemorrhagic complications.
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Affiliation(s)
| | - Lauren Allan
- 2Department of General Surgery, Mercy Medical Center, Des Moines, Iowa
| | | | | | | | - Nohra Chalouhi
- 5Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 5Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert D Brown
- 6Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | | | - Enrique C Leira
- 8Department of Neurology, University of Iowa College of Medicine.,9Department of Epidemiology, University of Iowa, Iowa City
| | - Joseph Broderick
- 10Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio; and
| | - Marc Chimowitz
- 11Department of Neurology, Medical University of South Carolina, Charleston, South Carolina
| | - James C Torner
- 9Department of Epidemiology, University of Iowa, Iowa City
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McBride DW, Blackburn SL, Peeyush KT, Matsumura K, Zhang JH. The Role of Thromboinflammation in Delayed Cerebral Ischemia after Subarachnoid Hemorrhage. Front Neurol 2017; 8:555. [PMID: 29109695 PMCID: PMC5660311 DOI: 10.3389/fneur.2017.00555] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 10/02/2017] [Indexed: 01/13/2023] Open
Abstract
Delayed cerebral ischemia (DCI) is a major determinant of patient outcome following aneurysmal subarachnoid hemorrhage. Although the exact mechanisms leading to DCI are not fully known, inflammation, cerebral vasospasm, and microthrombi may all function together to mediate the onset of DCI. Indeed, inflammation is tightly linked with activation of coagulation and microthrombi formation. Thromboinflammation is the intersection at which inflammation and thrombosis regulate one another in a feedforward manner, potentiating the formation of thrombi and pro-inflammatory signaling. In this review, we will explore the role(s) of inflammation and microthrombi in subarachnoid hemorrhage (SAH) pathophysiology and DCI, and discuss the potential of targeting thromboinflammation to prevent DCI after SAH.
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Affiliation(s)
- Devin W McBride
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Spiros L Blackburn
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Kumar T Peeyush
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Kanako Matsumura
- The Vivian L. Smith Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda School of Medicine, Loma Linda University, Loma Linda, CA, United States.,Department of Neurosurgery, Loma Linda School of Medicine, Loma Linda University, Loma Linda, CA, United States
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46
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Xu H, Li J, Wang Z, Feng M, Shen Y, Cao S, Li T, Peng Y, Fan L, Chen J, Gu C, Yan F, Wang L, Chen G. Methylene blue attenuates neuroinflammation after subarachnoid hemorrhage in rats through the Akt/GSK-3β/MEF2D signaling pathway. Brain Behav Immun 2017; 65:125-139. [PMID: 28457811 DOI: 10.1016/j.bbi.2017.04.020] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/14/2017] [Accepted: 04/25/2017] [Indexed: 12/12/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a serious medical problem with few effective pharmacotherapies available, and neuroinflammation has been identified as an important pathological process in early brain injury (EBI) after SAH. Methylene blue (MB) is an older drug that has been recently proven to exert extraordinary neuroprotective effects in several brain insults. However, no study has reported the beneficial effects of MB in SAH. In the current investigation, we studied the neuroprotective effects of MB in EBI after SAH and focused on its anti-inflammatory role. A total of 303 rats were subjected to an endovascular perforation process to produce an SAH model. We found that MB could significantly ameliorate brain edema secondary to BBB disruption and alleviate neurological dysfunction after SAH. MB administration also promoted the phosphorylation of Akt and GSK-3β, leading to an increased concentration of MEF2D in the nucleus. The cytokine IL-10 was up-regulated, and IL-1β, IL-6 and TNF-α were down-regulated after MB administration. MB administration could also alleviate neutrophil infiltration and microglia activation after SAH. MK2206, a selective inhibitor of Akt, abolished the neuroprotective effects of MB, inhibited the phosphorylation of Akt and prevented the nuclear localization of MEF2D. MK2206 also reduced the expression of IL-10 and increased the expression of pro-inflammatory cytokines. In conclusion, these data suggested that MB could ameliorate neuroinflammatory responses after SAH, and its anti-inflammatory effects might be exerted via activation of the Akt/GSK-3β/MEF2D pathway.
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Affiliation(s)
- Hangzhe Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Jianru Li
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Zhijiang Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Majing Feng
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China; Department of Neurosurgery, Changxing People's Hospital, Taihuzhong Road 66th, Changxin, Huzhou 313100, China
| | - Yongfeng Shen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China; Department of Neurosurgery, Hangzhou First People's Hospital, Huansha Road 261st, Hangzhou 310006, China
| | - Shenglong Cao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Tao Li
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Yucong Peng
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Linfeng Fan
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Jingyin Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Chi Gu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Feng Yan
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Lin Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China
| | - Gao Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road 88th, Hangzhou 310016, China.
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Zeiler FA, Thelin EP, Czosnyka M, Hutchinson PJ, Menon DK, Helmy A. Cerebrospinal Fluid and Microdialysis Cytokines in Aneurysmal Subarachnoid Hemorrhage: A Scoping Systematic Review. Front Neurol 2017; 8:379. [PMID: 28848487 PMCID: PMC5550693 DOI: 10.3389/fneur.2017.00379] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/18/2017] [Indexed: 01/03/2023] Open
Abstract
Objective To perform two scoping systematic reviews of the literature on cytokine measurement in cerebral microdialysis (CMD) and cerebrospinal fluid (CSF) in aneurysmal subarachnoid hemorrhage (SAH) patients, aiming to summarize the evidence relating cytokine levels to pathophysiology, disease progression, and outcome. Methods Two separate systematic reviews were conducted: one for CMD cytokines and the second for CSF cytokines. Data sources Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library (inception to October 2016), reference lists of relevant articles, and gray literature were searched. Study selection Two reviewers independently identified all manuscripts utilizing predefined inclusion/exclusion criteria. A two-tier filter of references was conducted. Data extraction Patient demographic and study data were extracted to tables. Results There were 9 studies identified describing the analysis of cytokines via CMD in 246 aneurysmal SAH patients. Similarly, 20 studies were identified describing the analysis of CSF cytokines in 630 patients. The two scoping systematic reviews demonstrated the following: (1) limited literature available on CMD cytokine measurement in aneurysmal SAH with some preliminary data supporting feasibility of measurement and potential association between interleukin (IL)-6 and patient outcome. (2) Various CSF measured cytokines may be associated with patient outcome at 3–6 months, including IL-1ra, IL-6, IL-8, and tumor necrosis factor-alpha. (3) There is a small literature body supporting an association between acute/subacute CSF transforming growth factor levels and the development of chronic hydrocephalus at 2–3 months. Conclusion The evaluation of CMD and CSF cytokines is an emerging area of the literature in aneurysmal SAH. Further large prospective multicenter studies on cytokines in CMD and CSF need to be conducted.
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Affiliation(s)
- Frederick A Zeiler
- Rady Faculty of Health Sciences, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.,Clinician Investigator Program, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Eric Peter Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom.,Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - David K Menon
- Department of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Chamling B, Gross S, Stoffel-Wagner B, Schubert GA, Clusmann H, Coburn M, Höllig A. Early Diagnosis of Delayed Cerebral Ischemia: Possible Relevance for Inflammatory Biomarkers in Routine Clinical Practice? World Neurosurg 2017; 104:152-157. [PMID: 28512045 DOI: 10.1016/j.wneu.2017.05.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is one of the main causes of neurologic deterioration. However, it frequently evades timely detection. Early identification and effective reversal may improve the clinical outcome. In this prospective study, we evaluate several serum inflammatory markers after aneurysmal SAH with regard to the occurrence of DCI. METHODS On days 1, 4, 7, 10, and 14 after SAH, leucocyte count, C-reactive protein, interleukin 6, E-selectin, matrix metallopeptidase 9, intercellular adhesion molecule 1, and leukemia inhibitory factor were assessed in patients' serum samples. Using a Cox regression model (SPSS 21.0), associations of baseline parameters, maximum and delta (maximum minus baseline) values with occurrence of DCI were evaluated. RESULTS Considering the assessed parameters, leucocyte count (high baseline and delta values) matches most closely with occurrence of DCI. Although baseline levels of C-reactive protein are also associated with occurrence of DCI, neither maximum (only on a borderline level) nor delta levels do so. CONCLUSIONS Our data analysis identified leucocyte count as the parameter most likely associated with occurrence of DCI. However, because of its lack of specificity leucocyte count, it cannot be used as a biomarker. As hypothesized earlier, the results indicate a possible involvement of the inflammatory reaction after aneurysmal SAH in the pathomechanism of DCI.
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Affiliation(s)
- Bishwas Chamling
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany and DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
| | - Stefan Gross
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany and DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Greifswald, Germany
| | - Birgit Stoffel-Wagner
- Department of Clinical Chemistry and Clinical Pharmacology, University Hospital of Bonn, Bonn, Germany
| | | | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Mark Coburn
- Department of Anesthesiology, RWTH Aachen University, Aachen, Germany
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
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Effects of Tenascin-C Knockout on Cerebral Vasospasm After Experimental Subarachnoid Hemorrhage in Mice. Mol Neurobiol 2017; 55:1951-1958. [DOI: 10.1007/s12035-017-0466-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 02/20/2017] [Indexed: 12/20/2022]
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50
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Abstract
Subarachnoid hemorrhage (SAH) affects 30,000 people in the Unites States alone each year. Delayed cerebral ischemia occurs days after subarachnoid hemorrhage and represents a potentially treatable cause of morbidity for approximately one-third of those who survive the initial hemorrhage. While vasospasm has been traditionally linked to the development of cerebral ischemia several days after subarachnoid hemorrhage, emerging evidence reveals that delayed cerebral ischemia is part of a much more complicated post-subarachnoid hemorrhage syndrome. The development of delayed cerebral ischemia involves early arteriolar vasospasm with microthrombosis, perfusion mismatch and neurovascular uncoupling, spreading depolarizations, and inflammatory responses that begin at the time of the hemorrhage and evolve over time, culminating in cortical infarction. Large-vessel vasospasm is likely a late contributor to ongoing injury, and effective treatment for delayed cerebral ischemia will require improved detection of critical early pathophysiologic changes as well as therapeutic options that target multiple related pathways.
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