Neuroprotective effects of anesthetic agents

Inhalational anesthetics as neuroprotectants or chemical preconditioning agents in ischemic brain

This review will focus on inhalational anesthetic neuroprotection during cerebral ischemia and inhalational anesthetic preconditioning before ischemic brain injury. The limitations and challenges of past and current research in this area will be addressed before reviewing experimental and clinical studies evaluating the effects of inhalational anesthetics before and during cerebral ischemia. Mechanisms underlying volatile anesthetic neuroprotection and preconditioning will also be examined. Lastly, future directions for inhalational anesthetics and ischemic brain injury will be briefly discussed.

Detrimental effects of halothane narcosis on damage after endothelin-1-induced MCAO

The influence of anaesthesia in experimental stroke research is controversial. We addressed this problem using the model of endothelin-1-induced occlusion of the middle cerebral artery (eMCAO). This model provided the opportunity to compare the infarct volumes of rats which were under halothane anaesthesia during eMCAO induction with the lesions of rats which were without anaesthesia during eMCAO. All animals were implanted with guide cannulae which allowed the induction of ischaemia in freely moving animals. For comparison, one group of animals was exposed to halothane during the induction of ischaemia. Seven days after eMCAO, the average infarct volume of halothane-anaesthetised rats was significantly larger than the lesion in freely moving animals. This difference was mainly due to increased cortical damage, whereas the striatum was much less influenced. The cortical infarct volume 21 days after induction of eMCAO under anaesthesia was significantly reduced compared to the infarct volume 7 days after eMCAO under anaesthesia. Our results indicate that halothane anaesthesia during eMCAO can cause a transient cortical increase in ischaemic infarct volume. The influence of volatile anaesthetics on ischaemic pathophysiology should be taken into consideration when preclinically testing potential neuroprotective drugs for clinical applications.

The Effects of General Anesthetics on P2X7 and P2Y Receptors in a Rat Microglial Cell Line

BACKGROUND

Microglial cells play important roles in coordinating the inflammatory brain responses to hypoxia and trauma. Ionotropic P2X receptors and metabotropic P2Y receptors (P2YRs) expressed in microglia can be activated by extracellular adenosine triphosphate (ATP) derived from damaged cells or astrocytes, and participate in the signaling pathways evoked in brain insult. Although several inhaled and IV anesthetics produce neuroprotective effects through neuronal mechanisms, little is known about how general anesthetics modulate microglial responses in the pathological state. We examined the effects of various general anesthetics on purinergic responses in a rat microglial cell line.

METHODS

Currents were consistently activated by applications of ATP via a U-tube system under the whole-cell configuration. ATP-induced nondesensitizing currents observed after several applications of ATP exhibited characteristics of P2X7 receptors. The P2YRs-mediated mobilization of intracellular Ca2+ was measured using a Ca2+-sensitive fluorescent dye (fura-2).

RESULTS

Inhaled anesthetics (sevoflurane, isoflurane, and halothane) at doses three times as high as minimum alveolar concentrations had no effect on the P2X7Rs-mediated currents. IV anesthetics (ketamine, propofol, and thiopental) enhanced the P2X7Rs-mediated currents reversibly. The potencies for activation of P2X7Rs were not correlated with the octanol/buffer partition coefficients. Thiopental, at low concentrations, slightly inhibited the P2X7Rs-mediated currents, suggesting its dual actions on P2X7Rs. The P2YRs-mediated mobilization of intracellular Ca2+ was not affected by any of the general anesthetics tested.

CONCLUSIONS

Our results suggest that IV anesthetics, particularly thiopental and propofol, may modulate microglial functions through P2X7Rs in pathological conditions.

Neuroprotection against surgically induced brain injury

BACKGROUND

Neurosurgical procedures are carried out routinely in health institutions across the world. A key issue to be considered during neurosurgical interventions is that there is always an element of inevitable brain injury that results from the procedure itself because of the unique nature of the nervous system. Brain tissue at the periphery of the operative site is at risk of injury by various means, including incisions and direct trauma, electrocautery, hemorrhage, and retractor stretch.

METHODS/RESULTS

In the present review, we will elaborate upon this surgically induced brain injury and also present a novel animal model to study it. In addition, we will summarize preliminary results obtained by pretreatment with PP1, an Src tyrosine kinase inhibitor reported to have neuroprotective properties in in vivo experimental studies. Any form of pretreatment to limit the damage to the susceptible functional brain tissue during neurosurgical procedures may have a significant impact on patient recovery.

CONCLUSION

This brief review is intended to raise the question of 'neuroprotection against surgically induced brain injury' in the neurosurgical scientific community and stimulate discussions.

Hemodynamic changes due to infiltration of the scalp with epinephrine-containing lidocaine solution: a hypotensive episode before craniotomy

Epinephrine-containing lidocaine solution is commonly infiltrated on the scalp before craniotomy. But the hemodynamic changes caused by epinephrine-containing lidocaine solution have been less intensely studied. A prospective randomized double blind control study was designed to observe hemodynamic changes caused by epinephrine-containing lidocaine solution in neurosurgical operations under general anesthesia. One hundred twenty patients undergoing scheduled craniotomy were allocated randomly to 4 groups. All the patients received 1% lidocaine 16 mL with different dose (concentration) epinephrine: group 1 with 40 microg (2.5 microg/mL); group 2 with 80 microg (5 microg/mL); group 3 with 160 microg (10 microg/mL); and group 4 (control group) without epinephrine. mean arterial pressure (MAP) and heart rate were recorded at 30-second interval in 5 minutes after the beginning of local infiltration. In group 1, group 2, and group 3, the lowest MAP and the highest MAP during this period also were recorded. Bleeding was assessed after raising the craniotomy flap. Compared with the baseline, significant hemodynamic changes, particularly decrease in MAP with increase in heart rate at 1.5 minutes after the beginning of local infiltration, were observed in group 1, group 2, and group 3 (P<0.001), but not in group 4. The highest MAP increased significantly compared with the baseline in group 3 (P<0.05), but not in group 1 or group 2. Epinephrine-containing lidocaine solution reduced bleeding significantly (P<0.01). Infiltration with epinephrine-containing lidocaine solution elicits temporary but significant hemodynamic changes including hypotension before craniotomy. Commonly clinically used concentrations of epinephrine (2.5 to 10 microg/mL) can reduce the bleeding on the scalp.

Brain protection by anesthetic agents

PURPOSE OF REVIEW

Patients at risk for perioperative stroke, or those who have suffered recent cerebral injury, may benefit from neuroprotective properties of anesthetic agents during surgery. This manuscript reviews recent clinical and experimental evidence for neuroprotective effects of common anesthetic agents, and presents potential mechanisms involved in anesthetic neuroprotection.

RECENT FINDINGS

Although strong experimental data support a neuroprotective potential of several anesthetic agents, specifically isoflurane and xenon, consistent long-term protection by either agent has not been demonstrated. Unfortunately, there is a lack of clinical studies that would support the use of any one anesthetic agent over the others. Mechanisms of neuroprotection by anesthetic agents appear to involve suppression of excitatory neurotransmission, and potentiation of inhibitory activity, which may contribute to the reduction of excitotoxic injury. Activation of intracellular signaling cascades that lead to altered expression of protective genes may also be involved.

SUMMARY

Solid experimental evidence supports neuroprotection by anesthetic agents. It is too early to recommend any specific agent for clinical use as a neuroprotectant, however. Further study is warranted to unravel relevant mechanisms and to appreciate the potential clinical relevance of experimental findings.

Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices

Neurologic complications after cardiac surgery are of growing importance for an aging surgical population. In this review, we provide a critical appraisal of the impact of current cardiopulmonary bypass (CPB) management strategies on neurologic complications. Other than the use of 20-40 microm arterial line filters and membrane oxygenators, newer modifications of the basic CPB apparatus or the use of specialized equipment or procedures (including hypothermia and "tight" glucose control) have unproven benefit on neurologic outcomes. Epiaortic ultrasound can be considered for ascending aorta manipulations to avoid atheroma, although available clinical trials assessing this maneuver are limited. Current approaches for managing flow, arterial blood pressure, and pH during CPB are supported by data from clinical investigations, but these studies included few elderly or high-risk patients and predated many other contemporary practices. Although there are promising data on the benefits of some drugs blocking excitatory amino acid signaling pathways and inflammation, there are currently no drugs that can be recommended for neuroprotection during CPB. Together, the reviewed data highlight the deficiencies of the current knowledge base that physicians are dependent on to guide patient care during CPB. Multicenter clinical trials assessing measures to reduce the frequency of neurologic complications are needed to develop evidence-based strategies to avoid increasing patient morbidity and mortality.

The Long-Term Effect of Sevoflurane on Neuronal Cell Damage and Expression of Apoptotic Factors After Cerebral Ischemia and Reperfusion in Rats

We investigated the long-term effects of sevoflurane on histopathologic injury and key proteins of apoptosis in a rat hemispheric ischemia/reperfusion model. Sixty-four male Sprague-Dawley rats were randomly assigned to Group 1 (fentanyl and N2O/O2; control) and Group 2 (2.0 vol% sevoflurane and O2/air). Ischemia (45 min) was produced by unilateral common carotid artery occlusion plus hemorrhagic hypotension (mean arterial blood pressure 40 mm Hg). Animals were killed after 1, 3, 7, and 28 days. In hematoxylin and eosin-stained brain sections eosinophilic hippocampal neurons were counted. Activated caspase-3 and the apoptosis-regulating proteins Bax, Bcl-2, Mdm-2, and p53 were analyzed by immunostaining. No eosinophilic neurons were detected in sevoflurane-anesthetized rats over time, whereas 9%-38% of the hippocampal neurons were eosinophilic (days 1-28) in control animals. On days 1 and 3, the concentration of Bax was 140%-200% larger in fentanyl/N2O-anesthetized animals compared with sevoflurane. Bcl-2 was 100% less in control animals during the first 3 days. Activated caspase-3 was detected in neurons of both groups (0.75%-2.2%). These data support a sustained neuroprotective potency of sevoflurane related to reduced eosinophilic injury after cerebral ischemia/reperfusion.

Electrophysiology in ischemic neocortical brain slices: species differences vs. influences of anaesthesia and preparation

Ischemia models are indispensable for the evaluation of measures to be clinically applied to brain trauma or stroke patients. Slice models provide good control over experimental parameters and allow for comparative examinations of human and animal brain tissue. Experimental tissue, however, may be altered by anaesthesia, preparatory technique, and, in the case of human tissue, by underlying diseases. These influences on tissue behaviour under ischemia were examined electrophysiologically. Native rat tissue slices were prepared either immediately after decapitation (n = 13), during short ether/barbiturate narcosis (n = 18), or after two hours of inhalation anaesthesia (n = 12) imitating clinical narcosis. Tissue from rats in which generalized amygdala-kindled seizures had been triggered by electric stimulation (n = 10) was prepared according to the decapitation protocol, while human tissue (n = 10) was obtained during epilepsy or tumour surgery. Electrophysiological data (latency and amplitude of anoxic depolarization, recovery of evoked potentials) were recorded during ischemia simulation. Neither details of preparation or anaesthesia nor a history of epileptic fits were associated with significant changes of electrophysiological reactions under ischemia. Human tissue showed a significantly higher ability to uphold transmembrane ion gradients under ischemia. The ability of brain tissue to withstand ischemia is obviously species dependent. For the transfer of experimental results into clinical use it is important that interspecies differences alone can bring about a significant change of tissue behaviour.

New cerebral protection strategies

PURPOSE OF REVIEW

This article presents an overview of the most recent and important strategies to reduce secondary brain damage.

RECENT FINDING

There is currently no magic bullet available to protect the brain after neuronal injury. This is related to the complex pathophysiology of cerebral ischemia, which makes it unlikely that a single pharmacological intervention results in sustained neuroprotection. Analyses of clinical studies reveal that acute physiologic derangements (e.g. fever, hypertension and hypotension, hypoxemia, hypercapnia, hyperglycemia) are the most important predictors of unfavorable outcome after brain injury and have to be treated. The effectiveness of anesthetic agents to extend the ischemic tolerance of neurons has been demonstrated in experimental settings, but such benefits have not been demonstrated in humans. The effectiveness of osmodiuretics to decrease elevated intracranial pressure, a factor with relevance to outcome, has been demonstrated. Infusion of magnesium in patients with subarachnoidal hemorrhage can reduce the occurrence of delayed ischemia caused by cerebrovascular spasm. The prophylactic administration of glucocorticoids should be avoided. While the positive effects of chronic administration of statins to reduce the incidence of stroke has been demonstrated in several clinical studies, the protective effect of acute administration of statins after a cerebral insult has do be defined.

SUMMARY

Control of physiological variables, avoidance of hyperthermia, intensive control of plasma glucose concentrations, use of anesthetic agents and osmodiuretics to control intracranial hypertension and the possible prophylactic administration of magnesium in patients at risk of vasospasm and of statins in patients with cerebrovascular risk factors are currently the most important strategies to reduce neuronal injury.