Inflammatory markers for brain edema after aneurysmal subarachnoid hemorrhage

Inflammatory markers for brain edema after aneurysmal subarachnoid hemorrhage

The onset of aneurysmal subarachnoid hemorrhage (aSAH) elicits activation of the inflammatory cascade, and ongoing neuroinflammation is suspected to contribute to secondary complications, such as vasospasm and delayed cerebral ischemia.

To date, the monitoring of the inflammatory response to detect secondary complications such as DCI has not become part of the clinical routine diagnostic.

Höllig et al. estimated that the wide range of the measured values hampers their interpretation and usage as a biomarker. However, understanding the inflammatory response after aSAH and generating a multicenter database may facilitate further studies: realistic sample size calculations on the basis of a multicenter database will increase the quality and clinical relevance of the acquired results 1).


In a review, of Watson et al. analyze the extent literature regarding the relationship between neuroinflammation and cognitive dysfunction after aSAH. Pro-inflammatory cytokines appear to play a role in maintaining normal cognitive function in adults unaffected by aSAH. However, in the setting of aSAH, elevated cytokine levels may correlate with worse neuropsychological outcomes. This seemingly dichotomous relationship between neuroinflammation and cognition suggests that the action of cytokines varies, depending on their physiologic environment. Experimental therapies which suppress the immune response to aSAH appear to have a beneficial effect on cognitive outcomes. However, further studies are necessary to determine the utility of inflammatory mediators as biomarkers of neurocognitive outcomes, as well as their role in the management of aSAH 2).


Ahn et al. investigated inflammatory markers in subjects with early brain edema which does not resolve, i.e., persistent brain edema after SAH.

Computed tomography scans of SAH patients were graded at admission and at 7 days after SAH for Brain edema using the 0-4 ‘subarachnoid hemorrhage early brain edema score‘ (SEBES). SEBES ≤ 2 and SEBES ≥ 3 were considered good and poor grade, respectively. Serum samples from the same subject cohort were collected at 4 time periods (at < 24 h [T1], at 24 to 48 h [T2]. 3-5 days [T3] and 6-8 days [T4] post-admission) and concentration levels of 17 cytokines (implicated in peripheral inflammatory processes) were measured by multiplex immunoassay. Multivariable logistic regression analyses were step-wisely performed to identify cytokines independently associated with persistent CE adjusting for covariables including age, sex and past medical history (model 1), and additional inclusion of clinical and radiographic severity of SAH and treatment modality (model 2).

Of the 135 patients enrolled in the study, 21 of 135 subjects (15.6%) showed a persistently poor SEBES grade. In multivariate model 1, higher Eotaxin (at T1 and T4), sCD40L (at T4), IL-6 (at T1 and T3) and TNF-α (at T4) were independently associated with persistent CE. In multivariate model 2, Eotaxin (at T4: odds ratio [OR] = 1.019, 95% confidence interval [CI] = 1.002-1.035) and possibly PDGF-AA (at T4), sCD40L (at T4), and TNF-α (at T4) was associated with persistent CE.

They identified serum cytokines at different time points that were independently associated with persistent Brain edema. Specifically, persistent elevations of Eotaxin is associated with persistent Brain edema after SAH 3).


Leucocytosis and change in IL-6 prior to DCI reflect impending cerebral ischemia. The time-independent association of ESR with DCI after SAH may identify this as a risk factor. These data suggest that systemic inflammatory mechanisms may increase the susceptibility to the development of DCI after SAH 4)


Platelet-derived growth factor (PDGF)-AA, PDGF-AB/BB, soluble CD40 ligand, and tumor necrosis factor-α (TNF-α) increased over time. Colony-stimulating factor (CSF) 3, interleukin (IL)-13, and FMS-like tyrosine kinase 3 ligand decreased over time. IL-6, IL-5, and IL-15 peaked and decreased. Some cytokines with insignificant trends show high correlations with other cytokines and vice versa. Many correlated cytokine clusters, including a platelet-derived factor cluster and an endothelial growth factor cluster, were observed at all times. Participants with higher clinical severity at admission had elevated levels of several proinflammatory and anti-inflammatory cytokines, including IL-6, CCL2, CCL11, CSF3, IL-8, IL-10, CX3CL1, and TNF-α, compared to those with lower clinical severity 5).


1)

Höllig A, Stoffel-Wagner B, Clusmann H, Veldeman M, Schubert GA, Coburn M. Time Courses of Inflammatory Markers after Aneurysmal Subarachnoid Hemorrhage and Their Possible Relevance for Future Studies. Front Neurol. 2017 Dec 22;8:694. doi: 10.3389/fneur.2017.00694. PMID: 29312122; PMCID: PMC5744005.
2)

Watson E, Ding D, Khattar NK, Everhart DE, James RF. Neurocognitive outcomes after aneurysmal subarachnoid hemorrhage: Identifying inflammatory biomarkers. J Neurol Sci. 2018 Jun 25;394:84-93. doi: 10.1016/j.jns.2018.06.021. [Epub ahead of print] Review. PubMed PMID: 30240942.
3)

Ahn SH, Burkett A, Paz A, Savarraj JP, Hinds S, Hergenroeder G, Gusdon AM, Ren X, Hong JH, Choi HA. Systemic inflammatory markers of persistent cerebral edema after aneurysmal subarachnoid hemorrhage. J Neuroinflammation. 2022 Aug 4;19(1):199. doi: 10.1186/s12974-022-02564-1. PMID: 35927663.
4)

McMahon CJ, Hopkins S, Vail A, King AT, Smith D, Illingworth KJ, Clark S, Rothwell NJ, Tyrrell PJ. Inflammation as a predictor for delayed cerebral ischemia after aneurysmal subarachnoid haemorrhage. J Neurointerv Surg. 2013 Nov;5(6):512-7. doi: 10.1136/neurintsurg-2012-010386. Epub 2012 Sep 5. PMID: 22952245; PMCID: PMC3812893.
5)

Savarraj JPJ, Parsha K, Hergenroeder GW, Zhu L, Bajgur SS, Ahn S, Lee K, Chang T, Kim DH, Liu Y, Choi HA. Systematic model of peripheral inflammation after subarachnoid hemorrhage. Neurology. 2017 Apr 18;88(16):1535-1545. doi: 10.1212/WNL.0000000000003842. Epub 2017 Mar 17. PMID: 28314864; PMCID: PMC5395070.
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