1
|
Serra R, Wilhelmy B, Chen C, Oliver JD, Stokum JA, Bodanapally UK, Simard JM, Schwartzbauer G, Aarabi B. Acute Development of Traumatic Intracranial Aneurysms After Civilian Gunshot Wounds to the Head. J Neurotrauma 2024. [PMID: 38308472 DOI: 10.1089/neu.2023.0576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024] Open
Abstract
In previous studies, the incidence of traumatic intracranial aneurysms (TICAs) after civilian gunshot wound to the head (cGSWH) was ∼3%. Given the use of delayed vessel imaging, we hypothesize that a significant fraction of TICAs is missed on initial non-contrasted scans. This study was designed to characterize acute TICAs using admission computed tomographic angiography (aCTA) in cGSWH. Over the period from 2017 to 2022, 341 patients were admitted to R. Adams Cowley Shock Trauma Center with cGSWH; 136 subjects had aCTA ∼3 (standard deviation [SD] 3.5) h post-injury. Demographics, clinical findings, imaging techniques, endovascular/surgical interventions, and outcomes were analyzed. Mean age was 34.7 (SD 13.1), male:female ratio was 120:16. Average admission Glasgow Coma Scale (GCS) score was 6 (SD 3.9). Entry site was frontal in 41, temporal in 55, parietal in 18, occipital in 6, suboccipital in 9, temporo-parietal in 1, and frontobasal-temporal in 6. Projectiles crossed multiple dural compartments in 76 (55%) patients. 35 TICAs were diagnosed in 28 subject: 24 were located along the middle cerebral artery (MCA), 6 in the anterior cerebral artery (ACA), 3 in the internal carotid artery (ICA), 1 in the posterior cerebral artery (PCA), and 1 in the middle meningeal artery (MMA). Eleven TICAs resolved spontaneously in nine patients. Eight aneurysms were treated by endovascular means, two via combined endovascular/open approaches. Forty-nine patients died, 10 of whom had 15 TICAs. Eighty patients developed intracerebral hematoma s (ICHs). Regression models showed that the presence of an ICH was the main predictor of TICA in cGSWH. Larger ICHs (average 22.3 cc vs. 9.4 cc in patients with and without aneurysms, respectively) in patients with cGSWH suggest hidden TICAs. Nearly 30% of patients had spontaneous resolution within 1 week. When CTA was performed acutely, TICAs were 10 times more frequent in cGSWH than in previous literature, and those patients were more likely to proceed to surgery. Almost one third of patients in this series died from the devastating effects of cGSWH.
Collapse
Affiliation(s)
- Riccardo Serra
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Bradley Wilhelmy
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Chixiang Chen
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, Division of Biostatistics and Bioinformatics, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey D Oliver
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Uttam K Bodanapally
- Department of Diagnostic Radiology and Nuclear Medicine, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
- Department of Physiology, University of Maryland, Baltimore, Maryland, USA
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
- Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
- Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
2
|
Rivera GS, Stokum JA, Dean J, Sadowsky CL, Belzberg AJ, Elrick MJ. Nerve Transfer Surgery in Acute Flaccid Myelitis: Prognostic Factors, Long-Term Outcomes, Comparison With Natural History. Pediatr Neurol 2024; 150:74-81. [PMID: 37981447 PMCID: PMC10894453 DOI: 10.1016/j.pediatrneurol.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/13/2023] [Accepted: 10/26/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Nerve transfer surgery is sometimes offered to patients with acute flaccid myelitis (AFM). The objectives of this study were to evaluate surgical efficacy, assess which clinical and neurophysiological data are valuable for preoperative planning, and report long-term outcomes. METHODS This is a single-center, retrospective case series of patients with AFM who received nerve transfer surgery. All patients had preoperative electromyography and nerve conduction studies (EMG/NCS). Matched control muscles that did not receive nerve transfer surgery were defined in the same cohort. RESULTS Ten patients meeting inclusion criteria received a total of 23 nerve transfers (19 upper extremity, four lower extremity). The mean age at symptom onset was 3.8 years, surgery was 0.5 to 1.25 years after diagnosis, and mean follow-up was 2.3 years (range 1.3 to 4.5 years). Among muscles with preoperative strength Medical Research Council (MRC) grade 0, muscles receiving nerve transfers performed significantly better than those that did not (MRC grade 2.17 ± 0.42 vs 0 ± 0, respectively, P = 0.0001). Preoperative EMG/NCS predicted worse outcomes in recipient muscles with more abundant acute denervation potentials (P = 0.0098). Donor nerves found to be partially denervated performed equally well as unaffected nerves. Limited data suggested functional improvement accompanying strength recovery. CONCLUSIONS Nerve transfer surgery is an effective strategy to restore strength for patients with AFM with persistent, severe motor deficits. Postoperative outcomes in patients with complete paralysis are better than the natural history of disease. This study demonstrates the utility of preoperative clinical and electrophysiological data in guiding patient selection for nerve transfer surgery.
Collapse
Affiliation(s)
- Glenn S Rivera
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Janet Dean
- Department of Physical Medicine and Rehabilitation, Kennedy Krieger Institute, Baltimore, Maryland
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, Kennedy Krieger Institute, Baltimore, Maryland
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland.
| |
Collapse
|
3
|
Cardona S, Baqai H, Mikdashi F, Aligabi A, Solomon J, Frederick H, Seyoum N, Olexa J, Stokum JA, Sharma A, Pergakis MB, Tran QK. Intracranial and Blood Pressure Variability and In-Hospital Outcomes in Intracranial Device-Monitored Patients with Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2023; 39:357-367. [PMID: 36759420 DOI: 10.1007/s12028-023-01677-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/09/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (sICH) is a major health concern and has high mortality rates up to 52%. Despite a decrease in its incidence, fatality rates remain unchanged; understanding and preventing of factors associated with mortality and treatments for these are needed. Blood pressure variability (BPV) has been shown to be a potential modifiable factor associated with clinical outcomes in patients with traumatic intracerebral hemorrhage and sICH. Few data are available on the effect of intracranial pressure (ICP) variability (ICPV) and outcomes in patients with sICH. The goal of our study was to investigate the association between ICPV and BPV during the first 24 h of intensive care unit (ICU) admission and external ventricular drain (EVD) placement, and mortality in patients with sICH who were monitored with an EVD. METHODS We conducted a single-center retrospective study of adult patients admitted to an ICU with a diagnosis of sICH who required EVD placement during hospitalization. We excluded patients with ICH secondary to other pathological conditions such as trauma, underlying malignancy, or arteriovenous malformation. Blood pressure and ICP measurements were collected and recorded hourly during the first 24 h of ICU admission and EVD placement, respectively. Measures of variability used were standard deviation (SD) and successive variation (SV). Primary outcome of interest was in-hospital mortality, and secondary outcomes were hematoma expansion and discharge home (a surrogate for good functional outcome at discharge). Descriptive statistics and multivariable logistic regressions were performed. RESULTS We identified 179 patients with sICH who required EVD placement. Of these, 52 (29%) patients died, 121 (68%) patients had hematoma expansion, and 12 (7%) patients were discharged home. Patient's mean age (± SD) was 56 (± 14), and 87 (49%) were women. The mean opening ICP (± SD) was 21 (± 8) and median ICH score (interquartile range) was 2 (2-3). Multivariable logistic regression found an association between ICP-SV and ICP-SD and hematoma expansion (odds ratio 1.6 [1.03-2.30], p = 0.035 and odds ratio 0.77 [0.63-0.93] p = 0.009, respectively). CONCLUSIONS Our study found an association between ICPV and hematoma expansion in patients with sICH monitored with an EVD. Measures of ICPV relating to rapid changes in ICP (ICP-SV) were associated with a higher odds of hematoma expansion, whereas measures relating to tight control of ICP (ICP-SD) were associated with a lower odds of hematoma expansion. One measure of BPV, sytolic blood pressure maximum-minimum (SBP max-min), was found to be weakly associated with discharge home (a surrogate for good functional outcome at hospital discharge). More research is needed to support these findings.
Collapse
Affiliation(s)
- Stephanie Cardona
- Department of Critical Care Medicine, The Mount Sinai Hospital, 1468 Madison Ave, New York, NY, 10029, USA.
| | - Hammad Baqai
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Fatima Mikdashi
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ayah Aligabi
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Julianna Solomon
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hannah Frederick
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nahom Seyoum
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ashish Sharma
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melissa B Pergakis
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Quincy K Tran
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
4
|
Shim B, Stokum JA, Moyer M, Tsymbalyuk N, Tsymbalyuk O, Keledjian K, Ivanova S, Tosun C, Gerzanich V, Simard JM. Canagliflozin, an Inhibitor of the Na +-Coupled D-Glucose Cotransporter, SGLT2, Inhibits Astrocyte Swelling and Brain Swelling in Cerebral Ischemia. Cells 2023; 12:2221. [PMID: 37759444 PMCID: PMC10527352 DOI: 10.3390/cells12182221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Brain swelling is a major cause of death and disability in ischemic stroke. Drugs of the gliflozin class, which target the Na+-coupled D-glucose cotransporter, SGLT2, are approved for type 2 diabetes mellitus (T2DM) and may be beneficial in other conditions, but data in cerebral ischemia are limited. We studied murine models of cerebral ischemia with middle cerebral artery occlusion/reperfusion (MCAo/R). Slc5a2/SGLT2 mRNA and protein were upregulated de novo in astrocytes. Live cell imaging of brain slices from mice following MCAo/R showed that astrocytes responded to modest increases in D-glucose by increasing intracellular Na+ and cell volume (cytotoxic edema), both of which were inhibited by the SGLT2 inhibitor, canagliflozin. The effect of canagliflozin was studied in three mouse models of stroke: non-diabetic and T2DM mice with a moderate ischemic insult (MCAo/R, 1/24 h) and non-diabetic mice with a severe ischemic insult (MCAo/R, 2/24 h). Canagliflozin reduced infarct volumes in models with moderate but not severe ischemic insults. However, canagliflozin significantly reduced hemispheric swelling and improved neurological function in all models tested. The ability of canagliflozin to reduce brain swelling regardless of an effect on infarct size has important translational implications, especially in large ischemic strokes.
Collapse
Affiliation(s)
- Bosung Shim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Jesse A. Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Mitchell Moyer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Natalya Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Orest Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Kaspar Keledjian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Svetlana Ivanova
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Cigdem Tosun
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (B.S.); (J.A.S.); (M.M.); (N.T.); (O.T.); (K.K.); (S.I.); (C.T.); (V.G.)
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| |
Collapse
|
5
|
Stokum JA, Shim B, Negoita S, Tsymbalyuk N, Tsymbalyuk O, Ivanova S, Keledjian K, Bryan J, Blaustein MP, Jha RM, Kahle KT, Gerzanich V, Simard JM. Cation flux through SUR1-TRPM4 and NCX1 in astrocyte endfeet induces water influx through AQP4 and brain swelling after ischemic stroke. Sci Signal 2023; 16:eadd6364. [PMID: 37279286 PMCID: PMC10369355 DOI: 10.1126/scisignal.add6364] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 05/10/2023] [Indexed: 06/08/2023]
Abstract
Brain swelling causes morbidity and mortality in various brain injuries and diseases but lacks effective treatments. Brain swelling is linked to the influx of water into perivascular astrocytes through channels called aquaporins. Water accumulation in astrocytes increases their volume, which contributes to brain swelling. Using a mouse model of severe ischemic stroke, we identified a potentially targetable mechanism that promoted the cell surface localization of aquaporin 4 (AQP4) in perivascular astrocytic endfeet, which completely ensheathe the brain's capillaries. Cerebral ischemia increased the abundance of the heteromeric cation channel SUR1-TRPM4 and of the Na+/Ca2+ exchanger NCX1 in the endfeet of perivascular astrocytes. The influx of Na+ through SUR1-TRPM4 induced Ca2+ transport into cells through NCX1 operating in reverse mode, thus raising the intra-endfoot concentration of Ca2+. This increase in Ca2+ stimulated calmodulin-dependent translocation of AQP4 to the plasma membrane and water influx, which led to cellular edema and brain swelling. Pharmacological inhibition or astrocyte-specific deletion of SUR1-TRPM4 or NCX1 reduced brain swelling and improved neurological function in mice to a similar extent as an AQP4 inhibitor and was independent of infarct size. Thus, channels in astrocyte endfeet could be targeted to reduce postischemic brain swelling in stroke patients.
Collapse
Affiliation(s)
- Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Bosung Shim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Serban Negoita
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Natalya Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Orest Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Svetlana Ivanova
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Kaspar Keledjian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Joseph Bryan
- Pacific Northwest Diabetes Research Institute, Seattle, WA 98122, USA
| | - Mordecai P Blaustein
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Ruchira M Jha
- Department of Neurology, Barrow Neurological Institute and St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| |
Collapse
|
6
|
Chryssikos T, Stokum JA, Ahmed AK, Chen C, Wessell A, Cannarsa G, Caffes N, Oliver J, Olexa J, Shea P, Labib M, Woodworth G, Ksendzovsky A, Bodanapally U, Crandall K, Sansur C, Schwartzbauer G, Aarabi B. Surgical Decompression of Traumatic Cervical Spinal Cord Injury: A Pilot Study Comparing Real-Time Intraoperative Ultrasound After Laminectomy With Postoperative MRI and CT Myelography. Neurosurgery 2023; 92:353-362. [PMID: 36637270 PMCID: PMC9815093 DOI: 10.1227/neu.0000000000002207] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/30/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Decompression of the injured spinal cord confers neuroprotection. Compared with timing of surgery, verification of surgical decompression is understudied. OBJECTIVE To compare the judgment of cervical spinal cord decompression using real-time intraoperative ultrasound (IOUS) following laminectomy with postoperative MRI and CT myelography. METHODS Fifty-one patients were retrospectively reviewed. Completeness of decompression was evaluated by real-time IOUS and compared with postoperative MRI (47 cases) and CT myelography (4 cases). RESULTS Five cases (9.8%) underwent additional laminectomy after initial IOUS evaluation to yield a final judgment of adequate decompression using IOUS in all 51 cases (100%). Postoperative MRI/CT myelography showed adequate decompression in 43 cases (84.31%). Six cases had insufficient bony decompression, of which 3 (50%) had cerebrospinal fluid effacement at >1 level. Two cases had severe circumferential intradural swelling despite adequate bony decompression. Between groups with and without adequate decompression on postoperative MRI/CT myelography, there were significant differences for American Spinal Injury Association motor score, American Spinal Injury Association Impairment Scale grade, AO Spine injury morphology, and intramedullary lesion length (IMLL). Multivariate analysis using stepwise variable selection and logistic regression showed that preoperative IMLL was the most significant predictor of inadequate decompression on postoperative imaging (P = .024). CONCLUSION Patients with severe clinical injury and large IMLL were more likely to have inadequate decompression on postoperative MRI/CT myelography. IOUS can serve as a supplement to postoperative MRI/CT myelography for the assessment of spinal cord decompression. However, further investigation, additional surgeon experience, and anticipation of prolonged swelling after surgery are required.
Collapse
Affiliation(s)
- Timothy Chryssikos
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jesse A. Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Abdul-Kareem Ahmed
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Chixiang Chen
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aaron Wessell
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Gregory Cannarsa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Caffes
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey Oliver
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joshua Olexa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Phelan Shea
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mohamed Labib
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Graeme Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Alexander Ksendzovsky
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Uttam Bodanapally
- Department of Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kenneth Crandall
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Charles Sansur
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
7
|
Aarabi B, Chixiang C, Simard JM, Chryssikos T, Stokum JA, Sansur CA, Crandall KM, Olexa J, Oliver J, Meister MR, Cannarsa G, Sharma A, Lomangino C, Scarboro M, Ahmed AK, Han N, Serra R, Shea P, Aresco C, Schwartzbauer GT. Proposal of a Management Algorithm to Predict the Need for Expansion Duraplasty in American Spinal Injury Association Impairment Scale Grades A-C Traumatic Cervical Spinal Cord Injury Patients. J Neurotrauma 2022; 39:1716-1726. [PMID: 35876459 PMCID: PMC9734016 DOI: 10.1089/neu.2022.0218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Expansion duraplasty to reopen effaced subarachnoid space and improve spinal cord perfusion, autoregulation, and spinal pressure reactivity index (sPRX) has been advocated in patients with traumatic cervical spinal cord injury (tCSCI). We designed this study to identify candidates for expansion duraplasty, based on the absence of cerebrospinal fluid (CSF) interface around the spinal cord on magnetic resonance imaging (MRI), in the setting of otherwise adequate bony decompression. Over a 61-month period, 104 consecutive American Spinal Injury Association Impairment Scale (AIS) grades A-C patients with tCSCI had post-operative MRI to assess the adequacy of surgical decompression. Their mean age was 53.4 years, and 89% were male. Sixty-one patients had falls, 31 motor vehicle collisions, 11 sport injuries, and one an assault. The AIS grade was A in 56, B in 18, and C in 30 patients. Fifty-four patients had fracture dislocations; there was no evidence of skeletal injury in 50 patients. Mean intramedullary lesion length (IMLL) was 46.9 (standard deviation = 19.4) mm. Median time from injury to decompression was 17 h (interquartile range 15.2 h). After surgery, 94 patients had adequate decompression as judged by the presence of CSF anterior and posterior to the spinal cord, whereas 10 patients had effacement of the subarachnoid space at the injury epicenter. In two patients whose decompression was not definitive and post-operative MRI indicated inadequate decompression, expansion duraplasty was performed. Candidates for expansion duraplasty (i.e., those with inadequate decompression) were significantly younger (p < 0.0001), were AIS grade A (p < 0.0016), had either sport injuries (six patients) or motor vehicle collisions (three patients) (p < 0.0001), had fracture dislocation (p = 0.00016), and had longer IMLL (p = 0.0097). In regression models, patients with sport injuries and inadequate decompression were suitable candidates for expansion duraplasty (p = 0.03). Further, 9.6% of patients failed bony decompression alone and either did (2) or would have (8) benefited from expansion duraplasty.
Collapse
Affiliation(s)
- Bizhan Aarabi
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA.,R. Adams Cowley Shock Trauma Center, and Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Address correspondence to: Bizhan Aarabi, MD, Department of Neurosurgery, University of Maryland School of Medicine, 22 South Greene Street, Suite S-12-D, Baltimore, MD 21201, USA
| | - Chen Chixiang
- Department of Epidemiology and Public Health, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - J. Marc Simard
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Timothy Chryssikos
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jesse A. Stokum
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Charles A. Sansur
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kenneth M. Crandall
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joshua Olexa
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey Oliver
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Melissa R. Meister
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Gregory Cannarsa
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ashish Sharma
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Cara Lomangino
- R. Adams Cowley Shock Trauma Center, and Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Maureen Scarboro
- R. Adams Cowley Shock Trauma Center, and Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Abdul-Kareem Ahmed
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nathan Han
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Riccardo Serra
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Phelan Shea
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Carla Aresco
- R. Adams Cowley Shock Trauma Center, and Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gary T. Schwartzbauer
- Department of Neurosurgery, Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA.,R. Adams Cowley Shock Trauma Center, and Division of Biostatistics and Bioinformatics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
8
|
Kim KT, Wessell AP, Oliver J, Boulter JH, Stokum JA, Lomangino C, Scarboro M, Aarabi B, Chryssikos T, Schwartzbauer G. Comparative Therapeutic Effectiveness of Anticoagulation and Conservative Management in Traumatic Cerebral Venous Sinus Thrombosis. Neurosurgery 2022; 90:708-716. [PMID: 35315808 DOI: 10.1227/neu.0000000000001892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Consensus is currently lacking in the optimal treatment for blunt traumatic cerebral venous sinus thrombosis (tCVST). Anticoagulation (AC) is used for treating spontaneous CVST, but its role in tCVST remains unclear. OBJECTIVE To investigate the characteristics and outcomes of patients treated with AC compared with patients managed conservatively. METHODS We retrospectively reviewed patients who presented to a Level 1 trauma center with acute skull fracture after blunt head trauma who underwent dedicated venous imaging. RESULTS There were 137 of 424 patients (32.3%) presenting with skull fractures with tCVST on venous imaging. Among them, 82 (60%) were treated with AC while 55 (40%) were managed conservatively. Analysis of baseline characteristics demonstrated no significant difference in age, sex, admission Glasgow Coma Scale, admission Injury Severity Score, rates of associated intracranial hemorrhage, or neurosurgical interventions. New or worsening intracranial hemorrhage was seen in 7 patients treated with AC. Patients on AC had significantly lower mortality than non-AC (1% vs 15%; P = .003). There was no difference in the Glasgow Coma Scale or Glasgow Outcome Scale at last clinical follow-up. On follow-up venous imaging, patients treated with AC were more likely to experience full thrombus recanalization than non-AC (54% vs 32%; P = .012), and subsequent multiple regression analysis revealed that treatment with AC was a significant predictor of full thrombus recanalization (odds ratio, 5.18; CI, 1.60-16.81; P = .006). CONCLUSION Treatment with AC for tCVST due to blunt head trauma may promote higher rates of complete thrombus recanalization when compared with conservative management.
Collapse
Affiliation(s)
- Kevin T Kim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aaron P Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey Oliver
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jason H Boulter
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Cara Lomangino
- Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Maureen Scarboro
- Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Timothy Chryssikos
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| |
Collapse
|
9
|
Stokum JA, Chryssikos T, Shea P, Olexa J, Schwartzbauer GT, Aarabi B. Letter: Ultrasound in Traumatic Spinal Cord Injury: A Wide-Open Field. Neurosurgery 2022; 90:e110-e111. [PMID: 35175245 DOI: 10.1227/neu.0000000000001866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | | | | | | |
Collapse
|
10
|
Cannarsa GJ, Wessell AP, Chryssikos T, Stokum JA, Kim K, De Paula Carvalho H, Miller TR, Morris N, Badjatia N, Chaturvedi S, Gandhi D, Simard JM, Jindal G. Initial Stress Hyperglycemia Is Associated With Malignant Cerebral Edema, Hemorrhage, and Poor Functional Outcome After Mechanical Thrombectomy. Neurosurgery 2022; 90:66-71. [PMID: 34982872 DOI: 10.1227/neu.0000000000001735] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 08/10/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Malignant cerebral edema (MCE) and intracranial hemorrhage (ICH) are associated with poor neurological outcomes despite revascularization after mechanical thrombectomy (MT). The factors associated with the development of MCE and ICH after MT are not well understood. OBJECTIVE To determine periprocedural factors associated with MCE, ICH, and poor functional outcome. METHODS We retrospectively analyzed anterior cerebral circulation large vessel occlusion cases that underwent MT from 2012 to 2019 at a single Comprehensive Stroke Center. Multivariate logistic regression analyses were performed to determine significant predictors of MCE, ICH, and poor functional outcome (modified Rankin Scale, 3-6) at 90 d. RESULTS Four hundred patients were included. Significant independent predictors of MCE after MT included initial stress glucose ratio (iSGR) (odds ratio [OR], 14.26; 95% CI, 3.82-53.26; P < .001), National Institutes of Health Stroke Scale (NIHSS) (OR, 1.10; 95% CI, 1.03-1.18; P = .008), internal carotid artery compared with M1 or M2 occlusion, and absence of successful revascularization (OR, 0.16; 95% CI, 0.06-0.44; P < .001). Significant independent predictors of poor functional outcome included MCE (OR, 7.47; 95% CI, 2.20-25.37; P = .001), iSGR (OR, 5.15; 95% CI, 1.82-14.53; P = .002), ICH (OR, 4.77; 95% CI, 1.20-18.69; P = .024), NIHSS (OR, 1.10; 95% CI, 1.05-1.16; P < .001), age (OR, 1.04; 95% CI, 1.03-1.07; P < .001), and thrombolysis in cerebral infarction 2C/3 recanalization (OR, 0.12; 95% CI, 0.05-0.29; P < .001). CONCLUSION Elevated iSGR significantly increases the risk of MCE and ICH and is an independent predictor of poor functional outcome. Thrombolysis in cerebral infarction 2C/3 revascularization is associated with reduced risk of MCE, ICH, and poor functional outcome. Whether stress hyperglycemia represents a modifiable risk factor is uncertain, and further investigation is warranted.
Collapse
Affiliation(s)
- Gregory J Cannarsa
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Aaron P Wessell
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Timothy Chryssikos
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Kevin Kim
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Helio De Paula Carvalho
- Division of Interventional Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Timothy R Miller
- Division of Interventional Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Nicholas Morris
- Program in Trauma, Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Neeraj Badjatia
- Program in Trauma, Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Seemant Chaturvedi
- Program in Trauma, Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Dheeraj Gandhi
- Division of Interventional Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Gaurav Jindal
- Division of Interventional Neuroradiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| |
Collapse
|
11
|
Stokum JA, Shim B, Huang W, Kane M, Smith JA, Gerzanich V, Simard JM. A large portion of the astrocyte proteome is dedicated to perivascular endfeet, including critical components of the electron transport chain. J Cereb Blood Flow Metab 2021; 41:2546-2560. [PMID: 33818185 PMCID: PMC8504955 DOI: 10.1177/0271678x211004182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The perivascular astrocyte endfoot is a specialized and diffusion-limited subcellular compartment that fully ensheathes the cerebral vasculature. Despite their ubiquitous presence, a detailed understanding of endfoot physiology remains elusive, in part due to a limited understanding of the proteins that distinguish the endfoot from the greater astrocyte body. Here, we developed a technique to isolate astrocyte endfeet from brain tissue, which was used to study the endfoot proteome in comparison to the astrocyte somata. In our approach, brain microvessels, which retain their endfoot processes, were isolated from mouse brain and dissociated, whereupon endfeet were recovered using an antibody-based column astrocyte isolation kit. Our findings expand the known set of proteins enriched at the endfoot from 10 to 516, which comprised more than 1/5th of the entire detected astrocyte proteome. Numerous critical electron transport chain proteins were expressed only at the endfeet, while enzymes involved in glycogen storage were distributed to the somata, indicating subcellular metabolic compartmentalization. The endfoot proteome also included numerous proteins that, while known to have important contributions to blood-brain barrier function, were not previously known to localize to the endfoot. Our findings highlight the importance of the endfoot and suggest new routes of investigation into endfoot function.
Collapse
Affiliation(s)
- Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bosung Shim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Weiliang Huang
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Maureen Kane
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Jesse A Smith
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
12
|
Kole MJ, Wessell AP, Ugiliweneza B, Cannarsa GJ, Fortuny E, Stokum JA, Shea P, Chryssikos T, Khattar NK, Crabill GA, Schreibman DL, Badjatia N, Gandhi D, Aldrich EF, James RF, Simard JM. Low-Dose Intravenous Heparin Infusion After Aneurysmal Subarachnoid Hemorrhage is Associated With Decreased Risk of Delayed Neurological Deficit and Cerebral Infarction. Neurosurgery 2021; 88:523-530. [PMID: 33269390 DOI: 10.1093/neuros/nyaa473] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/03/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Patients who survive aneurysmal subarachnoid hemorrhage (aSAH) are at risk for delayed neurological deficits (DND) and cerebral infarction. In this exploratory cohort comparison analysis, we compared in-hospital outcomes of aSAH patients administered a low-dose intravenous heparin (LDIVH) infusion (12 U/kg/h) vs those administered standard subcutaneous heparin (SQH) prophylaxis for deep vein thrombosis (DVT; 5000 U, 3 × daily). OBJECTIVE To assess the safety and efficacy of LDIVH in aSAH patients. METHODS We retrospectively analyzed 556 consecutive cases of aSAH patients whose aneurysm was secured by clipping or coiling at a single institution over a 10-yr period, including 233 administered the LDIVH protocol and 323 administered the SQH protocol. Radiological and outcome data were compared between the 2 cohorts using multivariable logistic regression and propensity score-based inverse probability of treatment weighting (IPTW). RESULTS The unadjusted rate of cerebral infarction in the LDIVH cohort was half that in SQH cohort (9 vs 18%; P = .004). Multivariable logistic regression showed that patients in the LDIVH cohort were significantly less likely than those in the SQH cohort to have DND (odds ratio (OR) 0.53 [95% CI: 0.33, 0.85]) or cerebral infarction (OR 0.40 [95% CI: 0.23, 0.71]). Analysis following IPTW showed similar results. Rates of hemorrhagic complications, heparin-induced thrombocytopenia and DVT were not different between cohorts. CONCLUSION This cohort comparison analysis suggests that LDIVH infusion may favorably influence the outcome of patients after aSAH. Prospective studies are required to further assess the benefit of LDIVH infusion in patients with aSAH.
Collapse
Affiliation(s)
- Matthew J Kole
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aaron P Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Gregory J Cannarsa
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Enzo Fortuny
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Phelan Shea
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Timothy Chryssikos
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nicolas K Khattar
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - George A Crabill
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David L Schreibman
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - E Francois Aldrich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Robert F James
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky.,Department of Neurological Surgery, University of Indiana, Indianapolis, Indiana
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
13
|
Chryssikos T, Kim K, Wessell A, Stokum JA, Oliver J, Cannarsa G, Gaddam DS, Lomangino CD, Scarboro M, Kole M, Sansur C, Aarabi B, Schwartzbauer G. Radiographic Evaluation, Management, and Long-term Follow-up of Dural Venous Sinus Thrombosis in Surviving Gunshot Wounds to the Head. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
14
|
Stokum JA, Gerzanich V, Sheth KN, Kimberly WT, Simard JM. Emerging Pharmacological Treatments for Cerebral Edema: Evidence from Clinical Studies. Annu Rev Pharmacol Toxicol 2020; 60:291-309. [PMID: 31914899 DOI: 10.1146/annurev-pharmtox-010919-023429] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cerebral edema, a common and often fatal companion to most forms of acute central nervous system disease, has been recognized since the time of ancient Egypt. Unfortunately, our therapeutic armamentarium remains limited, in part due to historic limitations in our understanding of cerebral edema pathophysiology. Recent advancements have led to a number of clinical trials for novel therapeutics that could fundamentally alter the treatment of cerebral edema. In this review, we discuss these agents, their targets, and the data supporting their use, with a focus on agents that have progressed to clinical trials.
Collapse
Affiliation(s)
- Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA;
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA;
| | - Kevin N Sheth
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale University School of Medicine, New Haven, Connecticut 06510, USA
| | - W Taylor Kimberly
- Department of Neurology, Division of Neurocritical Care, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA; .,Departments of Pathology and Physiology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
| |
Collapse
|
15
|
Wessell AP, Carvalho HDP, Le E, Cannarsa G, Kole MJ, Stokum JA, Chryssikos T, Miller TR, Chaturvedi S, Gandhi D, Yarbrough K, Satti SR, Jindal G. A Critical Assessment of the Golden Hour and the Impact of Procedural Timing in Stroke Thrombectomy. AJNR Am J Neuroradiol 2020; 41:822-827. [PMID: 32414902 DOI: 10.3174/ajnr.a6556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 03/04/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies in acute ischemic stroke have demonstrated the importance of minimizing delays to endovascular treatment and keeping thrombectomy procedural times at <30-60 minutes. The purpose of this study was to investigate the impact of thrombectomy procedural times on clinical outcomes. MATERIALS AND METHODS We retrospectively compared 319 patients having undergone thrombectomy according to procedural time (<30 minutes, 30-60 minutes, and >60 minutes) and time from stroke onset to endovascular therapy (≤6 or >6 hours). Clinical characteristics of patients with postprocedural intracranial hemorrhage were also assessed. Logistic regression was used to determine independent predictors of poor outcome at 90 days (mRS ≥3). RESULTS Greater age (OR, 1.03; 95% CI, 1.01-1.06; P = .016), higher admission NIHSS score (OR, 1.10; 95% CI, 1.04-1.16; P = .001), history of diabetes mellitus (OR, 1.96; 95% CI, 1.05-3.65; P = .034), and postprocedural intracranial hemorrhage were independently associated with greater odds of poor outcome. Modified TICI scale scores of 2c (OR, 0.11; 95% CI, 0.04-0.28; P < .001) and 3 (OR, 0.15; 95% CI, 0.06-0.38; P < .001) were associated with reduced odds of poor outcome. Although not statistically significant on univariate analysis, onset to endovascular therapy of >6 hours was independently associated with increased odds of poor outcome (OR, 2.20; 95% CI, 1.11-4.36; P = .024) in the final multivariate model (area under the curve = 0.820). Procedural time was not independently associated with clinical outcome in the final multivariate model (P > .05). CONCLUSIONS Thrombectomy procedural times beyond 60 minutes are associated with lower revascularization rates and worse 90-day outcomes. Procedural time itself was not an independent predictor of outcome. While stroke thrombectomy procedures should be performed rapidly, our study emphasizes the significance of achieving revascularization despite the requisite procedural time. However, the potential for revascularization must be weighed against the risks associated with multiple thrombectomy attempts.
Collapse
Affiliation(s)
- A P Wessell
- Departments of Neurosurgery (A.P.W., G.C., M.J.K., J.A.S., T.C.)
| | - H D P Carvalho
- From the Division of Interventional Neuroradiology (H.D.P.C., E.L., T.R.M., D.G., G.J.)
| | - E Le
- From the Division of Interventional Neuroradiology (H.D.P.C., E.L., T.R.M., D.G., G.J.)
| | - G Cannarsa
- Departments of Neurosurgery (A.P.W., G.C., M.J.K., J.A.S., T.C.)
| | - M J Kole
- Departments of Neurosurgery (A.P.W., G.C., M.J.K., J.A.S., T.C.)
| | - J A Stokum
- Departments of Neurosurgery (A.P.W., G.C., M.J.K., J.A.S., T.C.)
| | - T Chryssikos
- Departments of Neurosurgery (A.P.W., G.C., M.J.K., J.A.S., T.C.)
| | - T R Miller
- From the Division of Interventional Neuroradiology (H.D.P.C., E.L., T.R.M., D.G., G.J.)
| | - S Chaturvedi
- Neurology (S.C., K.Y.), University of Maryland Medical Center, Baltimore, Maryland
| | - D Gandhi
- From the Division of Interventional Neuroradiology (H.D.P.C., E.L., T.R.M., D.G., G.J.)
| | - K Yarbrough
- Neurology (S.C., K.Y.), University of Maryland Medical Center, Baltimore, Maryland
| | - S R Satti
- Department of Neurointerventional Surgery (S.R.S.), Christiana Care Health System, Newark, Delaware
| | - G Jindal
- From the Division of Interventional Neuroradiology (H.D.P.C., E.L., T.R.M., D.G., G.J.)
| |
Collapse
|
16
|
Gerzanich V, Stokum JA, Ivanova S, Woo SK, Tsymbalyuk O, Sharma A, Akkentli F, Imran Z, Aarabi B, Sahuquillo J, Simard JM. Sulfonylurea Receptor 1, Transient Receptor Potential Cation Channel Subfamily M Member 4, and KIR6.2:Role in Hemorrhagic Progression of Contusion. J Neurotrauma 2018; 36:1060-1079. [PMID: 30160201 PMCID: PMC6446209 DOI: 10.1089/neu.2018.5986] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
In severe traumatic brain injury (TBI), contusions often are worsened by contusion expansion or hemorrhagic progression of contusion (HPC), which may double the original contusion volume and worsen outcome. In humans and rodents with contusion-TBI, sulfonylurea receptor 1 (SUR1) is upregulated in microvessels and astrocytes, and in rodent models, blockade of SUR1 with glibenclamide reduces HPC. SUR1 does not function by itself, but must co-assemble with either KIR6.2 or transient receptor potential cation channel subfamily M member 4 (TRPM4) to form KATP (SUR1-KIR6.2) or SUR1-TRPM4 channels, with the two having opposite effects on membrane potential. Both KIR6.2 and TRPM4 are reportedly upregulated in TBI, especially in astrocytes, but the identity and function of SUR1-regulated channels post-TBI is unknown. Here, we analyzed human and rat brain tissues after contusion-TBI to characterize SUR1, TRPM4, and KIR6.2 expression, and in the rat model, to examine the effects on HPC of inhibiting expression of the three subunits using intravenous antisense oligodeoxynucleotides (AS-ODN). Glial fibrillary acidic protein (GFAP) immunoreactivity was used to operationally define core versus penumbral tissues. In humans and rats, GFAP-negative core tissues contained microvessels that expressed SUR1 and TRPM4, whereas GFAP-positive penumbral tissues contained astrocytes that expressed all three subunits. Förster resonance energy transfer imaging demonstrated SUR1-TRPM4 heteromers in endothelium, and SUR1-TRPM4 and SUR1-KIR6.2 heteromers in astrocytes. In rats, glibenclamide as well as AS-ODN targeting SUR1 and TRPM4, but not KIR6.2, reduced HPC at 24 h post-TBI. Our findings demonstrate upregulation of SUR1-TRPM4 and KATP after contusion-TBI, identify SUR1-TRPM4 as the primary molecular mechanism that accounts for HPC, and indicate that SUR1-TRPM4 is a crucial target of glibenclamide.
Collapse
Affiliation(s)
- Volodymyr Gerzanich
- 1 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jesse A Stokum
- 1 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Svetlana Ivanova
- 1 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Seung Kyoon Woo
- 1 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Orest Tsymbalyuk
- 1 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Amit Sharma
- 1 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Fatih Akkentli
- 1 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ziyan Imran
- 1 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bizhan Aarabi
- 1 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Juan Sahuquillo
- 2 Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,3 Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Marc Simard
- 1 Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland.,4 Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland.,5 Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
17
|
Theriault BC, Woo SK, Karimy JK, Keledjian K, Stokum JA, Sarkar A, Coksaygan T, Ivanova S, Gerzanich V, Simard JM. Correction: Cerebral microbleeds in a neonatal rat model. PLoS One 2018; 13:e0201831. [PMID: 30063749 PMCID: PMC6067723 DOI: 10.1371/journal.pone.0201831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
18
|
Hayman E, Keledjian K, Stokum JA, Pampori A, Gerzanich V, Simard JM. Selective Vulnerability of the Foramen Magnum in a Rat Blast Traumatic Brain Injury Model. J Neurotrauma 2018; 35:2136-2142. [PMID: 29566593 DOI: 10.1089/neu.2017.5435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Primary blast traumatic brain injury (bTBI) accounts for a significant proportion of wartime trauma. Previous studies have demonstrated direct brain injury by blast waves, but the effect of the location of the blast epicenter on the skull with regard to brain injury remains poorly characterized. In order to investigate the role of the blast epicenter location, we modified a previously established rodent model of cranium-only bTBI to evaluate two specific blast foci: a rostrally focused blast centered on bregma (B-bTBI), which excluded the foramen magnum region, and a caudally focused blast centered on the occipital crest, which included the foramen magnum region (FM-bTBI). At all blast overpressures studied (668-1880 kPa), rats subjected to FM-bTBI demonstrated strikingly higher mortality, increased durations of both apnea and hypoxia, and increased severity of convexity subdural hematomas, than rats subjected to B-bTBI. Together, these data suggest a unique role for the foramen magnum region in mortality and brain injury following blast exposure, and emphasize the importance of the choice of blast focus location in experimental models of bTBI.
Collapse
Affiliation(s)
- Erik Hayman
- 1 Department of Neurosurgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Kaspar Keledjian
- 1 Department of Neurosurgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jesse A Stokum
- 1 Department of Neurosurgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Adam Pampori
- 1 Department of Neurosurgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Volodymyr Gerzanich
- 1 Department of Neurosurgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - J Marc Simard
- 1 Department of Neurosurgery, University of Maryland School of Medicine , Baltimore, Maryland.,2 Department of Pathology, University of Maryland School of Medicine , Baltimore, Maryland.,3 Department of Physiology, University of Maryland School of Medicine , Baltimore, Maryland
| |
Collapse
|
19
|
Connolly NP, Shetty AC, Stokum JA, Hoeschele I, Siegel MB, Miller CR, Kim AJ, Ho CY, Davila E, Simard JM, Devine SE, Rossmeisl JH, Holland EC, Winkles JA, Woodworth GF. Cross-species transcriptional analysis reveals conserved and host-specific neoplastic processes in mammalian glioma. Sci Rep 2018; 8:1180. [PMID: 29352201 PMCID: PMC5775420 DOI: 10.1038/s41598-018-19451-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/02/2018] [Indexed: 01/03/2023] Open
Abstract
Glioma is a unique neoplastic disease that develops exclusively in the central nervous system (CNS) and rarely metastasizes to other tissues. This feature strongly implicates the tumor-host CNS microenvironment in gliomagenesis and tumor progression. We investigated the differences and similarities in glioma biology as conveyed by transcriptomic patterns across four mammalian hosts: rats, mice, dogs, and humans. Given the inherent intra-tumoral molecular heterogeneity of human glioma, we focused this study on tumors with upregulation of the platelet-derived growth factor signaling axis, a common and early alteration in human gliomagenesis. The results reveal core neoplastic alterations in mammalian glioma, as well as unique contributions of the tumor host to neoplastic processes. Notable differences were observed in gene expression patterns as well as related biological pathways and cell populations known to mediate key elements of glioma biology, including angiogenesis, immune evasion, and brain invasion. These data provide new insights regarding mammalian models of human glioma, and how these insights and models relate to our current understanding of the human disease.
Collapse
Affiliation(s)
- Nina P Connolly
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Amol C Shetty
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ina Hoeschele
- Virginia Bioinformatics Institute and Department of Statistics, Virginia Tech, Blacksburg, Virginia, USA
| | - Marni B Siegel
- Departments of Pathology and Laboratory Medicine, Neurology, and Pharmacology, Lineberger Comprehensive Cancer Center and Neuroscience Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - C Ryan Miller
- Departments of Pathology and Laboratory Medicine, Neurology, and Pharmacology, Lineberger Comprehensive Cancer Center and Neuroscience Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anthony J Kim
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Cheng-Ying Ho
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Eduardo Davila
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Scott E Devine
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - John H Rossmeisl
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia, USA.,Wake Forest University Baptist Health Comprehensive Cancer Center, Brain Tumor Center of Excellence, Winston-Salem, North Carolina, USA
| | - Eric C Holland
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - Jeffrey A Winkles
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Center for Vascular and Inflammatory Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA. .,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland, USA.
| |
Collapse
|
20
|
Mehta RI, Tsymbalyuk N, Ivanova S, Stokum JA, Woo K, Gerzanich V, Simard JM. α-Endosulfine (ARPP-19e) Expression in a Rat Model of Stroke. J Neuropathol Exp Neurol 2017; 76:898-907. [PMID: 28922851 DOI: 10.1093/jnen/nlx074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In nutrient restricted environments, the yeast endosulfines Igo1/2 are activated via TORC1 inhibition and function critically to initiate and coordinate the cellular stress response that promotes survival. We examined expression of αEnsa, the mammalian homolog of yeast endosulfines, in rat stroke. Prominent neuronal upregulation of αEnsa was identified in 3 patterns within the ischemic gradient: (1) neurons in GFAP-/HSF1+ cortex showed upregulation and near-complete nuclear translocation of αEnsa protein within hours of ischemic onset; (2) neurons in GFAP+/HSF1+ cortex showed upregulation in cytoplasm and nuclei that persisted for days; (3) neurons in GFAP+/HSF1- cortex showed delayed cytosolic-only upregulation that persisted for days. Findings were corroborated using in situ hybridization for ENSA mRNA. Rapamycin treatment was found to reduce infarct size and behavioral deficits and, in GFAP+/HSF1+ zones, enhance αEnsa neuronal nuclear translocation and mitigate cell death, relative to controls. Based on the conservation of TOR signaling across species, and on the finding that the Rim15-Igo1/2-PP2A module is triggered by substrate deprivation in eukaryotic yeast, we speculate that αEnsa is activated by substrate deprivation, functioning through the homologous MASTL-αEnsa/ARPP19-PP2A module to promote neuronal survival. In conjunction with recent studies suggesting a neuroprotective role, our data highlight a potential function for αEnsa within ischemic brain.
Collapse
Affiliation(s)
- Rupal I Mehta
- Department of Pathology and Laboratory Medicine; Center for Neurotherapeutics Discovery, Department of Neuroscience; Center for Translational Neuromedicine, University of Rochester, Rochester, New York; Department of Pathology; Department of Neurosurgery; Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Natalia Tsymbalyuk
- Department of Pathology and Laboratory Medicine; Center for Neurotherapeutics Discovery, Department of Neuroscience; Center for Translational Neuromedicine, University of Rochester, Rochester, New York; Department of Pathology; Department of Neurosurgery; Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Svetlana Ivanova
- Department of Pathology and Laboratory Medicine; Center for Neurotherapeutics Discovery, Department of Neuroscience; Center for Translational Neuromedicine, University of Rochester, Rochester, New York; Department of Pathology; Department of Neurosurgery; Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jesse A Stokum
- Department of Pathology and Laboratory Medicine; Center for Neurotherapeutics Discovery, Department of Neuroscience; Center for Translational Neuromedicine, University of Rochester, Rochester, New York; Department of Pathology; Department of Neurosurgery; Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kyoon Woo
- Department of Pathology and Laboratory Medicine; Center for Neurotherapeutics Discovery, Department of Neuroscience; Center for Translational Neuromedicine, University of Rochester, Rochester, New York; Department of Pathology; Department of Neurosurgery; Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Volodymyr Gerzanich
- Department of Pathology and Laboratory Medicine; Center for Neurotherapeutics Discovery, Department of Neuroscience; Center for Translational Neuromedicine, University of Rochester, Rochester, New York; Department of Pathology; Department of Neurosurgery; Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - J M Simard
- Department of Pathology and Laboratory Medicine; Center for Neurotherapeutics Discovery, Department of Neuroscience; Center for Translational Neuromedicine, University of Rochester, Rochester, New York; Department of Pathology; Department of Neurosurgery; Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
21
|
Stokum JA, Kwon MS, Woo SK, Tsymbalyuk O, Vennekens R, Gerzanich V, Simard JM. SUR1-TRPM4 and AQP4 form a heteromultimeric complex that amplifies ion/water osmotic coupling and drives astrocyte swelling. Glia 2017; 66:108-125. [PMID: 28906027 DOI: 10.1002/glia.23231] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/23/2017] [Accepted: 08/23/2017] [Indexed: 12/17/2022]
Abstract
Astrocyte swelling occurs after central nervous system injury and contributes to brain swelling, which can increase mortality. Mechanisms proffered to explain astrocyte swelling emphasize the importance of either aquaporin-4 (AQP4), an astrocyte water channel, or of Na+ -permeable channels, which mediate cellular osmolyte influx. However, the spatio-temporal functional interactions between AQP4 and Na+ -permeable channels that drive swelling are poorly understood. We hypothesized that astrocyte swelling after injury is linked to an interaction between AQP4 and Na+ -permeable channels that are newly upregulated. Here, using co-immunoprecipitation and Förster resonance energy transfer, we report that AQP4 physically co-assembles with the sulfonylurea receptor 1-transient receptor potential melastatin 4 (SUR1-TRPM4) monovalent cation channel to form a novel heteromultimeric water/ion channel complex. In vitro cell-swelling studies using calcein fluorescence imaging of COS-7 cells expressing various combinations of AQP4, SUR1, and TRPM4 showed that the full tripartite complex, comprised of SUR1-TRPM4-AQP4, was required for fast, high-capacity transmembrane water transport that drives cell swelling, with these findings corroborated in cultured primary astrocytes. In a murine model of brain edema involving cold-injury to the cerebellum, we found that astrocytes newly upregulate SUR1-TRPM4, that AQP4 co-associates with SUR1-TRPM4, and that genetic inactivation of the solute pore of the SUR1-TRPM4-AQP4 complex blocked in vivo astrocyte swelling measured by diolistic labeling, thereby corroborating our in vitro functional studies. Together, these findings demonstrate a novel molecular mechanism involving the SUR1-TRPM4-AQP4 complex to account for bulk water influx during astrocyte swelling. These findings have broad implications for the understanding and treatment of AQP4-mediated pathological conditions.
Collapse
Affiliation(s)
- Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, 21201-1595
| | - Min S Kwon
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, 21201-1595
| | - Seung K Woo
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, 21201-1595
| | - Orest Tsymbalyuk
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, 21201-1595
| | - Rudi Vennekens
- Department of Cellular and Molecular Medicine, Laboratory of Ion Channel Research, Katholieke Universiteit Leuven, Leuven, 3000, Belgium
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, 21201-1595
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, 21201-1595.,Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, 21201-1595.,Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland, 21201-1595
| |
Collapse
|
22
|
Gerzanich V, Makar TK, Guda PR, Kwon MS, Stokum JA, Woo SK, Ivanova S, Ivanov A, Mehta RI, Morris AB, Bryan J, Bever CT, Simard JM. Salutary effects of glibenclamide during the chronic phase of murine experimental autoimmune encephalomyelitis. J Neuroinflammation 2017; 14:177. [PMID: 28865458 PMCID: PMC5581426 DOI: 10.1186/s12974-017-0953-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 08/27/2017] [Indexed: 01/03/2023] Open
Abstract
Background In multiple sclerosis (MS) and experimental autoimmune encephalomyelitis (EAE), inflammation is perpetuated by both infiltrating leukocytes and astrocytes. Recent work implicated SUR1-TRPM4 channels, expressed mostly by astrocytes, in murine EAE. We tested the hypothesis that pharmacological inhibition of SUR1 during the chronic phase of EAE would be beneficial. Methods EAE was induced in mice using myelin oligodendrocyte glycoprotein (MOG) 35–55. Glibenclamide (10 μg/day) was administered beginning 12 or 24 days later. The effects of treatment were determined by clinical scoring and tissue examination. Drug within EAE lesions was identified using bodipy-glibenclamide. The role of SUR1-TRPM4 in primary astrocytes was characterized using patch clamp and qPCR. Demyelinating lesions from MS patients were studied by immunolabeling and immunoFRET. Results Administering glibenclamide beginning 24 days after MOG35–55 immunization, well after clinical symptoms had plateaued, improved clinical scores, reduced myelin loss, inflammation (CD45, CD20, CD3, p65), and reactive astrocytosis, improved macrophage phenotype (CD163), and decreased expression of tumor necrosis factor (TNF), B-cell activating factor (BAFF), chemokine (C-C motif) ligand 2 (CCL2) and nitric oxide synthase 2 (NOS2) in lumbar spinal cord white matter. Glibenclamide accumulated within EAE lesions, and had no effect on leukocyte sequestration. In primary astrocyte cultures, activation by TNF plus IFNγ induced de novo expression of SUR1-TRPM4 channels and upregulated Tnf, Baff, Ccl2, and Nos2 mRNA, with glibenclamide blockade of SUR1-TRPM4 reducing these mRNA increases. In demyelinating lesions from MS patients, astrocytes co-expressed SUR1-TRPM4 and BAFF, CCL2, and NOS2. Conclusions SUR1-TRPM4 may be a druggable target for disease modification in MS.
Collapse
Affiliation(s)
- Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Tapas K Makar
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.,Research Service and MS Center of Excellence, Veterans Affairs Maryland Health Care System, Baltimore, MD, 21201, USA
| | - Poornachander Reddy Guda
- Research Service and MS Center of Excellence, Veterans Affairs Maryland Health Care System, Baltimore, MD, 21201, USA
| | - Min Seong Kwon
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Seung Kyoon Woo
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Svetlana Ivanova
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Alexander Ivanov
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Rupal I Mehta
- Department of Pathology, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Alexandra Brooke Morris
- Research Service and MS Center of Excellence, Veterans Affairs Maryland Health Care System, Baltimore, MD, 21201, USA
| | - Joseph Bryan
- Pacific Northwest Diabetes Research Institute, 720 Broadway, Seattle, WA, 98122, USA
| | - Christopher T Bever
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.,Research Service and MS Center of Excellence, Veterans Affairs Maryland Health Care System, Baltimore, MD, 21201, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA. .,Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA. .,Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA. .,Neurosurgical Service, Veterans Affairs Maryland Health Care System, Baltimore, MD, 21201, USA.
| |
Collapse
|
23
|
Karimy JK, Zhang J, Kurland DB, Theriault BC, Duran D, Stokum JA, Furey CG, Zhou X, Mansuri MS, Montejo J, Vera A, DiLuna ML, Delpire E, Alper SL, Gunel M, Gerzanich V, Medzhitov R, Simard JM, Kahle KT. Inflammation-dependent cerebrospinal fluid hypersecretion by the choroid plexus epithelium in posthemorrhagic hydrocephalus. Nat Med 2017; 23:997-1003. [PMID: 28692063 DOI: 10.1038/nm.4361] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 05/31/2017] [Indexed: 02/07/2023]
Abstract
The choroid plexus epithelium (CPE) secretes higher volumes of fluid (cerebrospinal fluid, CSF) than any other epithelium and simultaneously functions as the blood-CSF barrier to gate immune cell entry into the central nervous system. Posthemorrhagic hydrocephalus (PHH), an expansion of the cerebral ventricles due to CSF accumulation following intraventricular hemorrhage (IVH), is a common disease usually treated by suboptimal CSF shunting techniques. PHH is classically attributed to primary impairments in CSF reabsorption, but little experimental evidence supports this concept. In contrast, the potential contribution of CSF secretion to PHH has received little attention. In a rat model of PHH, we demonstrate that IVH causes a Toll-like receptor 4 (TLR4)- and NF-κB-dependent inflammatory response in the CPE that is associated with a ∼3-fold increase in bumetanide-sensitive CSF secretion. IVH-induced hypersecretion of CSF is mediated by TLR4-dependent activation of the Ste20-type stress kinase SPAK, which binds, phosphorylates, and stimulates the NKCC1 co-transporter at the CPE apical membrane. Genetic depletion of TLR4 or SPAK normalizes hyperactive CSF secretion rates and reduces PHH symptoms, as does treatment with drugs that antagonize TLR4-NF-κB signaling or the SPAK-NKCC1 co-transporter complex. These data uncover a previously unrecognized contribution of CSF hypersecretion to the pathogenesis of PHH, demonstrate a new role for TLRs in regulation of the internal brain milieu, and identify a kinase-regulated mechanism of CSF secretion that could be targeted by repurposed US Food and Drug Administration (FDA)-approved drugs to treat hydrocephalus.
Collapse
Affiliation(s)
- Jason K Karimy
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jinwei Zhang
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
- Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Hatherly Laboratory, Exeter, UK
| | - David B Kurland
- Department of Neurosurgery, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | | | - Daniel Duran
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | | | - Xu Zhou
- Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - M Shahid Mansuri
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Julio Montejo
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alberto Vera
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael L DiLuna
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Eric Delpire
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Seth L Alper
- Division of Nephrology, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Vascular Biology Research Center, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Murat Gunel
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Ruslan Medzhitov
- Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland, School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
- Department of Physiology, University of Maryland, School of Medicine, Baltimore, Maryland, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Cellular & Molecular Physiology, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Mendelian Genomics, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
24
|
Stokum JA, Keledjian K, Hayman E, Karimy JK, Pampori A, Imran Z, Woo SK, Gerzanich V, Simard JM. Glibenclamide pretreatment protects against chronic memory dysfunction and glial activation in rat cranial blast traumatic brain injury. Behav Brain Res 2017; 333:43-53. [PMID: 28662892 DOI: 10.1016/j.bbr.2017.06.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/20/2017] [Accepted: 06/24/2017] [Indexed: 02/03/2023]
Abstract
Blast traumatic brain injury (bTBI) affects both military and civilian populations, and often results in chronic deficits in cognition and memory. Chronic glial activation after bTBI has been linked with cognitive decline. Pharmacological inhibition of sulfonylurea receptor 1 (SUR1) with glibenclamide was shown previously to reduce glial activation and improve cognition in contusive models of CNS trauma, but has not been examined in bTBI. We postulated that glibenclamide would reduce chronic glial activation and improve long-term memory function after bTBI. Using a rat direct cranial model of bTBI (dc-bTBI), we evaluated the efficacy of two glibenclamide treatment paradigms: glibenclamide prophylaxis (pre-treatment), and treatment with glibenclamide starting after dc-bTBI (post-treatment). Our results show that dc-bTBI caused hippocampal astrocyte and microglial/macrophage activation that was associated with hippocampal memory dysfunction (rapid place learning paradigm) at 28days, and that glibenclamide pre-treatment, but not post-treatment, effectively protected against glial activation and memory dysfunction. We also report that a brief transient time-window of blood-brain barrier (BBB) disruption occurs after dc-bTBI, and we speculate that glibenclamide, which is mostly protein bound and does not normally traverse the intact BBB, can undergo CNS delivery only during this brief transient opening of the BBB. Together, our findings indicate that prophylactic glibenclamide treatment may help to protect against chronic cognitive sequelae of bTBI in warfighters and other at-risk populations.
Collapse
Affiliation(s)
- Jesse A Stokum
- Departments of Neurosurgery, University of Maryland School of Medicine, 10 S Pine St, MSTF, Room 634B, Baltimore, MD 21201, USA.
| | - Kaspar Keledjian
- Departments of Neurosurgery, University of Maryland School of Medicine, 10 S Pine St, MSTF, Room 634B, Baltimore, MD 21201, USA
| | - Erik Hayman
- Departments of Neurosurgery, University of Maryland School of Medicine, 10 S Pine St, MSTF, Room 634B, Baltimore, MD 21201, USA
| | - Jason K Karimy
- Departments of Neurosurgery, University of Maryland School of Medicine, 10 S Pine St, MSTF, Room 634B, Baltimore, MD 21201, USA
| | - Adam Pampori
- Departments of Neurosurgery, University of Maryland School of Medicine, 10 S Pine St, MSTF, Room 634B, Baltimore, MD 21201, USA
| | - Ziyan Imran
- Departments of Neurosurgery, University of Maryland School of Medicine, 10 S Pine St, MSTF, Room 634B, Baltimore, MD 21201, USA
| | - Seung Kyoon Woo
- Departments of Neurosurgery, University of Maryland School of Medicine, 10 S Pine St, MSTF, Room 634B, Baltimore, MD 21201, USA
| | - Volodymyr Gerzanich
- Departments of Neurosurgery, University of Maryland School of Medicine, 10 S Pine St, MSTF, Room 634B, Baltimore, MD 21201, USA
| | - J Marc Simard
- Departments of Pathology, University of Maryland School of Medicine, 10 S Pine St, MSTF, Room 634B, Baltimore, MD 21201, USA; Departments of Physiology, University of Maryland School of Medicine, 10 S Pine St, MSTF, Room 634B, Baltimore, MD 21201, USA
| |
Collapse
|
25
|
Carusillo Theriault B, Woo SK, Karimy JK, Keledjian K, Stokum JA, Sarkar A, Coksaygan T, Ivanova S, Gerzanich V, Simard JM. Cerebral microbleeds in a neonatal rat model. PLoS One 2017; 12:e0171163. [PMID: 28158198 PMCID: PMC5291518 DOI: 10.1371/journal.pone.0171163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/15/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In adult humans, cerebral microbleeds play important roles in neurodegenerative diseases but in neonates, the consequences of cerebral microbleeds are unknown. In rats, a single pro-angiogenic stimulus in utero predisposes to cerebral microbleeds after birth at term, a time when late oligodendrocyte progenitors (pre-oligodendrocytes) dominate in the rat brain. We hypothesized that two independent pro-angiogenic stimuli in utero would be associated with a high likelihood of perinatal microbleeds that would be severely damaging to white matter. METHODS Pregnant Wistar rats were subjected to intrauterine ischemia (IUI) and low-dose maternal lipopolysaccharide (mLPS) at embryonic day (E) 19. Pups were born vaginally or abdominally at E21-22. Brains were evaluated for angiogenic markers, microhemorrhages, myelination and axonal development. Neurological function was assessed out to 6 weeks. RESULTS mRNA (Vegf, Cd31, Mmp2, Mmp9, Timp1, Timp2) and protein (CD31, MMP2, MMP9) for angiogenic markers, in situ proteolytic activity, and collagen IV immunoreactivity were altered, consistent with an angiogenic response. Vaginally delivered pups exposed to prenatal IUI+mLPS had spontaneous cerebral microbleeds, abnormal neurological function, and dysmorphic, hypomyelinated white matter and axonopathy. Pups exposed to the same pro-angiogenic stimuli in utero but delivered abdominally had minimal cerebral microbleeds, preserved myelination and axonal development, and neurological function similar to naïve controls. CONCLUSIONS In rats, pro-angiogenic stimuli in utero can predispose to vascular fragility and lead to cerebral microbleeds. The study of microbleeds in the neonatal rat brain at full gestation may give insights into the consequences of microbleeds in human preterm infants during critical periods of white matter development.
Collapse
Affiliation(s)
- Brianna Carusillo Theriault
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Seung Kyoon Woo
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Jason K. Karimy
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Kaspar Keledjian
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Jesse A. Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Amrita Sarkar
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Turhan Coksaygan
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Svetlana Ivanova
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| |
Collapse
|
26
|
Abstract
Advancements in molecular biology have led to a greater understanding of the individual proteins responsible for generating cerebral edema. In large part, the study of cerebral edema is the study of maladaptive ion transport. Following acute CNS injury, cells of the neurovascular unit, particularly brain endothelial cells and astrocytes, undergo a program of pre- and post-transcriptional changes in the activity of ion channels and transporters. These changes can result in maladaptive ion transport and the generation of abnormal osmotic forces that, ultimately, manifest as cerebral edema. This review discusses past models and current knowledge regarding the molecular and cellular pathophysiology of cerebral edema.
Collapse
Affiliation(s)
- Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, USA Department of Pathology, University of Maryland School of Medicine, Baltimore, USA Department of Physiology, University of Maryland School of Medicine, Baltimore, USA
| |
Collapse
|
27
|
Iqbal S, Hayman EG, Hong C, Stokum JA, Kurland DB, Gerzanich V, Simard JM. Inducible nitric oxide synthase (NOS-2) in subarachnoid hemorrhage: Regulatory mechanisms and therapeutic implications. Brain Circ 2016; 2:8-19. [PMID: 27774520 PMCID: PMC5074544 DOI: 10.4103/2394-8108.178541] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) typically carries a poor prognosis. Growing evidence indicates that overabundant production of nitric oxide (NO) may be responsible for a large part of the secondary injury that follows SAH. Although SAH modulates the activity of all three isoforms of nitric oxide synthase (NOS), the inducible isoform, NOS-2, accounts for a majority of NO-mediated secondary injuries after SAH. Here, we review the indispensable physiological roles of NO that must be preserved, even while attempting to downmodulate the pathophysiologic effects of NO that are induced by SAH. We examine the effects of SAH on the function of the various NOS isoforms, with a particular focus on the pathological effects of NOS-2 and on the mechanisms responsible for its transcriptional upregulation. Finally, we review interventions to block NOS-2 upregulation or to counteract its effects, with an emphasis on the potential therapeutic strategies to improve outcomes in patients afflicted with SAH. There is still much to be learned regarding the apparently maladaptive response of NOS-2 and its harmful product NO in SAH. However, the available evidence points to crucial effects that, on balance, are adverse, making the NOS-2/NO/peroxynitrite axis an attractive therapeutic target in SAH.
Collapse
Affiliation(s)
- Sana Iqbal
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Erik G Hayman
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Caron Hong
- Department of Anesthesiology, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Jesse A Stokum
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - David B Kurland
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - J Marc Simard
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA; Department of Pathology, School of Medicine, University of Maryland, Baltimore, Maryland, USA; Department of Physiology, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| |
Collapse
|
28
|
Stokum JA, Mehta RI, Ivanova S, Yu E, Gerzanich V, Simard JM. Heterogeneity of aquaporin-4 localization and expression after focal cerebral ischemia underlies differences in white versus grey matter swelling. Acta Neuropathol Commun 2015; 3:61. [PMID: 26419740 PMCID: PMC4588314 DOI: 10.1186/s40478-015-0239-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 09/17/2015] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Ischemic stroke, a major cause of mortality, is frequently accompanied by life-threatening cerebral edema. Aquaporin-4 (Aqp4), an astrocytic transmembrane water channel, is an important molecular contributor to cerebral edema formation. Past studies of Aqp4 expression and localization after ischemia examined grey matter exclusively. However, as white matter astrocytes differ developmentally, physiologically, and molecularly from grey matter astrocytes, we hypothesized that functionally important regional heterogeneity exists in Aqp4 expression and subcellular localization following cerebral ischemia. RESULTS Subcellular localization of Aqp4 was compared between cortical and white matter astrocytes in postmortem specimens of patients with focal ischemic stroke versus controls. Subcellular localization and expression of Aqp4 was examined in rats subjected to experimental stroke. Volumetric analysis was performed on the cortex and white matter of rats subjected to experimental stroke. Following cerebral ischemia, cortical astrocytes exhibited reduced perivascular Aqp4 and unchanged Aqp4 protein abundance. In contrast, white matter astrocytes exhibited increased perivascular and plasmalemmal Aqp4 and a 2.2- to 6.2-fold increase in Aqp4 isoform abundance. Ischemic white matter swelled by approximately 40 %, while cortex swelled by approximately 9 %. CONCLUSIONS The findings reported here raise the possibility that cerebral white matter may play a heretofore underappreciated role in the formation of cerebral edema following ischemia.
Collapse
|
29
|
Stokum JA, Sours C, Zhuo J, Kane R, Shanmuganathan K, Gullapalli RP. A longitudinal evaluation of diffusion kurtosis imaging in patients with mild traumatic brain injury. Brain Inj 2014; 29:47-57. [PMID: 25259786 DOI: 10.3109/02699052.2014.947628] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PRIMARY OBJECTIVE To investigate longitudinal diffusion tensor imaging (DTI) and diffusion kurtosis imaging (DKI) changes in white and grey matter in patients with mild traumatic brain injury (mTBI). RESEARCH DESIGN A prospective case-control study. METHODS AND PROCEDURES DKI data was obtained from 24 patients with mTBI along with cognitive assessments within 10 days, 1 month and 6 months post-injury and compared with age-matched control (n¼ 24). Fractional anisotropy (FA), mean diffusivity (MD), radial diffusion (l(r)), mean kurtosis (MK) and radial kurtosis (Kr) were extracted from the thalamus, internal capsule and corpus callosum. MAIN OUTCOMES AND RESULTS Results demonstrate reduced Kr and MK in the anterior internal capsule in patients with mTBI across the three visits, and reduced MK in the posterior internal capsule during the 10 day time point. Correlations were observed between the change in MK or Kr between 1–6 months and the improvements in cognition between the 1 and 6 month visits in the thalamus, internal capsule and corpus callosum. CONCLUSIONS These data demonstrate that DKI may be sensitive in tracking pathophysiological changes associated with mTBI and may provide additional information to conventional DTI parameters in evaluating longitudinal changes following TBI.
Collapse
|
30
|
Stokum JA, Kurland DB, Gerzanich V, Simard JM. Mechanisms of astrocyte-mediated cerebral edema. Neurochem Res 2014; 40:317-28. [PMID: 24996934 DOI: 10.1007/s11064-014-1374-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/18/2014] [Accepted: 06/26/2014] [Indexed: 11/26/2022]
Abstract
Cerebral edema formation stems from disruption of blood brain barrier (BBB) integrity and occurs after injury to the CNS. Due to the restrictive skull, relatively small increases in brain volume can translate into impaired tissue perfusion and brain herniation. In excess, cerebral edema can be gravely harmful. Astrocytes are key participants in cerebral edema by virtue of their relationship with the cerebral vasculature, their unique compliment of solute and water transport proteins, and their general role in brain volume homeostasis. Following the discovery of aquaporins, passive conduits of water flow, aquaporin 4 (AQP4) was identified as the predominant astrocyte water channel. Normally, AQP4 is highly enriched at perivascular endfeet, the outermost layer of the BBB, whereas after injury, AQP4 expression disseminates to the entire astrocytic plasmalemma, a phenomenon termed dysregulation. Arguably, the most important role of AQP4 is to rapidly neutralize osmotic gradients generated by ionic transporters. In pathological conditions, AQP4 is believed to be intimately involved in the formation and clearance of cerebral edema. In this review, we discuss aquaporin function and localization in the BBB during health and injury, and we examine post-injury ionic events that modulate AQP4-dependent edema formation.
Collapse
Affiliation(s)
- Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | | | | | | |
Collapse
|
31
|
Patrick MJ, Janjic JM, Teng H, O’Hear MR, Brown CW, Stokum JA, Schmidt BF, Ahrens ET, Waggoner AS. Intracellular pH measurements using perfluorocarbon nanoemulsions. J Am Chem Soc 2013; 135:18445-57. [PMID: 24266634 PMCID: PMC4208472 DOI: 10.1021/ja407573m] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
We report the synthesis and formulation of unique perfluorocarbon (PFC) nanoemulsions enabling intracellular pH measurements in living cells via fluorescent microscopy and flow cytometry. These nanoemulsions are formulated to readily enter cells upon coincubation and contain two cyanine-based fluorescent reporters covalently bound to the PFC molecules, specifically Cy3-PFC and CypHer5-PFC conjugates. The spectral and pH-sensing properties of the nanoemulsions were characterized in vitro and showed the unaltered spectral behavior of dyes after formulation. In rat 9L glioma cells loaded with nanoemulsion, the local pH of nanoemulsions was longitudinally quantified using optical microscopy and flow cytometry and displayed a steady decrease in pH to a level of 5.5 over 3 h, indicating rapid uptake of nanoemulsion to acidic compartments. Overall, these reagents enable real-time optical detection of intracellular pH in living cells in response to pharmacological manipulations. Moreover, recent approaches for in vivo cell tracking using magnetic resonance imaging (MRI) employ intracellular PFC nanoemulsion probes to track cells using (19)F MRI. However, the intracellular fate of these imaging probes is poorly understood. The pH-sensing nanoemulsions allow the study of the fate of the PFC tracer inside the labeled cell, which is important for understanding the PFC cell loading dynamics, nanoemulsion stability and cell viability over time.
Collapse
Affiliation(s)
- Michael J. Patrick
- Molecular Biosensor and Imaging Center, Carnegie Mellon University, Pittsburgh, PA
| | - Jelena M. Janjic
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA
| | - Haibing Teng
- Molecular Biosensor and Imaging Center, Carnegie Mellon University, Pittsburgh, PA
| | - Meredith R. O’Hear
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA
| | - Cortlyn W. Brown
- Department of Biological Sciences, University of Chicago, Chicago, IL
| | - Jesse A. Stokum
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA
| | - Brigitte F. Schmidt
- Molecular Biosensor and Imaging Center, Carnegie Mellon University, Pittsburgh, PA
| | - Eric T. Ahrens
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA
- Pittsburgh NMR Center for Biomedical Research, Carnegie Mellon University, Pittsburgh, PA
| | - Alan S. Waggoner
- Molecular Biosensor and Imaging Center, Carnegie Mellon University, Pittsburgh, PA
| |
Collapse
|