Research Programs
Active research programs of the faculty of the Department of Neurology span the full spectrum of translational neuroscience
research from the most basic neuroscience to highly clinically-oriented research, such as clinical trials. Our faculty
place a strong emphasis on training future neuroscience researchers. The unique training environment in our department has
provided the foundation for our graduate and postdoctoral training program in Translational Neuroscience.
Brain Imaging Research
Brain imaging research in our department has been applied to a variety of research projects, in large part to the
leadership of Steven Small MD PhD. Research directions
include application of functional MRI and neuropsychological tools to the study of language, neural plasticity in recovery
from stroke, and disease biomarkers.
- Dr. Small uses functional magnetic resonance imaging (fMRI) to study the organization of the normal human cerebral
cortex and the changes that it undergoes after neurological injury, particularly stroke. Damage to the cerebral cortex has
profound effects on such functions as learning, memory, language, and complex motor activity. Damage to structures that
must communicate with the cortex or damage to the communication network also causes serious impairments. By studying the
neuroanatomical substrates of recovery from injury, Dr. Small is attempting construct a functional basis for neurological
rehabilitation that is grounded in basic neuroscience. Current projects in the Small group are in the areas of language and
motor function, and are concerned with both the normal anatomy of these functions and their recovery after stroke. In the
study of normal adults, the lab has found that the language areas of the brain are more widely distributed than previously
thought, extending to brain regions that are anatomically removed from those originally postulated by Broca, Wernicke, and
Déjérine, and extending to both cerebral hemispheres. Furthermore they have discovered that the parts of the brain that
previously appeared specialized for language production (i.e., Broca’s area and ventral premotor cortex) play a fundamental
role in language comprehension as well, by a process in which the listener uses this premotor language production system to
make guesses about what he or she is hearing. In hand motor function, Dr. Small’s laboratory has found that left and right
handed people use somewhat different brain networks when making simple and complex finger movements. Further, the brain
seems to encode such finger movements by both individual muscle and pattered movement, expanding one view of motor
representations of the cortex. Finally they have demonstrated a critical role for the cerebellum contralateral to the
injury in mediating successful recovery from stroke.
Brain Tumors
In addition to a very active clinical research program, The University of Chicago Medical Center Department of Neurology is involved
in basic science research of brain tumors. We are actively investigating the development of novel vaccine therapies for primary and metastatic
brain tumors. Investigators in other departments including neurosurgery and radiation oncology are also actively involved in research
for the treatment of brain tumors.
Cerebrovascular Diseases
Researchers in the Department of Neurology Stroke Program focus on a range of issues from basic mechanisms of ischemic
neuronal death to nanotechnological interventions.
For more information visit our Neurosciences Critical Care page.
Cerebrovascular Diseases & Aging
- Richard Kraig MD PhD focusses his research on deciphering how the
brain can protect itself against neurological disease. The brain is unique among organ structures. It can alter its regional, cellular and
molecular structure in response to activity. This classically is evidenced by Hebbian synaptic plasticity but it also extends to
environmental enrichment (i.e., increased intellectual, social, and physical activity), which protects the brain against neurodegeneration.
The mechanisms by which naturally increased brain activity strengthens brain are largely unknown. Deciphering the bases by which increased
brain from environmental enrichment alters both the form and function of brain has immense clinical value since environmental enrichment
reduces subsequent neurological disease by half without negative sequelae.
Dr. Kraig's work, and that of others, shows that learning involves increased production of tumor necrosis factor alpha (TNF-a), one a group
of innate cytokines, typically recognized for their involvement as early responders to disease. Furthermore, his work shows that
neuroprotection from activity depends on intrinsic production of TNF-a. This is an adaptive change that requires time to develop and
extinguishes if not maintained by activity. Cytokines, including TNF-a, alter tissue structure and function by altering gene expression of
related transcription factors, growth factors and anti-apoptotic genes.
TNF-a and the other innate cytokines are highly pleiotropic and interactive. Accordingly, Dr. Kraig's lab has developed cell-specific
genomic and proteomic techniques to acquire the “vocabulary” needed to understand the “syntax” of activity-dependent neuroprotection via
the application of computational analysis strategies.
Dr. Kraig uses in vitro and in vivo animal models of epilepsy, stroke, aging, and migraine as our exemplary diseases for study. They use
cellular and molecular imaging strategies as well as genomic and proteomic techniques and computational analyses of data from these
approaches to search for the “signaling syntax” by which natural neural activity makes brain more resilient to disease. Their tools include
real-time cellular imaging, laser dissection microscopy, real-time RT-PCR, semi-quantitative cellular cytological and immunohistochemical
imaging, all proteomic tools (including bead-based, multiplexed ELISAs), and nanoparticle gene delivery systems now in development.
Specific Research Projects:
- The mechanisms and consequences of spreading depression
- The mechanisms by which brain activity results in neuroprotection
- How sleep modulates activity-dependent neuroprotection
- How cold generates neuroprotection
- Development and use of nanoparticle-based gene delivery for epilepsy treatment
- Development and use of macrophage-nanoparticle gene delivery systems for treatment of brain disease
Neuronal Ischemia Cell Death
- James Brorson MD is interested in how
glutamate-mediated "excitotoxic" stress contributes to neuronal death in several neurodegenerative diseases and ischemic
stroke. Dr. Brorson is attempting to understand the molecular basis for functional properties of glutamate receptors,
particularly those of the AMPA receptor class, and relate the subunit expression patterns in specific neurons to their
selective vulnerability to glutamate-mediated cell death. He employs both electrophysiological and molecular methods to
relate functional properties of expressed glutamate receptors to expression patterns of subunits and vulnerability to
excitotoxic death in neurons growing in primary dissociated cultures or in chronic organotypic slices. Recent studies have
focused on modeling ischemia-reperfusion in neurons in a realistic way that includes features of excess glutamate as well
as oxygen and substrate depletion during real-time fluorescence imaging of neurons in order to understand the timing and
molecular mechanisms leading to neuronal death. Endogenous systems of transcription factors including Hypoxia-inducible
factor-1 and signaling molecules such as nitric oxide may play both protective and destructive roles during reperfusion
injury, depending on the levels and timing of their expression. Understanding the responses to injury may point to novel
therapeutic targets for neuroprotection during the reperfusion phase of ischemic stroke.
Cortical Mapping Laboratory
- V. Leo Towle PhD has focussed his research to
utilize functional MRI, direct electrophysiologic cortical recordings obtained during surgery, and noninvasive human
cerebral evoked potentials as tools for understanding the functional organization of the human neocortex. A primary focus
is to relate electrophysiologic findings to specific brain areas which can be imaged with MRI. The non-invasive
electrophysiologic findings are compared to histology, intraoperative cortical mapping studies and parallel noninvasive
functional MRI findings. Currently investigations involve the accuracy of dipole models, ECOG patterns, and the development
and lateralization of language in epileptic and normal subjects using function MRI. This research has both practical value
for neurosurgical procedures and theoretical implications for theories of brain organization and development. Dr. Towle has
also studied cognitive event-related potentials as they relate to sensory and cognitive dysfunction in multiple sclerosis
(MS), stroke and renal disease patients participating in drug trials.
Developmental Disorders
- William Dobyns MD (Department of Human Genetics)
research focus over the past two decades has centered on the genetic basis of human brain malformations, and bringing new
discoveries back to clinical practice. Several different types of malformations, including agenesis of the corpus callosum,
Dandy-Walker malformation, congenital microcephaly, lissencephaly, cobblestone malformation and polymicrogyria are typically
associated with developmental abnormalities especially mental retardation, motor abnormalities (cerebral palsy) and
epilepsy. Dr. Dobyns research uses human brain malformations as tools to map and clone important developmental genes, and
brings these new discoveries back to patients and families by way of more accurate information regarding diagnosis,
prognosis, clinical management and genetic counseling. In addition, as epilepsy affecting more than 80% of patients in most
groups these conditions represent a paradigm for understanding the pathobiology of some forms of epilepsy.
Dr. Dobyns research program has three components that span the translational spectrum:
- Patient-oriented research designed to identify and study patients with brain malformations;
- Disease-oriented research directed toward finding the molecular basis of a disorder; and
- Patient-oriented research, which applies our new knowledge to the care of patients and families.
Identification of the genes involved in these malformations will help to define new molecular pathways and the location of
these genes within each pathway. Close collaboration with mouse geneticists, including at the University of Chicago, will
increase the power of gene discoveries by manipulating homologous genes in the murine system.
- Kathryn Millen PhD (Department of Human Genetics)
is interested disorders of the cerebellum, the primary center of motor coordination in the central nervous system.
Cerebellar disorders in both mouse and humans cause ataxia, tremor and abnormal eye movements. The cerebellum is also
involved in cognitive processing deficits and sensory discrimination in multiple medical conditions including pervasive
developmental disorders of childhood such as autism. Dr. Millen’s group is attempting to discover molecular and cellular
mechanisms by which the cerebellum is formed in the mouse as a paradigm for human congenital cerebellar malformations and
other developmental disorders. This is based on the hypothesis that similar patterning defects underlie mouse and human
malformations. Several mouse mutants with severe cerebellar defects have been described and attributed to disrupted
mechanisms of pattern formation during early embryogenesis. Currently, work focuses on several mutants, including the
dreher mouse, in which the dorsal signaling center in the developing CNS, the roof plate, is missing in homozygous
mutant mice. Neurons along the entire dorsal CNS, including the cerebellum, are inappropriately patterned and differentiate
abnormally. Dr. Millen’s group has identified mutations in the Lmx1a gene as the cause of the dreher phenotype.
Lmx1a now provides an entry point into the previously unknown molecular pathway of roof plate formation and function.
Through use of gene expression arrays and chick electroporation technologies they are defining other genes in the Lmx1a
roof plate cascade.
Dr. Millen’s group has recently extended their analysis to congenital human cerebellar malformations particularly
Dandy-Walker malformation (DWM) syndrome, a common, but poorly understood congenital cerebellar malformation. Recently,
they demonstrated that heterozygous loss of two dorsally expressed genes, ZIC1 and ZIC4 is involved in DWM
and have generated mouse models with Zic1+4 deletions. Sequence analysis of these genes in DWM patients suggests
that ZIC4 mutations increase susceptibility to DWM alone, but are not sufficient to cause DWM. The likely oligogenic or
polygenic model of inheritance has led to an active search for additional DWM loci and ZIC1/4 interacting genes
using array comparative genomic hybridization. An understanding of the basis of this and other common brain malformations
will not only provide valuable, currently unavailable diagnostic information but may also lead to treatments for those with
the congenital malformation. By combining the power and strengths of both mouse and human genetics, the studies in Dr.
Millen’s lab is providing clinically relevant data leading to better diagnosis and treatment of human congenital cerebellar
malformations as well as lead to a more comprehensive understanding of the basic biology and genetics of cerebellar
development.
Epilepsy
The University of Chicago neuroscience community is host to a diverse group of researchers investigating epilepsy and
seizure disorders. The faculty of Department of Neurology play a key role in this research, conducting critical clinical
and neurophysiological studies, and providing valuable collaborations with the neuroscience researchers in other
departments.
- John Ebersole MD directs a research program aimed
at:
- Clarifying the relationships between cerebral electrical activity and the resultant scalp EEG; and
- Developing and validating computational techniques of functional imaging and seizure localization using scalp,
intracranial EEG, and magnetoencephalography (MEG).
Over the past fifteen years research from his laboratory has established the usefulness of spike and seizure dipole
modeling with both EEG and MEG in order to localize non-invasively epileptogenic foci in epilepsy surgery candidates. He
is a foremost proponent of and authority on the use of source models in the evaluation of epilepsy. Ongoing projects
include studies of the accuracy of dipole and other extended source models of epileptic foci using simultaneously recorded
scalp and intracranial EEG, comparisons of real-time EEG imaging with other functional imaging techniques using
three-dimensional co-registrations, and the development of a new spatio-temporal analysis technique for intracranial EEG
utilizing field and source display on the patient’s reconstructed cortex. These direct applications of neurocomputational,
neuroimaging, and electrical engineering developments to the evaluation of epileptic foci in the human brain are an example
of translational research at its best.
- Maria Baldwin MD is interested in research
involving characterization of various periodic lateralizing epileptiform discharges (PLEDS) patterns and treatment issues
involving PLEDS plus patients.
- James Tao MD PhD is interested in determining the
cerebral substrates of scalp EEG epileptiform patterns, in order to improve the accuracy of non-invasive seizure
localization during epilepsy surgery. His long-term interests include investigations of the mechanisms of epileptogenesis
and of new modalities of epilepsy therapy. Current projects include:
- The impact of cerebral source area and synchrony on recording scalp EEG ictal patterns; and
- The pathophysiology of interictal temporal delta activity (ITDA) and its value in localizing epileptogenic zone.
His long term goals are to investigate the electrophysiological behavior of cerebral epileptogenic networks and the
mechanism of epileptogenesis at the neural network level in order to identify new preventive and therapeutic modalities.
- Jan M. Ramirez PhD (Department of Organismal Biology
and Anatomy) studies epileptogenesis using excised human tissue from epilepsy surgery to produce neocortical slices. This
approach has been able to allow one to predict the optimal anti-epileptic drugs effective at stopping recurrent seizures in
at least four patients after neurosurgery. Dr. Ramirez also studies rhythmic activity generated by the in vitro respiratory
network of the mouse medulla to understand neuronal control of breathing using slice electrophysiological and
immunohistochemical techniques. These studies have important basic scientific and clinical implications, such as
understanding the underlying causes of sleep apnea, periodic breathing, erratic breathing in Rett Syndrome and sudden
infant death syndrome (SIDS). Dr. Ramirez is also investigating bursting in dopaminergic neurons and exploring mechanisms
that lead to cell death in dopaminergic neurons of the substantia nigra. Calcium influx could potentially explain the
vulnerability of these neurons.
- Wim Van Drongelen PhD (Department of Pediatrics)
has focussed his research on the long-range goal of optimizing therapeutic intervention in pediatric epilepsy by improved
spatial and temporal localization of seizure activity and examining the underlying mechanisms in the pathogenesis of
seizures. His research focuses on:
- Underlying neuronal mechanisms in epilepsy (synchrony, recruitment, oscillation, weak coupling);
- Relationships between neuronal activity at different scales (neuron, network, brain);
- Detection and prediction of brain electrical activity during seizures using various signal processing techniques
(correlation dimension, Kolmogorov entropy, wavelet analysis);
- Localization of sources from surface recordings (dipole analysis, MUSIC, LORETA, spatial filtering); and
- Monitoring of the nervous system in the intensive care environment (EEG, evoked potential).
Glial Neurobiology Laboratory
- Glial Neurobiology Laboratory - Betty Soliven MD is
interested in CNS and peripheral nerve demyelinating diseases. One area of research concerns immune mechanisms that
underlie peripheral nervous system demyelination. She is studying s line of the non-obese diabetic (NOD) mouse that was
genetically engineered to be deficient in the major histocompatability complex gene product, B7.2. Dr. Soliven and
colleagues found that these mice do not develop diabetes, but instead develop a progressive autoimmune polyneuropathy
(SAP), with electrophysiologic and histologic features resembling chronic immune demyelinating polyneuropathy (CIDP). This
model is unique in that, in the absence of B7.2, there is a shift from one autoimmune disease (type 1 diabetes) to another
(SAP). Dr. Soliven’s group is using this model to investigate the link between islet cell and peripheral nervous system
autoimmunity in order to characterize pertinent antigen/s that elicit T cell and possibly B cell reactivity, and to examine
the effect of new drugs or therapeutic approaches for the treatment of inflammatory neuropathies.
Dr. Soliven’s group is also interested in signal transduction mechanisms in oligodendrocytes and Schwann cells. They have
studied the role of different potassium channel subtypes in oligodendroglial (OLG) regeneration and recovery from
demyelination. Her group is also studying autocrine signaling of glial-derived neurotrophic factor in Schwann cells and the
effect of sphingosine-1-phosphate (S1P) receptor modulators, and AT motif-binding factor 1 in cell cycle control in
oligodendrocytes. Finally, Dr. Soliven directs a significant effort in training fellows to assist several investigators at
The University of Chicago in the electrophysiological characterization of peripheral nervous system function in novel mouse
mutants which are models for human neurological disease.
Multiple Sclerosis & Neuroimmunology
The roots of translational research in multiple sclerosis extend to the foundations of the Department of Neurology. In
1977, Barry G.W. Arnason MD established the Department
with a team of talented young neuroimmunologists and neurovirologists, who have since become leaders in their fields
throughout North America. This legacy has continued with a strong program in MS clinical trials and basic neuroimmunology
and genetics of myelin disorders.
- Anthony Reder MD has focussed his research on the
interaction between the central nervous system and the immune system; Dr. Reder is investigating expression of lymphocyte
surface molecules necessary for immune activation, and also regulation of cytokine and interferon (IFN) genes after
IFN-beta activation. Dr. Reder’s group has recently found an increase in the B7 costimulatory molecule on lymphocytes in
active MS, which was corrected by IFN therapy as well as a specific defect in IFN signaling during active MS. His group
also studies experimental autoimmune encephalomyelitis (EAE), an animal model of MS. The lab has also studied regulation of
killer T cell killing of astrocytes by using hormones and lymphokines to modify astrocyte glial surface antigens and
secretion of cytokines.
- Barry G.W. Arnason MD focusses his reseach interests
on understanding the interplay between the immune and nervous systems. Insights from both in vitro and in vivo models
studied in his lab have contributed to our understanding of the disease mechanisms underlying T cell and B cell autoimmune
syndromes of the nervous system as exemplified by multiple sclerosis (MS) and myasthenia gravis. The role of interferons,
in particular the role of interferon-B, in moderating disease pathogenesis in MS has been an ongoing research effort of the
group. Interferons are cytokines secreted by many cell types that possess immuno-modulatory activity. A second interest of
the lab is examining the role of CD8+ suppressor T cells in modulating immune activation. Whereas activating Th1-type CD4+
T cells are widely recognized as a critical lymphocyte population for disease pathogenesis in MS, CD8+ suppressor T cells
can down-regulate the activity of the Th1-type CD4+ T cell. Despite the critical role of T cells in MS pathogenesis,
macrophages are the final vectors of tissue destruction in MS. Upon infiltrating the CNS, activated T cells secrete
cytokines which in turn recruit activated macrophages resulting in tissue destruction. Recent efforts in the lab have
focused on the development of immunomodulatory agents that have the potential to transform activated, pro-inflammatory
macrophages to a more protective type.
- Brian Popko PhD has a long-standing interest in the effects that CNS inflammation, a key aspect of MS, has on oligodendrocytes and myelin. He has used in vitro and in vivo models to show that the inflammatory response has a direct deleterious effect on oligodendrocytes. The underlying hypothesis of his work is that myelinating oligodendrocytes, because of their need to synthesize enormous amounts of membrane lipids and proteins, are particularly sensitive to disruptions in the protein secretory pathway. Researchers in his lab have reported that the deleterious effects of the inflammatory response on developmental myelination and the remyelination of demyelinated lesions are associated with the activation of the ER stress pathway in oligodendrocytes. His goal, in understanding the ER stress pathway, is to enable the identification of therapeutics that may protect oligodendrocytes and their adult progenitors from the harsh CNS environment present in MS patients.
Neurocritical Care Research
The primary thrust of the neurocritical care program is clinical and educational. However, we are seriously committed to
provocative scholarly projects dedicated
to advancing our field. While our portfolio of projects is highly dynamic, our primary areas of present activity are listed in
the following sections. Since the neurocritical care program is organizationally linked to the vascular neurology program, reference
is made to the research delineated in the cerebrovascular section for further information about additional research on ischemic
stroke (laboratory and clinical). For prospective trainees, there are two additional points to emphasize. We embrace working with
medical students and residents, and many of the projects below have included trainees both in project design, formal
presentation at national/international conferences, and manuscript preparation. In addition, these projects are derived from the
present faculty in our section, and we are presently recruiting a third faculty who will bring additional areas of interest to
our research endeavors, particularly in the laboratory.
The Neurological Complications of Acute Liver Failure
Brain swelling is an important complication from acute liver failure (ALF), and it is a frequent cause of death in patients who suffer this complication. Some cases of acute liver failure spontaneously recover and some are so destructive that a liver transplant would be required to achieve survival. In either scenario, deterring brain swelling and optimizing brain perfusion when brain swelling does occur is a critical element in creating the option of good survivorship in patients with ALF.Since the conventional approaches to limiting brain swelling and lowering intracranial pressure (ICP) are not reliable in patients with ALF, we have been involved with several projects focused on this important treatable but life-threatening neurological complication. While monitoring ICP is an important step toward properly treating these patients, the ALF causes a coagulopathy that often creates hesitance for inserting an invasive device into the skull. Our extensive experience with this disease led to adopting a standardized approach to ICP monitor placement in ALF patients with coagulopathy. We have since systematically studied this approach and presented and published our results demonstrating the safe insertion of ICP monitors in ALF patients without causing significant hemorrhagic complications. This study has been an important step toward changing the clinical approach to optimizing brain perfusion and neurological outcome in ALF patients. In addition, hypothermia is a promising approach to limit brain swelling in patients with ALF in experimental animals and small human series. Given our experience and interest in both ALF and hypothermia, we have partnered with the well-established Acute Liver Failure Research Consortium and are involved with protocol development and organization for a multi-center clinical trial focused on this topic. We also have developed a strong interest in the role of continuous hemodialysis techniques to facilitate ammonia clearance, and we have a project dedicated to correlate dialysis flow rates to the quality of ammonia clearance.The mechanism of brain swelling from ALF relates, in part, to hyperammonemia. The liver usually creates urea from the ammonia produced as a byproduct of protein metabolism. When the liver acutely fails, ammonia accumulates and is an important contributing factor to the development of brain swelling. The elevated level of ammonia enhances the conversion of glutamic acid to glutamine within astrocytes (the supporting cells of the brain), and this (through several hypothesized mechanisms) leads to cellular swelling and, in aggregate, brain swelling. While it has been long hypothesized that ammonia is not toxic to neurons, we have recently demonstrated (and formally presented) the unique impact of hyperammonemia on specific brain cortical regions in human survivors. This has recently raised questions on whether high ammonia concentrations may have some toxic effects on neurons in addition to its role in astrocytic swelling.In order to more formally study the role of ammonia in causing brain swelling, we have teamed up with our departmental scientists, and colleagues at other institutions to establish an experimental model using fetal mouse brain organotypic cultures (FMBOTC). This method allows the architectural and physiological preservation of intact slices of brain in culture (absent blood flow) to study the impact of variable environmental conditions. We have employed FMBOTC to explore the dose-response relationship of ammonia concentrations to astrocytic swelling and the potential effect of other systemic mediators that may effect the potency of this relationship. Initial success in establishing this model has led to our formal presentation of our work and dedicating a focused laboratory effort on this topic. It is our hope that we will be able to use this model to discover important modifiable factors that have a critical but yet un-described role in the brain swelling associated with ALF. This, in turn, can potentially lead to new treatments for this deadly problem.
Novel Approaches to In-Field Detection of Intracranial Mass Lesions
Spontaneous and traumatic intracerebral hemorrhages are considered acute intracranial mass lesions (AICML) and can cause catastrophic brain injury. However, surgical hematoma evacuation can lead to stabilization. While proper patient selection for invasive procedures is challenging, it is clear that timing is everything. Unnecessary delays in the diagnosis and treatment of brain hemorrhage in patients who can benefit from evacuation procedures can lead to worse brain injury, outcome and, sometimes, unnecessary death.Most of these spontaneous and traumatic hemorrhages occur outside a hospital in “the field.” Unfortunately, however, there is no reliable, sensitive, and specific method for in field identification of AICML. While clinical and situational factors can help discriminate between those patients more likely to have central nervous system injury, they do not reliably identify those, specifically, with mass lesions. This distinction can be important in a variety of settings. For example, patients with intracerebral hemorrhage should be selectively triaged to medical centers with neurocritical care and neurosurgical services able to accomplish acute hemorrhage evacuation or ventricular drain insertion. In a war zone, early identification of AICML from trauma (e.g. subdural hematoma, epidural hematoma, etc.) can facilitate appropriate triage for those patients (soldiers and civilians) who acutely require neurosurgical intervention. Delays in appropriate triage in these two example scenarios can increase a patient’s extent of brain injury and mortality. Unfortunately, it is not practical to have neuroimaging (e.g. computerized axial tomography or magnetic resonance imaging) available on all ambulances.We are spearheading the development and assessment of practical tools that may be helpful in early identification of patients with AICML in the field or emergency department. We are approaching this challenge with two projects. Through an intellectual partnership with a team of scientists, we are facilitating the development and preliminarily testing of a simple and inexpensive device that could accomplish detection of AICML. After several planning meetings, we have embarked on the first stage of this project which involves device design and prototype development. We are now preparing the in-vitro testing of the device. After secondary refinements we will design and carry-out in-vivo experiments on the device and its sensitivity to detect experimental models of intra-axial and extra-axial brain hemorrhages. Ultimately, we hope to bring the device to human testing.We are also involved with project development that will apply a new technology to better assess specific autonomic functions likely to be affected by AICML. This new technology is automated, inexpensive, and has promise to facilitate early discrimination of AICML in the field and emergency departments.
Brain Swelling from Large Hemispheric Infarctions
We have had a long-standing interest in brain swelling after large hemispheric supratentorial hemispheric infarctions (LHI). Some of our early work, presentations, and publications were instrumental in changing the thinking about the mechanisms of deterioration after LHI and the ideal approach to medical management. We eventually accomplished funding from the National Institutes of Health for a multi-center clinical trial we designed and coordinated on the role of surgical decompression (hemicraniectomy) for brain swelling from LHI (HeADDFIRST).This was the first randomized, control clinical trial on the topic, and the design of this study was used to design several similar European trials on the same topic. The results of our trial, HeADDFIRST, demonstrated a set of criteria that sensitively discriminate between those patients with low and high mortality from LHI. It also showed that the medical treatment protocol accomplished the lowest mortality every reported in patients with strokes of this magnitude; half of that reported in the literature (including those patients in the recent European trial on the same subject that did not similarly standardize the medical treatment). We continue to explore the results of this study to develop new insights into how to better approach patients with this life-threatening complication.Our experience with hemicraniectomy and the surgical protocol we developed for the procedure has led our facility in discovering other patients who may benefit from this procedure. We have since published our application of this procedure in children with LHI as well as in patients with brain swelling from acute disseminated encephalomyelitis. In addition, last year we described our series of patients with surgical decompression and insights on how to approach its more safe application with more uniform benefit to patients.
Novel Approaches to Establishing Regional Brain Hypothermia
Brain cooling is the most promising approach to protect the brain from injury due to low blood flow (ischemia). Most lay public is familiar with the miraculous stories of exciting survival from near drowning in ice cold bodies of water. The capacity of cooling to limit brain injury from ischemia has been validated in numerous experimental models. More recently, human trials on systemic cooling after cardiac arrest (global cerebral ischemia) have shown significant benefit to neurological outcome such that it has become a standard of care for select patients. The most applicable and successful approach to brain cooling is cooling that involves lowering the temperature of the whole body (systemic hypothermia) through external cooling devices or indwelling cooling catheters (we were part of one of the clinical trials that showed the benefit of one of these devices in controlling body temperature in humans) in combination with systemic sedation and inhibition of reflex shivering. The undertaking of systemic cooling is cumbersome and requires escalation of medical care that carries inherent risks such as arrhythmia, pneumonia, and coagulopathy. While the typically dismal outcomes after cardiac arrest showed a favorable risk benefit ratio with systemic hypothermia, its risk profile is somewhat prohibitive with less extreme presentations as in the case of focal cerebral ischemia (ischemic stroke). Why not cool the brain selectively? The primary reason relates to the simple fact that we are made in a manner that protects the brain from “the elements” in the environment. In short, external cooling devices applied to the head simply do not cool the brain. However, we are presently a participant in a multi-center trial on a new promising device that uses a novel approach to selectively and rapidly cooling the brain, and, if successful and safe, it may lead to an exciting breakthrough in our ability to rapidly accomplish regional brain hypothermia in the acute setting.In addition to the above mentioned clinical trial, we have an exciting partnership with our colleague scientists at Argonne National Laboratories. Our collaborative research consortium with them, and development of innovative methods to establish regional hypothermia has been an important thrust of our work together. We are co-inventors with them on a now patented device for creating regional brain hypothermia. In addition, we are presently involved in an exciting initiative to develop a new approach to brain hypothermia to protect from reperfusion injury after recanalization of an occluded artery.
Management of Patients with Intracerebral Hemorrhage
In addition to our projects on AICML, we are involved with several projects that relate to the triage and management of intracerebral hemorrhage (ICH). The Emergency Medical Services (EMS) triage system in Chicago and many other cities, requires ambulances to transfer non-trauma patients to the nearest emergency department. Unfortunately, those with ICH often end up in urban or community hospitals without any acute neurological/neurosurgical services. The only economically feasible way to preferentially triage ICH patients to appropriate medical centers with acute neurological/neurosurgical services is to have a method to enhance the in-field detection of ICH. Our work on AICML detection (see above) is one approach to rectify this problem.While we are working on technology that can help with acute in-field detection of ICH, we have done important work defining the present state of ICH care in urban emergency and community departments without acute neurological/neurosurgical services. We did initial work defining delays in acute definitive management of ICH patients related to hospital-to-hospital transfers due to the initial triage of ICH patients to hospitals with inadequate neurological resources. As a follow-up to that foundational work, we developed a stroke triage survey tool. We have personally surveyed emergency doctors at key urban and community medical centers without acute neurological/neurosurgical services and asked them to identify their inadequacies in this clinical area, share their perceptions of the impact of their clinical limitations on ICH patient outcome, and their reflections on methods to better triage ICH patients. Doctors who work in these emergency departments plainly stated that patients highly suspected to have suffered ICH should not be sent to their hospitals, and that patients have suffered worse outcome (including death) because of their inability to acutely treat these patients. This work has been accepted for formal presentation to an upcoming international conference and serves as an important foundation for the exciting movement within the stroke community to change the approach to triage of stroke patients. We also have an interest in some of the readily detectable and modifiable factors that may contribute to ICH expansion. One of these factors is abnormal platelet function, and we have recently described a consecutive series of patients with platelet dysfunction in patient with acute ICH – many without known previously exposure to anti-platelet agents. This work has recently been formally presented and adds to a growing body of literature that promises to shed new insights into the potential role of acute platelet function screening in ICH patients and the role for restoration with medication and/or platelet transfusion.The prognosis of motor outcome is an important consideration in acute decision making with ICH. An emerging magnetic resonance image acquisition and processing technique called diffusion tensor imaging (DTI) shows promise as a tool to estimate motor recoverability after ICH. In partnership with our neuroradiologists, neurosurgeons, and a physicist at the Illinois Institute of Technology we have demonstrated the feasibility of DTI acquisition in critically ill ICH patients as a step toward more widely studying its practical utility in clinical decision support. The results of this exploration were recently presented at an international conference.
Neurological Prognostication, Brain Death and Neuroethics
Our group has a unique expertise in brain death diagnosis and management. We have made provocative clinical observations in brain death that have been formally presented and published, and we have been instrumental in facilitating the evolution, understanding and approach to brain death. More recently, we have become interested in the process of solid organ donation after cardiac death (DCD), and we have systematically studies both pitfalls in the process as well as the neurological spectrum of patients considered ideal candidates for DCD. Our work has been formally presented at international meetings as the foundation for the development of more definitive projects on the topic. This work (and other related projects) underscores our clinical and scholarly interest in neurological prognostication, brain death, end-of-life decision making, and neuroethics.
Approach to Nourishment of Neurocritical Care Patients
Neurocritical care patients usually have increased metabolic demands, but our observations have suggested that we do not always meet their enhanced metabolic demand with proper nourishment. This can have a negative impact on patient outcome and increase the risk of complications and prolongation of hospitalization. In order to study this problem further we established a partnership with our Nutrition Department colleagues to systematically quantify patients’ daily nutritional needs and our success in accomplishing delivery to those targets. So far, we have shown that it is presently taking 5 days to achieve nutritional support toward those targets and there are various modifiable factors that can improve on this performance. We also disproved certain dogmatic concepts that have historically led to sluggishness in meeting the nutritional goals for individual patients. We recently formally presented our preliminary work on the topic and are reporting those results. This, in turn, will lead to our next phase on an interventional study to improve our adequacy in more rapidly accomplishing necessary nutritional support in our neurocritical care patients.
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