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Sandra B. Cadichon, Hoang M. Le, David A. Wright, Daniel J. Curry, Un Kang and David M. Frim

Object

Neuronal injury remains a leading cause of morbidity in both neonates and adults with injuries induced by intracranial hemorrhage, ischemia–reperfusion, and excitotoxicity. To date, a number of neuroprotective strategies have been evaluated, but they have shown little benefit. Poloxamer 188 (P-188), a membrane-active triblock copolymer, has been studied extensively as a cell-membrane sealant. The authors used an animal model to study the neuroprotectant effects of P-188 administered by intracisternal (IC) injection after experimentally induced intraparenchymal hemorrhage.

Methods

Sprague–Dawley rats received an IC injection of either P-188 or vehicle (artificial cerebrospinal fluid) 10 minutes after striatal infusion of 50 μl of autologous blood. Animals from both treatment groups were killed either 2 or 7 days later. In a second experiment, after striatal blood infusion and early IC injection of either P-188 or vehicle, animals received daily IC injections of either P-188 or vehicle for 5 days, and were killed 7 days after induction of the experimental hemorrhage. Striatal tissues were histologically analyzed for neuronal loss, and lesion volumes were determined.

Lesion volumes in the animals that received a single dose of P-188 were significantly smaller (mean ± standard deviation 18.3 ± 4.3 mm3, six rats; p = 0.04) than those in the control group (31.4 ± 4.3 mm3, seven rats) when measured 2 days postinjection; however, no difference in lesion volumes was present 7 days postinjection. Lesion volumes in the animals who received 5 days of daily P-188 injections were significantly smaller (1.50 ± 0.58 mm3, 10 rats; p = 0.04) than those in the corresponding control group (5.04 ± 1.85 mm3, eight rats) when measured at 7 days.

Conclusions

A single dose of P-188 protects against early neuronal loss after hemorrhage but has no effect on long-term hemorrhage-induced neuronal loss. However, repeated daily P-188 treatment appears to produce effective long-term neuronal protection.

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Daniel J. Curry, David A. Wright, Raphael C. Lee, Un Jung Kang and David M. Frim

Object. The surfactant, poloxamer 188 (P-188), has been found to protect against tissue injury in various experimental models. Its protective mechanism may involve the effects of the surfactant against oxidative stress and inflammation. The authors investigated the role of P-188 in the reduction of tissue injury and macrophage response in a model of excitotoxic brain injury in the rat striatum.

Methods. Fifteen Sprague—Dawley rats underwent stereotactic injection of 120 nmol of quinolinic acid into the striatum and received intracisternal injection of vehicle or P-188 (40 mg/kg) at 10 minutes and 4 hours postinjury. Rats were killed after 1 week, and the histological score was determined based on the degree of overall tissue injury (Grades 1–4) at the lesion site. The number of macrophages within the lesioned striatum was compared with that found within the striatum on the nonoperated contralateral side. The scores related to tissue damage and the macrophage ratios of each group were then compared using t-tests.

Striatal injection of the toxin produced a lesion characterized by necrosis and inflammation surrounding the injection site in all six control animals. In rats in which intracisternal P-188 was administered, significantly less tissue injury was demonstrated (mean score 2.45 ± 0.74) than in controls (mean score 3.14 ± 0.75) (p = 0.045). The rats that received intracisternal surfactant also had significantly less macrophage infiltrate (mean ratio 1.06 ± 0.18) than control animals (mean ratio 2.00 ± 0.48) (p = 0.004).

Conclusions. The surfactant P-188 reduces tissue loss and macrophage infiltrate after excitotoxic brain injury in the rat. Possible mechanisms of this effect may include direct surfactant modulation of inflammatory cell membrane fluidity.

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Ryan M. Martin, Matthew J. Wright, Evan S. Lutkenhoff, Benjamin M. Ellingson, John D. Van Horn, Meral Tubi, Jeffry R. Alger, David L. McArthur and Paul M. Vespa

OBJECTIVE

Hemorrhagic contusions are often the most visible lesions following traumatic brain injury. However, the incidence, location, and natural history of traumatic parenchymal hemorrhage and its impact on neurological outcome have been understudied. The authors sought to examine the location and longitudinal evolution of traumatic parenchymal hemorrhage and its association with cognitive outcome.

METHODS

Sixteen patients with hemorrhagic contusions due to acceleration-deceleration injuries underwent MRI in the acute (mean 6.3 days postinjury) and chronic (mean 192.9 days postinjury) phases. ImageJ was used to generate GRE and FLAIR volumes. To account for the effect of head-size variability across individuals, the authors calculated each patient's total brain tissue volume using SIENAX. GRE and FLAIR volumes were normalized to the total brain tissue volume, and values for absolute and percent lesion volume and total brain volume change were generated. Spearman's rank correlations were computed to determine associations between neuroimaging and 6-month postinjury neuropsychological testing of attention (Symbol Digit Modalities Test [SDMT], oral [O] and written [W] versions), memory (Selective Reminding Test, total learning and delayed recall), and executive function (Trail Making Test Part B [TMT-B]).

RESULTS

The patients' mean age was 31.4 ± 14.0 years and their mean Glasgow Coma Scale score at admission was 7.9 ± 2.8. Lesions were predominantly localized to the frontal (11 lesions) and temporal (9 lesions) lobes. The average percent reductions in GRE and FLAIR volumes were 44.2% ± 46.1% and 80.5% ± 26.3%, respectively. While total brain and frontal lesion volumes did not correlate with brain atrophy, larger temporal lobe GRE and FLAIR volumes were associated with larger volumes of atrophy (GRE: acute, −0.87, p < 0.01, chronic, −0.78, p < 0.01; FLAIR: acute, −0.81, p < 0.01, chronic, −0.88, p < 0.01). Total percent volume change of GRE lesions correlated with TMT-B (0.53, p < 0.05) and SDMT-O (0.62, p < 0.05) scores. Frontal lobe lesion volume did not correlate with neuropsychological outcome. However, robust relationships were seen in the temporal lobe, with larger acute temporal lobe GRE volumes were associated with worse scores on both oral and written versions of the SDMT (SDMT-W, −0.85, p < 0.01; SDMT-O, −0.73, p < 0.05). Larger absolute change in temporal GRE volume was strongly associated with worse SDMT scores (SDMT-W, 0.88, p < 0.01; SDMT-O, 0.75, p < 0.05). The same relationships were also seen between temporal FLAIR lesion volumes and neuropsychological outcome.

CONCLUSIONS

Traumatic parenchymal hemorrhages are largely clustered in the frontal and temporal lobes, and significant residual blood products are present at 6 months postinjury, a potential source of ongoing secondary brain injury. Neuropsychological outcome is closely tied to lesion volume size, particularly in the temporal lobe, where larger GRE and FLAIR volumes are associated with more brain atrophy and worse SDMT scores. Interestingly, larger volumes of hemorrhage resorption were associated with worse SDMT and TMT-B scores, suggesting that the initial tissue damage had a lasting impact on attention and executive function.

Open access

Ranjan Gupta, Justin P. Chan, Jennifer Uong, Winnie A. Palispis, David J. Wright, Sameer B. Shah, Samuel R. Ward, Thay Q. Lee and Oswald Steward

OBJECTIVE

Current management of traumatic peripheral nerve injuries is variable with operative decisions based on assumptions that irreversible degeneration of the human motor endplate (MEP) follows prolonged denervation and precludes reinnervation. However, the mechanism and time course of MEP changes after human peripheral nerve injury have not been investigated. Consequently, there are no objective measures by which to determine the probability of spontaneous recovery and the optimal timing of surgical intervention. To improve guidance for such decisions, the aim of this study was to characterize morphological changes at the human MEP following traumatic nerve injury.

METHODS

A prospective cohort (here analyzed retrospectively) of 18 patients with traumatic brachial plexus and axillary nerve injuries underwent biopsy of denervated muscles from the upper extremity from 3 days to 6 years after injury. Muscle specimens were processed for H & E staining and immunohistochemistry, with visualization via confocal and two-photon excitation microscopy.

RESULTS

Immunohistochemical analysis demonstrated varying degrees of fragmentation and acetylcholine receptor dispersion in denervated muscles. Comparison of denervated muscles at different times postinjury revealed progressively increasing degeneration. Linear regression analysis of 3D reconstructions revealed significant linear decreases in MEP volume (R = −0.92, R2 = 0.85, p = 0.001) and surface area (R = −0.75, R2 = 0.56, p = 0.032) as deltoid muscle denervation time increased. Surprisingly, innervated and structurally intact MEPs persisted in denervated muscle specimens from multiple patients 6 or more months after nerve injury, including 2 patients who had presented > 3 years after nerve injury.

CONCLUSIONS

This study details novel and critically important data about the morphology and temporal sequence of events involved in human MEP degradation after traumatic nerve injuries. Surprisingly, human MEPs not only persisted, but also retained their structures beyond the assumed 6-month window for therapeutic surgical intervention based on previous clinical studies. Preoperative muscle biopsy in patients being considered for nerve transfer may be a useful prognostic tool to determine MEP viability in denervated muscle, with surviving MEPs also being targets for adjuvant therapy.