Linking Notch Signaling to Ischemic Stroke

Total Page:16

File Type:pdf, Size:1020Kb

Linking Notch Signaling to Ischemic Stroke Linking Notch signaling to ischemic stroke Joseph F. Arboleda-Velasquez*, Zhipeng Zhou†, Hwa Kyoung Shin†, Angeliki Louvi‡, Hyung-Hwan Kim§, Sean I. Savitz†, James K. Liao§, Salvatore Salomone†, Cenk Ayata†, Michael A. Moskowitz†, and Spyros Artavanis-Tsakonas*¶ʈ *Department of Cell Biology, Harvard Medical School, Boston, MA 02115; †Stroke and Neurovascular Regulation Laboratory, Massachusetts General Hospital, Boston, MA 02129; ‡Program on Neurogenetics and Department of Neurosurgery, Yale University School of Medicine, New Haven, CT 06520; §Vascular Medicine Research Unit, Brigham and Women’s Hospital, Harvard Medical School, Cambridge, MA 02139; and ¶Colle`ge de France, 75231 Paris, France Edited by Pietro V. De Camilli, Yale University School of Medicine, New Haven, CT, and approved January 15, 2008 (received for review October 16, 2007) Vascular smooth muscle cells (SMCs) have been implicated in the from Notch 3ϩ/Ϫ or Notch 3Ϫ/Ϫ mice were isolated and shown to pathophysiology of stroke, the third most common cause of death express ␤-gal and specific markers confirming SMC identity (Fig. and the leading cause of long-term neurological disability in the 2 B and C and SI Appendix, SI Fig. 8). Availability of a highly world. However, there is little insight into the underlying cellular enriched population of SMCs allowed us to examine the impact pathways that link SMC function to brain ischemia susceptibility. of Notch 3 loss-of-function on the transcriptional profile of Using a hitherto uncharacterized knockout mouse model of Notch brain-derived SMCs (BrSMCs). Comparative analysis between 3, a Notch signaling receptor paralogue highly expressed in vas- Notch 3ϩ/Ϫ and Notch 3Ϫ/Ϫ cells revealed 662 differentially cular SMCs, we uncover a striking susceptibility to ischemic stroke regulated genes, using an arbitrary cutoff (P Յ 0.01, fold upon challenge. Cellular and molecular analyses of vascular SMCs change Ϯ 1.5). Notch 3 scores as the utmost down-regulated gene derived from these animals associate Notch 3 activity to the (Ϫ22.1-fold) in Notch 3Ϫ/Ϫ BrSMCs. Indicative of their abnor- expression of specific gene targets, whereas genetic rescue exper- mal Notch signaling capacity, the canonical Notch downstream iments unambiguously link Notch 3 function in vessels to the targets Heyl and Hes1 were down-regulated (both Ϫ1.5-fold). ischemic phenotype. Gene ontology analysis of all misregulated targets in BrSMCs showed statistical overrepresentation of genes classified under ischemia ͉ Notch3 ͉ vascular smooth muscle ͉ CADASIL four functional categories named ‘‘muscle contraction’’ (all down-regulated), ‘‘cell structure and motility,’’ ‘‘muscle devel- otch signaling defines one of the fundamental cell interac- opment,’’ and ‘‘mesoderm development’’ (SI Appendix, SI Tables Ntion mechanisms governing cell fate choices in metazoans 1 and 2), consistent with the notion that SMCs from knockout (1, 2). The central element of this signaling pathway is the Notch animals harbor significant functional differences compared with cell surface receptor, a single-pass transmembrane protein, those carrying WT Notch 3 receptors. which interacts with membrane-bound ligands expressed on Given the relevance of vascular SMCs to stroke, we examined adjacent cells linking the fate of one cell to that of its neighbor the ischemia susceptibility of mice lacking Notch 3 function in a (3, 4). In mammals, four paralogs of the Notch receptor have standard filament model of proximal middle cerebral artery Ϫ/Ϫ been identified, Notch 1–4, with overlapping but nonidentical (MCA) occlusion (11). In this assay, Notch 3 mice developed expression patterns (5). In adult tissues, Notch 3 expression is ischemic lesions approximately twice as large as those seen in ϩ/Ϫ restricted to vascular smooth muscle cells (SMCs) (5). Notwith- WT or heterozygous (Notch 3 ) 10- to 12-week-old male mice standing subtle arterial abnormalities reported in Notch 3 mu- (Fig. 3 A and B). Consistent with the severity of stroke, neuro- tant mice (6), the role of Notch 3 in vascular physiology remains logical deficits were more pronounced (Bederson neurological Ϫ/Ϫ unclear. score on day 1 median values: WT ϭ 1, Notch 3 ϭ 2, P Ͻ 0.01) and mortality higher upon MCA occlusion in Notch 3Ϫ/Ϫ mice Results compared with WT (Fig. 3C). To assess whether enlarged To explore Notch 3 function, we used a previously uncharacter- infarcts were the result of more severe cerebral blood flow (CBF) ized Notch 3 knockout mouse model provided by W. C. Skarnes deficits, we used laser speckle flowmetry (LSF) during distal and M. Tessier-Lavigne (7). Like Notch 3 knockouts studied in MCA occlusion (12). This two-dimensional optical imaging refs. 8 and 9, this mutant mouse was viable and fertile. The null technique measures cortical blood flow with high spatial reso- allele was generated by insertional mutagenesis with a lacZ lution, quantifies the ischemic area, and allows for monitoring of carrying vector so that ␤-galactosidase (␤-gal) expression par- spontaneous periinfarct depolarizations (PIDs) triggered by anoxic release of Kϩ and excitatory amino acids from the infarct allels that of Notch 3 (Fig. 1). Our analysis generally agrees with Ϫ Ϫ reported Notch 3 expression studies in the vasculature (10) but core (13, 14). Using this method, we found that Notch 3 / mice did reveal a broader distribution, including the neuronal pro- developed a 60% larger area of severe CBF deficit than WT mice genitor-containing ventricular zone of the developing neural (P Ͻ 0.01) (Fig. 3 D and E). Thus, using two distinct approaches, tube between embryonic day 12.5 (E12.5) and E15.5 and the we find complete loss of Notch 3 function to be associated with neonatal brain [supporting information (SI) Appendix, SI Fig. 6, significant ischemic abnormalities. Interestingly, the frequency and data not shown]. Relevant to this study, in situ hybridization, of spontaneous PIDs, which are known to aggravate stroke (15), X-gal staining, and immunofluorescence confirmed expression of Notch 3 in SMCs from brain vessels and aorta (Fig. 1 D–F and Author contributions: J.F.A.-V. and Z.Z. contributed equally to this work; J.F.A.-V., Z.Z., A.L., data not shown). A morphological study involving immunostain- S.S., C.A., M.A.M., and S.A.-T. designed research; J.F.A.-V., Z.Z., H.K.S., A.L., H.-H.K., S.I.S., ing with SMC-specific antibodies and electron microscopy did S.S., and C.A. performed research; J.F.A.-V., Z.Z., H.K.S., A.L., H.-H.K., S.I.S., J.K.L., S.S., C.A., not reveal any abnormalities in either brain vessels or the aorta M.A.M., and S.A.-T. analyzed data; and J.F.A.-V., A.L., C.A., M.A.M., and S.A.-T. wrote the of knockout mice (Fig. 1G; SI Appendix, SI Fig. 7; and data not paper. shown). The authors declare no conflict of interest. To investigate further the properties of SMCs lacking Notch This article is a PNAS Direct Submission. 3 function, we developed a FACS-based cell purification proto- ʈTo whom correspondence should be addressed. E-mail: [email protected]. col, taking advantage of the ␤-gal expression associated with the This article contains supporting information online at www.pnas.org/cgi/content/full/ Notch 3 knockout allele in SMCs, virtually the only cells in the 0709867105/DC1. adult brain to express Notch 3 (Figs. 1 and 2). Brain-derived cells © 2008 by The National Academy of Sciences of the USA 4856–4861 ͉ PNAS ͉ March 25, 2008 ͉ vol. 105 ͉ no. 12 www.pnas.org͞cgi͞doi͞10.1073͞pnas.0709867105 Downloaded by guest on September 23, 2021 Fig. 1. Characterization of the Notch 3 knockout mice. (A) A schematic of the heterodimeric Notch 3 receptor (Upper) indicating key structural features. In the extracellular domain, the 34 EGF-like repeats (gray boxes) and the three Lin12-Notch repeats (green boxes) are indicated. The transmembrane domain (TM), and the intracellular ankyrin repeat region are also shown (red boxes). The insertional mutagenesis, which generated the knockout allele, resulted in a fusion protein (Lower) containing EGF-like repeats 1–21 of Notch 3 fused to ␤-gal (blue box). (B) Long-range PCR amplified intron 16–17 (Ϸ2 kb) of the Notch 3 gene in DNA samples from WT (Notch 3ϩ/ϩ) or heterozygous animals (Notch 3ϩ/Ϫ) but failed to amplify the larger intron containing the trapped vector in DNA from knockout mice (Notch 3Ϫ/Ϫ). (C) The Notch 3 intracellular domain was detected by Western blot analysis of cultured aortic smooth muscle cells (SMCs) derived from WT and Notch 3ϩ/Ϫ but absent (also by qRT-PCR, data not shown) in those derived from Notch 3Ϫ/Ϫ mice. (D) Notch 3 expression. In situ hybridization, using a Notch 3 antisense riboprobe labeled vessels in brain from WT mice (Upper). Likewise, X-gal staining (Lower)ofNotch 3ϩ/Ϫ (Left) and Notch 3Ϫ/Ϫ (Right) brain vessels. (E) Immunofluorescence of brain tissue sections demonstrated the colocalization of ␤-gal and Notch 3 extracellular epitopes in brain arteries from Notch 3ϩ/Ϫ mice. (F) Aortic SMC layers from WT mice (white) showed Notch 3 expression. (G) Low magnification electron micrographs of arterial cortical vessels (Left) and aorta (Right) from 8-week-old WT and Notch 3Ϫ/Ϫ mice. Asterisks indicate smooth muscle cells. L, lumen. (Scale bars: Left,5␮m; Right,10␮m.) was more than doubled in Notch 3Ϫ/Ϫ compared with WT mice Discussion (6.0 Ϯ 2.5 vs. 2.9 Ϯ 2.5 PIDs per h, P Ͻ 0.05) (Fig. 4). However, Stroke burden is a key factor in determining short- and long-term Ϫ Ϫ Notch 3 / mice did not exhibit the characteristic transient neurological disability.
Recommended publications
  • The Role of Sartans in the Treatment of Stroke and Subarachnoid Hemorrhage: a Narrative Review of Preclinical and Clinical Studies
    brain sciences Review The Role of Sartans in the Treatment of Stroke and Subarachnoid Hemorrhage: A Narrative Review of Preclinical and Clinical Studies Stefan Wanderer 1,2,*, Basil E. Grüter 1,2 , Fabio Strange 1,2 , Sivani Sivanrupan 2 , Stefano Di Santo 3, Hans Rudolf Widmer 3 , Javier Fandino 1,2, Serge Marbacher 1,2 and Lukas Andereggen 1,2 1 Department of Neurosurgery, Kantonsspital Aarau, 5001 Aarau, Switzerland; [email protected] (B.E.G.); [email protected] (F.S.); [email protected] (J.F.); [email protected] (S.M.); [email protected] (L.A.) 2 Cerebrovascular Research Group, Neurosurgery, Department of BioMedical Research, University of Bern, 3008 Bern, Switzerland; [email protected] 3 Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; [email protected] (S.D.S.); [email protected] (H.R.W.) * Correspondence: [email protected] or [email protected]; Tel.: +41-628-384-141 Received: 17 January 2020; Accepted: 5 March 2020; Published: 7 March 2020 Abstract: Background: Delayed cerebral vasospasm (DCVS) due to aneurysmal subarachnoid hemorrhage (aSAH) and its sequela, delayed cerebral ischemia (DCI), are associated with poor functional outcome. Endothelin-1 (ET-1) is known to play a major role in mediating cerebral vasoconstriction. Angiotensin-II-type-1-receptor antagonists such as Sartans may have a beneficial effect after aSAH by reducing DCVS due to crosstalk with the endothelin system. In this review, we discuss the role of Sartans in the treatment of stroke and their potential impact in aSAH.
    [Show full text]
  • Implications for Brain Injury and Protection
    Antithrombotic, procoagulant, and fibrinolytic mechanisms in cerebral circulation: implications for brain injury and protection Berislav V. Zlokovic, M.D., Ph.D. Department of Neurosurgery and Division of Neurosurgery, Childrens Hospital, University of Southern California School of Medicine, Los Angeles, California Maintaining a delicate balance among anticoagulant, procoagulant, and fibrinolytic pathways in the cerebral microcirculation is of major importance for normal cerebral blood flow. Under physiological conditions and in the absence of provocative stimuli, the anticoagulant and fibrinolytic pathways prevail over procoagulant mechanisms. Blood clotting is essential to minimize bleeding and to achieve hemostasis; however, excessive clotting contributes to thrombosis and may predispose the brain to infarction and ischemic stroke. Conversely, excessive bleeding due to enhanced anticoagulatory and fibrinolytic mechanisms could predispose the brain to hemorrhagic stroke. Recent studies in the author's laboratory indicate that brain capillary endothelium in vivo produces thrombomodulin (TM), a key cofactor in the TM­protein C system that is of major biological significance to the antithrombotic properties of the blood-brain barrier (BBB). The BBB endothelium also expresses tissue plasminogen activator (tPA), a key protein in fibrinolysis, and its rapid inhibitor, plasminogen activator inhibitor (PAI-1). The procoagulant tissue factor is normally dormant at the BBB. There is a vast body of clinical evidence to document the importance of hemostasis in the pathophysiology of brain injury. In particular, functional changes caused by major stroke risk factors in the TM­protein C, tPA/PAI-1, and tissue factor systems at the BBB may result in large and debilitating infarctions following an ischemic insult. Thus, correcting this hemostatic imbalance could ameliorate drastic CBF reductions at the time of ischemic insult, ultimately resulting in brain protection.
    [Show full text]
  • Unarousable Unresponsiveness in Which the Patient Lies with the Eye Closed and Has No Awareness of Self and Surroundings (2)
    Neurological Disease Deborah M Stein, MD, MPH 1. Coma a. Coma is defined as “a state of extreme unresponsiveness, in which an individual exhibits no voluntary movement or behavior” (1). i. Alternatively, coma is a state of unarousable unresponsiveness in which the patient lies with the eye closed and has no awareness of self and surroundings (2). b. Coma lies on a spectrum with other alterations in consciousness – from confusion to delirium to obtundation to stupor to coma and, ultimately, brain death (2). c. To be clearly distinguished from syncope, concussion, or other states of transient unconsciousness coma must persist for at least one hour (2). d. There are 2 important characteristics of the conscious state (3) i. The level of consciousness – “arousal or wakefulness” 1. Regulated by physiological functioning and consists of more primitive responsiveness to the world such as predictable involuntary reflex responses to stimuli. 2. Arousal is maintained by the reticular activating system (RAS) - a network of structures (including the brainstem, the medulla, and the thalamus) ii. The content of consciousness – “awareness” 1. Regulated by cortical areas within the cerebral hemispheres, e. There are two main causes for coma: i. Bihemispheric diffuse cortical or white matter damage or ii. Brainstem lesions bilaterally affecting the subcortical reticular activating systems. f. A huge number of conditions can result in coma. One way to categorize these conditions is to divide them into the anatomic and the metabolic causes of coma. i. Anatomic causes of coma are those conditions that disrupt the normal physical architecture and anatomy, either at the level of the cerebral cortex or the brainstem ii.
    [Show full text]
  • Predicting Recurrent Stroke After Minor Stroke and Transient Ischemic Attack
    Review For reprint orders, please contact [email protected] Predicting recurrent stroke after minor stroke and transient ischemic attack Expert Rev. Cardiovasc. Ther. 7(10), 1273–1281 (2009) Philippe Couillard, The risk of a subsequent stroke following an acute transient ischemic attack or minor stroke is Alexandre Y Poppe high, with 90-day risk at approximately 10%. Identification of those patients at the highest risk and Shelagh B Coutts† for recurrent stroke following a transient ischemic attack or minor stroke may allow risk-specific †Author for correspondence management strategies to be implemented, such as hospital admission with expedited work-up Department of Clinical for those at high risk and emergency room discharge for those at low risk. Predictors of recurrent Neurosciences and Radiology, stroke, including the ABCD2 score, brain imaging and the stroke mechanism, are reviewed in University of Calgary, C1261, this article, with a focus on recent literature. An emphasis is placed on the importance of early Foothills Medical Centre, imaging of the brain parenchyma (diffusion-weighted imaging) and vascular imaging to identify 1403 29th St NW, Calgary, patients at high risk for recurrence. The need for identification of the cause of the initial event, AB, T2N 2T9, Canada allowing therapies to be tailored to the individual patient, is discussed. Tel.: 1 403 944 1594 Fax: 1 403 283 2270 KEYWORDS: imaging • prevention • prognosis • recurrence • stroke • transient ischemic attack shelagh.coutts@ albertahealthservices.ca Stroke is the second leading cause of death and is present very quickly after symptom onset. This a major cause of adult disability in the world [1,2].
    [Show full text]
  • Prevalence and Characteristics of Migraine in CADASIL
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Universität München: Elektronischen Publikationen Original Article Cephalalgia 2016, Vol. 36(11) 1038–1047 ! International Headache Society 2015 Prevalence and characteristics Reprints and permissions: sagepub.co.uk/journalsPermissions.nav of migraine in CADASIL DOI: 10.1177/0333102415620909 cep.sagepub.com Stephanie Guey1,2,Je´roˆme Mawet1,3, Dominique Herve´ 1,2, Marco Duering4, Ophelia Godin1, Eric Jouvent1,2, Christian Opherk5, Nassira Alili1, Martin Dichgans4,6 and Hugues Chabriat1,2 Abstract Background and objective: Migraine with aura (MA) is a major symptom of cerebral autosomal dominant arterio- pathy with subcortical infarcts and leukoencephalopathy (CADASIL). We assessed the spectrum of migraine symptoms and their potential correlates in a large prospective cohort of CADASIL individuals. Methods: A standardized questionnaire was used in 378 CADASIL patients for assessing headache symptoms, trigger factors, age at first attack, frequency of attacks and associated symptoms. MRI lesions and brain atrophy were quantified. Results: A total of 54.5% of individuals had a history of migraine, mostly MA in 84% of them; 62.4% of individuals with MA were women and age at onset of MA was lower in women than in men. Atypical aura symptoms were experienced by 59.3% of individuals with MA, and for 19.7% of patients with MA the aura was never accompanied by headache. MA was the inaugural manifestation in 41% of symptomatic patients and an isolated symptom in 12.1% of individuals. Slightly higher MMSE and MDRS scores and lower Rankin score were detected in the MA group.
    [Show full text]
  • Brain Ischemia Due to Direct Vascular Compression Associate with Rapid
    www.surgicalneurologyint.com Surgical Neurology International Editor-in-Chief: Nancy E. Epstein, MD, Clinical Professor of Neurological Surgery, School of Medicine, State U. of NY at Stony Brook. SNI: Neurovascular Editor Kazuhiro Hongo, MD Shinshu University, Matsumoto, Japan Open Access Case Report Brain ischemia due to direct vascular compression associate with rapid enlargement of unruptured middle cerebral artery aneurysm: A case report Hiroshi Miyachi*, Kohei Suzuki*, Shohei Nagasaka, Takehiro Kitagawa, Junkoh Yamamoto Department of Neurosurgery, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan. *ese authors contributed equally to this work. E-mail: Hiroshi Miyachi - [email protected]; *Kohei Suzuki - [email protected]; Shohei Nagasaka - [email protected]; Takehiro Kitagawa - [email protected]; Junkoh Yamamoto - [email protected] ABSTRACT Background: Acute cerebral infarction is a rare complication resulting from an unruptured cerebral aneurysm (UCA). ere is presently no consensus on the optimal strategy for the management of UCAs with cerebral infarctions. Case Description: A 53-year-old man presented with transient dysarthria and left hemiparesis. Magnetic resonance imaging (MRI) demonstrated the presence of a 7 mm UCA originating from the middle cerebral *Corresponding author: artery bifurcation, and diffusion-weighted imaging showed no evidence of cerebral infarction. One month later, Kohei Suzuki, his transient left hemiparesis recurred, and the patient was admitted to our hospital. Computed tomography Department of Neurosurgery, angiography showed enlargement of the aneurysm. His left hemiparesis worsened 3 days later. MRI showed University of Occupational cerebral infarction in the area of perforating arteries and further enlargement of the aneurysm with surrounding and Environmental Health, parenchymal edema.
    [Show full text]
  • A Pure Model for Studying Cerebral Small Vessel Disease
    From Department of Neurobiology, Care Sciences and Society (NVS) Karolinska Institutet, Stockholm, Sweden CADASIL: A PURE MODEL FOR STUDYING CEREBRAL SMALL VESSEL DISEASE Mahmod Panahi Stockholm 2019 All previously published papers were reproduced with permission from the publisher. Published by Karolinska Institutet. Printed by Printed by E-Print AB 2018 © Mahmod Panahi, 2019 ISBN 978-91-7831-485-0 CADASIL: A pure model for studying cerebral small vessel disease THESIS FOR DOCTORAL DEGREE (Ph.D.) By Mahmod Panahi Principal Supervisor: Opponent: Homira Behbahani Christof Haffner Karolinska Institutet Ludwig-Maximilians-University Department of Neurobiology, Care Sciences and Department of Biochemistry Society (NVS) Division of Stroke and Dementia Research Division of Neurogeriatrics Examination Board: Co-supervisor(s): Ewa Ehrenborg Matti Viitanen Karolinska Institutet Karolinska Institutet Department of Medicine Department of Neurobiology, Care Sciences and Society (NVS) Johan Lökk Division of Clinical geriatrics Karolinska Institutet Department of Neurobiology, Care Sciences and Taher Darreh-Shori Society (NVS) Karolinska Institutet Division of Clinical geriatrics Department of Neurobiology, Care Sciences and Society (NVS) Katarina Nägga Division of Clinical geriatrics Linköping University Department of Clinical and Experimental Medicine Division of Neuro and Inflammation Sciences ABSTRACT Cerebral autosomal dominant arteriopathy with subcortical infarct and leukoencephalopathy (CADASIL) is caused by a mutation on the NOTCH3 gene. The pathological driver behind this disease is the loss of vascular smooth muscle cells (VSMCs) in small blood vessels and subsequent fibrotic thickening of the vessel, causing stenosis. Although a great deal of knowledge has been accumulated through CADASIL research, more information is needed to fully grasp the pathological mechanisms as well as understand disease progression.
    [Show full text]
  • Mechanisms of Brain Injury After Global Cerebral Ischemia
    Neurol Clin 24 (2006) 1–21 Mechanisms of Brain Injury after Global Cerebral Ischemia Izumi Harukuni, MDa, Anish Bhardwaj, MDb,* aDepartment of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Division of Cardiac Anesthesiology, Tower 711, Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, USA bDepartments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Neurosciences Critical Care Division, Meyer 8-140, Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, USA Global cerebral ischemia occurs commonly in patients who have a variety of clinical conditions including cardiac arrest (CA), shock, and asphyxia and in patients undergoing complex cardiac surgery [1–4]. In addition to injury to other organs from systemic hypoperfusion, neurologic sequelae from brain injury are varied and constitute a spectrum that includes coma, sei- zures, ischemic stroke, delirium, and neurocognitive impairment [5–7]. The commonest postulated mechanism for ischemic brain injury after CA (with subsequent resuscitation) is global cerebral ischemia from systemic hypoperfusion that can occur with or without pre-existing large-vessel occlusive disease. Embolism that arises from the heart, from aortic arch ar- theromas, or from extracorporeal circulation devices occurs more commonly in the perioperative period following complex cardiac surgery and less com- monly during resuscitation following CA [7]. Irrespective of the etiology of cerebral ischemia, cellular and molecular processes trigger a cascade of events that culminate in a ‘‘final common pathway,’’ resulting in ischemic neuronal injury. Identification of these injury mediators and pathways in a variety of experimental animal models of global cerebral ischemia has led to investigation of target-specific cytoprotective strategies that are criti- cal to clinical brain injury outcome.
    [Show full text]
  • The Brain After Cardiac Arrest
    19 The Brain after Cardiac Arrest Jonathan Elmer, MD, MS1,2 Clifton W. Callaway, MD, PhD1 1 Department of Emergency Medicine, University of Pittsburgh, Address for correspondence Clifton W. Callaway, MD, PhD, Iroquois Pittsburgh, Pennsylvania Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA 15260 2 Department of Critical Care Medicine, University of Pittsburgh, (e-mail: [email protected]). Pittsburgh, Pennsylvania Semin Neurol 2017;37:19–24. Abstract Cardiac arrest is common and deadly. Most patients who are treated in the hospital after achieving return of spontaneous circulation still go on to die from the sequelae of anoxic brain injury. In this review, the authors provide an overview of the mechanisms and consequences of postarrest brain injury. Special attention is paid to potentially modifiable mechanisms of secondary brain injury including seizures, hyperpyrexia, Keywords cerebral hypoxia and hypoperfusion, oxidative injury, and the development of cerebral ► cardiac arrest edema. Finally, the authors discuss the outcomes of cardiac arrest survivors with a focus ► brain injury on commonly observed patterns of injury as well as the scales used to measure patient ► outcomes outcome and their limitations. Cardiac arrest (CA) is the most common cause of death in the Neuronal Death after Cardiac Arrest – developed world, claiming over 17 million lives annually.1 3 Despite advances in care, the majority of patients who are The physiological and molecular events associated with brain treated after the return of spontaneous circulation (ROSC) injury after CA are complex and have been described in – will succumb to the sequelae of hypoxic-ischemic brain injury detail.6 8 In the clinical setting, hypoxic-ischemic brain injury before hospital discharge.
    [Show full text]
  • Daily Low Dose of Erythropoietin in Neuroinflammation;
    Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 20 August 2020 doi:10.20944/preprints202006.0107.v2 Daily Low Dose of Erythropoietin in Neuroinflammation; EPO might be hazardous in COVID-19 Reza Nejat 1, Ahmad Shahir Sadr 2, 3, 4, Alireza Ebrahimi 5, Alireza Nabati 6, Elham Eshaghi7 1Anesthesiologist, Fellow of Critical Care Medicine, Former Assistant Professor, Anesthesia and Critical Care Medicine Dept., Shahid Beheshti University of Medical Sciences, Tehran, IRAN. [email protected], rezanejat.com 2Department of Computer Science, Faculty of Mathematical Sciences, Shahid Beheshti University, Tehran, Iran, 3Department of Phytochemistry, Medicinal Plants and Drugs Research Institute, Shahid Beheshti University, Tehran, Iran, 4School of Biological Sciences, Institute for Research in Fundamental Sciences (IPM), Tehran, Iran 5Anesthesiologist, Subspecialist of Critical Care Medicine, Chief of ICU, Shohadaye Gomnam Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 6Neurosurgeon, AJA University of Medical Sciences, Tehran, Iran 7Elham Eshaghi, Resident in Anesthesiology Program, AJA University of Medical Sciences, Tehran, Iran Abstract Neuroinflammation, defined as inflammatory reactions mediated by cytokines, chemokines, reactive oxygen species, and secondary messengers in the central nervous system (CNS) including the brain and spinal cord is the basis of many neurological disorders. Recently, erythropoietin (EPO) has been considered and studied as a modulator of neuroinflammation. On this article minireview of pathophysiology of neuroinflammation and the neuroprotective effects of EPO is discussed and a case of subacute huge subdural hematoma with double mydriasis operated urgently, treated with low daily dose (vs high dose once or twice a month in the literature) of EPO and recovered fully and discharged home with good consciousness is reported.
    [Show full text]
  • Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy: a Genetic Cause of Cerebral Small Vessel Disease
    REVIEW Print ISSN 1738-6586 / On-line ISSN 2005-5013 J Clin Neurol 2010;6:1-9 10.3988/jcn.2010.6.1.1 Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy: A Genetic Cause of Cerebral Small Vessel Disease Jay Chol Choi, MD, PhD Department of Neurology and Institute of Medical Science, Jeju National University School of Medicine, Jeju, Korea Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a single-gene disorder of the cerebral small blood vessels caused by mutations in the Notch3 gene. The exact prevalence of this disorder was unknown currently, and the number of reported CADASIL families is steadily increasing as the clinical picture and diagnostic ex- aminations are becoming more widely known. The main clinical manifestations are recurrent st- Received September 17, 2009 roke, migraine, psychiatric symptoms, and progressive cognitive impairment. The clinical course Revised November 25, 2009 of CADASIL is highly variable, even within families. The involvement of the anterior temporal Accepted November 25, 2009 lobe and the external capsule on brain magnetic resonance imaging was found to have high sen- Correspondence sitivity and specificity in differentiating CADASIL from the much more common sporadic cere- Jay Chol Choi, MD, PhD bral small-vessel disease (SVD). The pathologic hallmark of the disease is the presence of gran- Department of Neurology ular osmiophilic material in the walls of affected vessels. CADASIL is a prototype single-gene and Institute of Medical Science disorder that has evolved as a unique model for studying the mechanisms underlying cerebral Jeju National University, SVD. At present, the incidence and prevalence of CADASIL seem to be underestimated due to School of Medicine, limitations in clinical, neuroradiological, and genetic diagnoses of this disorder.
    [Show full text]
  • Transient Ischemic Attacks: Part I. Diagnosis and Evaluation NINA J
    COVER ARTICLE Transient Ischemic Attacks: Part I. Diagnosis and Evaluation NINA J. SOLENSKI, M.D., University of Virginia Health Sciences Center, Charlottesville, Virginia Transient ischemic attack is no longer considered a benign event but, rather, a critical harbinger of impending stroke. Failure to quickly recognize and evaluate this warning O A patient infor- sign could mean missing an opportunity to prevent permanent disability or death. The mation handout on 90-day risk of stroke after a transient ischemic attack has been estimated to be approxi- strokes and TIAs, writ- ten by the author of mately 10 percent, with one half of strokes occurring within the first two days of the this article, is provided attack. The 90-day stroke risk is even higher when a transient ischemic attack results on page 1679. from internal carotid artery stenosis. Most patients reporting symptoms of transient ischemic attack should be sent to an emergency department. Patients who arrive at the emergency department within 180 minutes of symptom onset should undergo an expedited history and physical examination, as well as selected laboratory tests, to determine if they are candidates for thrombolytic therapy. Initial testing should include complete blood count with platelet count, prothrombin time, International Normalized Ratio, partial thromboplastin time, and electrolyte and glucose levels. Computed tomo- graphic scanning of the head should be performed immediately to ensure that there is no evidence of brain hemorrhage or mass. A transient ischemic attack can be mis- diagnosed as migraine, seizure, peripheral neuropathy, or anxiety. (Am Fam Physician 2004;69:1665-74,1679-80. Copyright© 2004 American Academy of Family Physicians.) ased on an increased under- than 50 percent of all adverse events standing of brain ischemia occurred within the first four days after and the introduction of new the TIA.
    [Show full text]