Prolonged but delayed postischemic hypothermia: a long-term outcome study in the rat middle cerebral artery occlusion model

Hypothermia blocks beta-catenin degradation after focal ischemia in rats

Dephosphorylated and activated glycogen synthase kinase (GSK) 3beta hyperphosphorylates beta-catenin, leading to its ubiquitin-proteosome-mediated degradation. beta-catenin-knockdown increases while beta-catenin overexpression prevents neuronal death in vitro; in addition, protein levels of beta-catenin are reduced in the brain of Alzheimer's patients. However, whether beta-catenin degradation is involved in stroke-induced brain injury is unknown. Here we studied activities of GSK 3beta and beta-catenin, and the protective effect of moderate hypothermia (30 degrees C) on these activities after focal ischemia in rats. The results of Western blot showed that GSK 3beta was dephosphorylated at 5 and 24 h after stroke in the normothermic (37 degrees C) brain; hypothermia augmented GSK 3beta dephosphorylation. Because hypothermia reduces infarction, these results contradict with previous studies showing that GSK 3beta dephosphorylation worsens neuronal death. Nevertheless, hypothermia blocked degradation of total GSK 3beta protein. Corresponding to GSK 3beta activity in normothermic rats, beta-catenin phosphorylation transiently increased at 5 h in both the ischemic penumbra and core, and the total protein level of beta-catenin degraded after normothermic stroke. Hypothermia did not inhibit beta-catenin phosphorylation, but it blocked beta-catenin degradation in the ischemic penumbra. In conclusion, moderate hypothermia can stabilize beta-catenin, which may contribute to the protective effect of moderate hypothermia.

Neuroprotection of hypothermia against neuronal death in rat hippocampus through inhibiting the increased assembly of GluR6-PSD95-MLK3 signaling module induced by cerebral ischemia/reperfusion

Kainate receptor containing GluR6 subunit (KAR) is involved in the neuronal cell death induced by cerebral ischemia/reperfusion (I/R). Hypothermia is an effective neuroprotectant in brain ischemia, whereas the neuroprotective mechanisms have not been clearly established. The present study was set out to examine whether hypothermia would cause the alternation of the assembly of the GluR6-PSD95-MLK3 signaling module and the activation of c-Jun N-terminal kinase (JNK) pathway through KAR. Hypothermia (32 degrees C) was induced 10 min before ischemia and was maintained for 3 h after ischemia. Our results indicated that hypothermia could inhibit the assembly of GluR6-PSD95-MLK3 signaling module and suppressed the activation of MLK3, MKK4/7, and JNK3. The inhibition of JNK3 activation by hypothermia diminished the phosphorylation of the transcription factor c-Jun and downregulated FasL expression in hippocampal CA1. Meanwhile, the inhibition of JNK3 activation by hypothermia attenuated bax translocation, the release of cytochrome c, and the activation of caspase-3 in CA1 subfields. Both GluR6 antagonist NS102 and GluR6 antisense oligodeoxynucleotides partly blocked the aforementioned effects of hypothermia, which was further confirmed by histology. Taken together, our results strongly suggest that hypothermia decreased the increased assembly of the GluR6-PSD95-MLK3 signaling module and the activation of JNK pathway induced by I/R through KAR, which gave a new insight into the ischemic therapy.

Transient cooling during early reperfusion attenuates delayed edema and infarct progression in the Spontaneously Hypertensive Rat. Distribution and time course of regional brain temperature change in a model of postischemic hypothermic protection

The temperature threshold for protection by brief postischemic cooling was evaluated in a model of transient focal ischemia in the Spontaneously Hypertensive Rat, using an array of epidural probes to monitor regional brain temperatures. Rats were subjected to 90 mins tandem occlusion of the right middle cerebral artery (MCA) and common carotid artery. Systemic cooling to 32 degrees C was initiated 5 mins before recirculation, with simultaneous brain cooling to temperatures ranging from 28 degrees C to 32 degrees C within the MCA territory by means of a temperature-controlled saline drip. Rewarming was initiated at 2 h recirculation and was complete within 30 mins. Tissue damage and edema volume showed clear temperature-dependent reductions when evaluated at 3 days survival, with no protection evident in the group at 32 degrees C but progressive effects on both parameters after deeper cooling. A particularly striking effect was the essentially complete elimination of edema progression between 1 and 3 days. Temperature at distal sites within the MCA territory better predicted reductions in lesion volume, indicating that protection required effective cooling of the penumbral regions destined to be spared. These results show that even brief cooling can be highly protective when initiated at the time of recirculation after focal ischemia, but indicate a substantially lower temperature threshold for hypothermic protection than has been reported for other strains, occlusion methods, and cooling durations.

Head cooling for neonatal encephalopathy: the state of the art

The possibility that hypothermia started during or after resuscitation at birth might reduce brain damage and cerebral palsy has tantalized clinicians for a long time. The key insight was that transient severe hypoxia-ischemia can precipitate a complex biochemical cascade leading to delayed neuronal loss. There is now strong experimental and clinical evidence that mild to moderate cooling can interrupt this cascade, and improve the number of infants surviving without disability in the medium term. The key remaining issues are to finding better ways of identifying babies who are most likely to benefit, to define the optimal mode and conditions of hypothermia and to find ways to further improve the effectiveness of treatment.

Hypothermia

Experimental studies show that, following hypoxic ischaemic injury, mild induced hypothermia-a reduction of body temperature by about 3 degrees C -- preserves cerebral energy metabolism, reduces cerebral tissue injury and improves neurological function. Randomized trials in full-term and near-full-term newborns suggest that treatment with mild hypothermia is safe and improves survival without disabilities up to 18 months of age. Although the optimal time of initiation, the depth and duration, and the method of cooling are uncertain, in the absence of specific treatments many clinicians will wish to consider treating asphyxiated infants with hypothermia. Guidance now needs to be provided to promote uniform practice, to avoid inappropriate treatment and to foster continuing collaboration in future studies of neuroprotection following asphyxia. If the promising results of the current trials are confirmed by the findings from other on-going studies, with longer follow-up, the impact of such a treatment on the babies, their families and health resources in the shorter and longer terms will be considerable.

"Therapeutic time window" duration decreases with increasing severity of cerebral hypoxia-ischaemia under normothermia and delayed hypothermia in newborn piglets

OBJECTIVE

For optimal neuroprotection following transient perinatal hypoxia-ischaemia (HI), therapy should start before overt secondary energy failure and its irreversible neurotoxic cascade. Hypothermia is a promising neuroprotective intervention that also prolongs the therapeutic time window ("latent-phase"; the period between re-establishment of apparently normal cerebral metabolism after HI, and the start of secondary energy failure). The influences of HI severity on latent-phase duration and regional neuroprotection are unclear. Under normothermia and delayed whole-body cooling to 35 and 33 degrees C we aimed to assess relationships between HI severity and: (i) latent-phase duration; (ii) secondary-energy-failure severity; and (iii) neuronal injury 48 h following HI.

METHODS

Newborn piglets were randomized to: (i) HI-normothermia (n=12), (ii) HI-35 degrees C (n=7), and (iii) HI-33 degrees C (n=10). HI-35 degrees C and HI-33 degrees C piglets were cooled between 2 and 26 h after HI. Insult and secondary-energy-failure severity and latent-phase duration were evaluated using phosphorus magnetic resonance spectroscopy and compared with neuronal death in cortical-grey and deep-grey matter.

RESULTS

More severe HI was associated with shorter latent-phase (p=0.002), worse secondary energy failure (p=0.023) and more cortical-grey-matter neuronal death (p=0.016).

CONCLUSIONS

Latent-phase duration is inversely related to insult severity; latent-phase brevity may explain the apparently less effective neuroprotection following severe cerebral HI.

Therapeutic time window of post-ischemic mild hypothermia and the gene expression associated with the neuroprotection in rat focal cerebral ischemia

Hypothermia is the only neuroprotective therapy proven to be clinically effective. Identifying the molecules that play important roles in the efficacy of hypothermia, we developed a multi-channel computer-controlled system, in which the brain temperatures of freely moving rats were telemetrically monitored and maintained below 35 degrees C, and examined the time window necessary to exert its significant neuroprotective effects. Eight-week-old SD rats were subjected to a 2h middle cerebral artery occlusion (MCAO) with an intraluminal filament, and post-ischemic hypothermia was introduced at 0, 2, 4, or 6h after reperfusion until the rats were killed 2 days after MCAO. Since a significant protection was observed when hypothermia was started within 4h after reperfusion, it was concluded that the therapeutic time window of mild hypothermia lasts for 4h after reperfusion in our model. On the basis of the window, comprehensive gene expression analyses using oligonucleotide microarrays were conducted and identified potential genes related to the efficacy of hypothermia, which included inflammatory genes like osteopontin, early growth response-1, or macrophage inflammatory protein-3alpha. Therefore, the neuroprotective effects of post-ischemic mild hypothermia were strongly suggested to be mainly associated with the reduction of neuronal inflammation.

Mismatch recovery of regional cerebral blood flow and brain temperature during reperfusion after prolonged brain ischemia in gerbils

BACKGROUND

Recovery of cerebral reperfusion after stroke or cardiac arrest can take a long time. We aimed to identify differences in the postischemic recovery of physiologic parameters between short and prolonged brain ischemia.

METHODS

Eighteen Mongolian gerbils were assigned to one of three groups: 5-minute (G5), 15-minute (G15), or 30-minute (G30) ischemia. With the use of our original microspectroscopy system, global ischemic reperfusion was performed. We measured changes in regional cerebral blood flow (r-CBF), microvessel diameter, and brain temperature (BrT) simultaneously. We also monitored somatosensory evoked potentials (SEPs) to evaluate electrophysiologic response.

RESULTS

Both G5 and G15 showed concurrent recovery of r-CBF and BrT with hyperemia and hyperthermia, respectively, 10 to 15 minutes after reperfusion. The increase in BrT was <1 degree C and recovered to baseline within 60 minutes after reperfusion. In G30, recovery of r-CBF was significantly delayed relative to that of BrT. The increase in BrT was >2 degrees C, peaking approximately 15 minutes after reperfusion, and then maintained increases of >1 degree C for 120 minutes. SEPs in G5 and G15 showed concomitant recovery with that of r-CBF, whereas SEP recovery in G30 was delayed relative to that of r-CBF, eventually disappearing. All except one of the G30 gerbils died within 24 hours, but all in G5 and G15 survived.

CONCLUSIONS

These results suggest that mismatch recovery of r-CBF and BrT after prolonged ischemia initiates metabolic derangement in brain tissue, leading to the electrochemical dysfunction and mortality.

Induced Hypothermia for Acute Stroke

Induced hypothermia is one of the most promising neuroprotective therapies. Technological limitations and homeostatic mechanisms that maintain core body temperature have impeded the clinical use of hypothermia. Recent advances in intravascular cooling catheters and successful trials of hypothermia for cardiac arrest and neonatal asphyxia renewed interest in hypothermia for stroke, resulting in early phase clinical trials and plans for further development. This review elaborates on the clinical implications of hypothermia research in stroke and technical and logistical issues associated with the application of hypothermia.

A simple method to induce focal brain hypothermia in rats

Hypothermia reduces cell death and promotes recovery in models of cerebral ischemia, intracerebral hemorrhage and trauma. Clinical studies report significant benefit for treating cardiac arrest and studies are investigating hypothermia for stroke and related conditions. Both local (head) and generalized hypothermia have been used. However, selective brain cooling has fewer side effects than systemic cooling. In this study, we developed a method to induce local (hemispheric) brain hypothermia in rats. The method involves using a small metal coil implanted between the Temporalis muscle and adjacent skull. This coil is then cooled by flushing it with cold water. In our first experiment, we tested whether this method induces focal brain hypothermia in anesthetized rats. Brain temperature was assessed in the ipsilateral cortex and striatum, and contralateral striatum, while body temperature was kept normothermic. Focal, ipsilateral cooling was successfully produced, while the other locations remained normothermic. In the second experiment, we implanted the coil, and brain and body temperature telemetry probes. The coil was connected via overhead swivel to a cold-water source. Brain hypothermia was produced for 24 h, while body temperature remained normothermic. A third experiment measured brain and body temperature along with heart rate and blood pressure. Brain cooling was produced for 24 h without significant alterations in pressure, heart rate or body temperature. In summary, our simple method allows for focal brain hypothermia to be safely induced in anesthetized or conscious rats, and is, therefore, ideally suited to stroke and trauma studies.

Clinical review: Therapy for refractory intracranial hypertension in ischaemic stroke

The treatment of patients with large hemispheric ischaemic stroke accompanied by massive space-occupying oedema represents one of the major unsolved problems in neurocritical care medicine. Despite maximum intensive care, the prognosis of these patients is poor, with case fatality rates as high as 80%. Therefore, the term 'malignant brain infarction' was coined. Because conservative treatment strategies to limit brain tissue shift almost consistently fail, these massive infarctions often are regarded as an untreatable disease. The introduction of decompressive surgery (hemicraniectomy) has completely changed this point of view, suggesting that mortality rates may be reduced to approximately 20%. However, critics have always argued that the reduction in mortality may be outweighed by an accompanying increase in severe disability. Due to the lack of conclusive evidence of efficacy from randomised trials, controversy over the benefit of these treatment strategies remained, leading to large regional differences in the application of this procedure. Meanwhile, data from randomised trials confirm the results of former observational studies, demonstrating that hemicraniectomy not only significantly reduces mortality but also significantly improves clinical outcome without increasing the number of completely dependent patients. Hypothermia is another promising treatment option but still needs evidence of efficacy from randomised controlled trials before it may be recommended for clinical routine use. This review gives the reader an integrated view of the current status of treatment options in massive hemispheric brain infarction, based on the available data of clinical trials, including the most recent data from randomised trials published in 2007.

Quantitative measurement of neurological deficit after mild (30 min) transient middle cerebral artery occlusion in rats

Although 30-min transient middle cerebral artery occlusion (30-min tMCAo) causes reproducible subcortical infarction in rats, it is difficult to evaluate the resulting neurological deficit using common behavioral tests such as the rota-rod test, adhesive-removal test, or narrow beam test. Establishment of a method of quantitative evaluation would help to develop a novel therapeutic approach to treat cerebral infarction. To solve this problem, we examined whether the neurological deficit could be detected by the Montoya staircase test or methamphetamine-induced rotation, which are commonly used in a Parkinson disease model induced by intrastriatal injection of 6-hydroxydopamine (6-OHDA). From 10 to 14 days after tMCAo, the Montoya staircase test showed significant clumsiness in forelimb tasks contralateral to the lesion side, whereas sham-operated rats showed no significant clumsiness in both forelimbs. The number of ipsilateral rotations induced by methamphetamine was also increased in tMCAo-rats at 21 days after tMCAo. Although Pearson's correlations coefficient showed that the results of these tests were correlated with the infarction volume, there was no significant correlation between the results of these two tests. These findings imply that the neurological deficit detected by both tests might reflect the severity of ischemic injury, but each test might evaluate different aspects of neurological deficit. Thus, the Montoya staircase test and methamphetamine-induced rotation are useful to evaluate neurological deficit in the chronic stage of subcortical infarction induced by 30-min tMCAo.

Skilled reaching impairments follow intrastriatal hemorrhagic stroke in rats

The infusion of autologous blood into the brain of rats is a widely used model of intracerebral hemorrhage (ICH). Careful assessment of functional recovery is an essential part of preclinical testing (e.g., putative cytoprotectants). However, few tests detect long-term deficits in this model. In this study, we used the staircase and single pellet tests to characterize skilled reaching ability after striatal ICH. Rats were trained to reach for food pellets in these tasks before ICH, which was created by infusing 100muL of autologous blood into the striatum. We assessed reaching success in both tasks for 5 days starting 7 and 28 days after ICH. We counted the number of reaching attempts made with each forelimb in the staircase task and performed kinematic analysis of reaching in the single pellet task. The contralateral (to lesion) forelimb reaching success was significantly impaired in the staircase task 1 week after ICH, but this recovered to pre-surgical levels thereafter. Reaching deficits in the single pellet task were more severe and persistent. Detailed analysis of reaches on day 11 revealed several abnormalities in the following movement components: pronation, grasping, supinating the paw and releasing the pellet. At 1 month, only digit opening and supination were impaired. Accordingly, the single pellet task is better at detecting long-term skilled reaching impairments in the whole blood model of ICH. Thus, the single pellet task seems suited to cytoprotection and rehabilitation studies.

Temperature Management in Acute Neurologic Disorders

Temperature management in acute neurologic disorders has received considerable attention in the last 2 decades. Numerous trials of hypothermia have been performed in patients with head injury, stroke, and cardiac arrest. This article reviews the physiology of thermoregulation and mechanisms responsible for hyperpyrexia. Detrimental effects of fever and benefits of normalizing elevated temperature in experimental models are discussed. This article presents a detailed analysis of trails of induced hypothermia in patients with acute neurologic insults and describes methods of fever control.

Selective, reversible occlusion of the middle cerebral artery in rats by an intraluminal approach

These studies optimized design and application of an intraluminal filament method to achieve selective middle cerebral artery (MCA) occlusion in rats. Silicone plugs of 300 microm diameter and 700-800 microm length were molded onto 6-0 suture. These were introduced into Wistar rats previously fitted with telemetric probes, using established placement procedures, with and without heparinization. Temperature and activity were monitored for 3 days, after which lesion volumes were assessed by triphenyltetrazolium chloride staining. Optimized filaments entered the MCA in 85% of Wistar rats, failures being attributable to anatomical variation at its origin from the internal carotid artery. Infarcts restricted to the MCA territory were apparent after 90 min occlusion, and maximal after 3 h occlusion. Intraischemic hyperthermia was noted in a third of occlusions performed without heparin, but never with anticoagulant treatment. Permanent occlusions were also evaluated in Fisher, Lewis, Long-Evans, Spontaneously Hypertensive and Sprague-Dawley rats, and Wistar rats from a second supplier, and compared with data for surgical MCA occlusions. Success rates varied among strains, but infarct volumes correlated with those obtained after surgical occlusions in respective populations. These studies demonstrate the feasibility and limitations of reversible and selective intraluminal filament occlusion of the MCA in rats.

Non-Pharmacological Neuroprotection: Role of Emergency Stroke Management

Acute stroke should be considered a medical emergency, where actions taken in the first hours are fundamental for achieving recovery of the damaged cerebral tissue and a better prognosis for the patient. Recanalization and neuroprotective treatment has been used with mixed results. The effectiveness observed in the first hours with thrombolytic drug treatment is only applicable to a small percentage of patients, and attempts to widen this treatment window have not yet proved fruitful. Pharmacological neuroprotective treatment has not yet demonstrated the clinical effectiveness observed in experimental models. The concept of neuroprotection in cerebral ischemia also involves a series of mechanisms that take place at the cerebral level following vascular occlusion. In this context, it should be borne in mind that a series of physiological functions usually involved in the cerebral metabolism (control of blood pressure, of temperature, of glycemia and of arterial oxygen saturation) play a key role in modulation of the ischemic process. Changes in the control of these mechanisms may aggravate the process of cerebral damage in the first hours of ischemic stroke. In this work we review the prognostic importance of the main mechanisms that may influence the acute phase of cerebral ischemic stroke, as well as their therapeutic management and control in the clinical situation.

Hypothermic neuroprotection

The possibility that hypothermia during or after resuscitation from asphyxia at birth, or cardiac arrest in adults, might reduce evolving damage has tantalized clinicians for a very long time. It is now known that severe hypoxia-ischemia may not necessarily cause immediate cell death, but can precipitate a complex biochemical cascade leading to the delayed neuronal loss. Clinically and experimentally, the key phases of injury include a latent phase after reperfusion, with initial recovery of cerebral energy metabolism but EEG suppression, followed by a secondary phase characterized by accumulation of cytotoxins, seizures, cytotoxic edema, and failure of cerebral oxidative metabolism starting 6 to 15 h post insult. Although many of the secondary processes can be injurious, they appear to be primarily epiphenomena of the 'execution' phase of cell death. Studies designed around this conceptual framework have shown that moderate cerebral hypothermia initiated as early as possible before the onset of secondary deterioration, and continued for a sufficient duration in relation to the severity of the cerebral injury, has been associated with potent, long-lasting neuroprotection in both adult and perinatal species. Two large controlled trials, one of head cooling with mild hypothermia, and one of moderate whole body cooling have demonstrated that post resuscitation cooling is generally safe in intensive care, and reduces death or disability at 18 months of age after neonatal encephalopathy. These studies, however, show that only a subset of babies seemed to benefit. The challenge for the future is to find ways of improving the effectiveness of treatment.

Neuroprotection in malignant MCA infarction

Massive unilateral hemispheric infarction often develops progressive postischemic edema that leads to a malignant course of stroke with mortality of up to 80% with conventional medical therapies. Hypothermia and decompressive hemicraniectomy have shown neuroprotective effects in several animal models of focal transient and permanent MCA occlusion by reducing infarct size and improving neurological outcome. Our aim in this paper was to review the possible mechanisms of both therapies as well as the optimal time window and duration of application of each treatment in animal model and in human malignant MCA infarction reported in the literature.

The Influence of Hypothermia on Outcome After Intracerebral Hemorrhage in Rats

Background and Purpose— Late hypothermia (HYPO) reduces injury after collagenase-induced intracerebral hemorrhage (ICH), whereas early HYPO does not because it exacerbates the protracted bleeding that occurs in this model. We hypothesized that early HYPO would not increase bleeding after whole blood infusion and thus expected early HYPO to improve outcome through reducing secondary consequences of ICH (eg, inflammation).

Methods— Autologous blood (100 μL) was infused into the striatum. Rats were maintained at normothermia or subjected to mild (33°C to 35°C) HYPO for 2 days starting 1 (HYPO-1) or 4 hours (HYPO-4) after ICH. Hematoma volume was measured at 12 hours to determine whether HYPO-1 aggravated bleeding. We measured blood–brain barrier (BBB) disruption and edema 2 days after ICH in all groups. At 4 days, we counted degenerating neurons, neutrophils, and iron-positive cells (eg, macrophages) in the lesioned hemisphere. Recovery was assessed using several behavioral tests (ie, staircase reaching task, ladder walking task, limb use cylinder test) over 7 or 30 days, at which time we quantified lesion volume.

Results— HYPO did not increase bleeding. Both HYPO treatments reduced BBB disruption and infiltration of inflammatory cells. HYPO-1 treatment modestly reduced edema and provided limited to no functional benefit in the behavioral tests. HYPO did not affect lesion volume.

Conclusions— HYPO reduced edema, BBB disruption, and inflammation. Although encouraging, HYPO treatment must be improved so that histological and functional benefit are obtained before clinical investigation. Otherwise clinical failure is anticipated.

Therapeutic hypothermia for stroke: do new outfits change an old friend?

Clinically significant neuroprotection for the brain continues to be an elusive quest. All attempts at developing effective pharmacologic agents have failed in clinical trials. Hypothermia has been thought to confer protection after brain injury for many years, but has recently regained interest as a neuroprotectant for focal ischemic stroke in the basic science and clinical literature. The failure to develop safe and efficacious pharmacologic agents along with promising clinical data on the efficacy of hypothermia for cardiac arrest patients have raised a great interest in hypothermia as a neuroprotectant for ischemic stroke. As a clinically meaningful neuroprotectant for stroke, hypothermia confers several theoretical advantages over pharmacologic agents. A major problem with neuroprotectant therapy is instituting therapy within a narrow time window. This obstacle may be easier for hypothermia to overcome as emergency medical service personnel can theoretically initiate it in the field. Additionally, pharmacologic agents are usually restricted to one aspect of the pathophysiologic cascade triggered by focal ischemia, whereas hypothermia acts on several of these pathways simultaneously. The recent advances and future directions in the utilization of hypothermia as a potential therapy for focal ischemic stroke are reviewed.

Therapeutic hypothermia following perinatal asphyxia

Well constructed and carefully analysed trials of hypothermic neural rescue therapy for infants with neonatal encephalopathy have recently been reported. The data suggest that either selective head cooling or total body cooling reduces the combined chance of death or disability after birth asphyxia. However, as there are still unanswered questions about these treatments, many may still feel that further data are needed before health care policy can be changed to make cooling the standard of care for all babies with suspected birth asphyxia.

Subcortical middle cerebral artery ischemia abolishes the digit flexion and closing used for grasping in rat skilled reaching

That rats reach for and grasp a food item using a single paw has prompted their use in neurobiological studies of skilled movements and modeling neural injury including middle cerebral artery stroke. Although motor system lesions have been shown to disrupt various qualitative aspects of the transport of a limb to a food target and withdrawal of the limb with the food, no lesion has been found to abolish digit flexion for grasping. Here, rats received unilateral transient middle cerebral artery ischemia that was restricted mainly to subcortical tissue of the forebrain (caudate-putamen, globus pallidus, and associated fibers) or a sham operation. Both paws were later trained and evaluated on skilled reaching using a rating scale for digit use. Middle cerebral artery rats did not flex and close their digits to grasp food when using their contralateral-to-lesion limb. The grasp impairment was not due to a failure to learn the task as middle cerebral artery rats used the ipsilateral limb as successfully as control rats and they were reinforced for reaching by raking food into the reaching box using an open paw. The impairment was also not due to an inability to move the digits, as they were flexed and closed in other phases of the reach. The paradigm should prove useful for further studies of rehabilitation in relation to the idea that digit closure may be controlled by the joint action of a number of neural systems that converge in the basal ganglia.

Therapeutic hypothermia: from lab to NICU

The possibility of a therapeutic role for cerebral hypothermia during or after resuscitation from perinatal asphyxia has been a long-standing focus of research. However, early studies had limited and contradictory results. It is now known that severe hypoxia-ischemia may not cause immediate cell death, but may precipitate a complex biochemical cascade leading to the delayed development of neuronal loss. These phases include a latent phase after reperfusion, with initial recovery of cerebral energy metabolism but EEG suppression, followed by a secondary phase characterized by accumulation of cytotoxins, seizures, cytotoxic edema, and failure of cerebral oxidative metabolism from 6 to 15 h post insult. Although many of the secondary processes can be injurious, they appear to be primarily epiphenomena of the 'execution' phase of cell death. This conceptual framework allows a better understanding of the experimental parameters that determine effective hypothermic neuroprotection, including the timing of initiation of cooling, its duration and the depth of cooling attained. Moderate cerebral hypothermia initiated in the latent phase, between one and as late as 6 h after reperfusion, and continued for a sufficient duration in relation to the severity of the cerebral injury, has been consistently associated with potent, long-lasting neuroprotection in both adult and perinatal species. The results of the first large multicentre randomized trial of head cooling for neonatal encephalopathy and previous phase I and II studies now strongly suggest that prolonged cerebral hypothermia is both generally safe - at least in an intensive care setting - and can improve intact survival up to 18 months of age. Both long-term followup studies and further large studies of whole body cooling are in progress.

Hypothermia and ERK activation after cardiac arrest

Mild hypothermia improves survival and neurological outcome after cardiac arrest, as well as increasing activation of the extracellular-signal-regulated kinase (ERK) in hippocampus. ERK signaling is involved in neuronal growth and survival. We tested the hypothesis that the beneficial effects of hypothermia required ERK activation. ERK activation was measured by immunoblotting with phosphorylation-specific antibodies. Rats (n = 8 per group) underwent 8 min of asphyxial cardiac arrest and were resuscitated with chest compressions, ventilation, epinephrine and bicarbonate. At 30 min after resuscitation, vehicle (50% saline:50% DMSO) or the ERK kinase inhibitor U0126 (100 microg) was infused into the lateral ventricle. Cranial temperature was kept at either 33 degrees C (hypothermia) or 37 degrees C (normothermia) between 1 and 24 h. Neurological function was assessed daily for 14 days. Surviving neurons were counted in the hippocampus. A dose of 100 mug U0126 inhibited ERK bilaterally for 12 to 24 h and decreased phosphorylation of the ERK substrates ATF-2 and CREB. As in previous studies, hypothermia improved survival, neurological and histological outcome after cardiac arrest. However, survival, neurological score and histology did not differ between U0126 and vehicle-treated rats after cardiac arrest. Therefore, a dose of U0126 sufficient to inhibit biochemical markers of ERK signaling in hippocampus does not alter the beneficial effects of hypothermia induced after resuscitation in rats and did not affect recovery of normothermia-treated rats. These results suggest that hypothermia-induced improvement in outcomes does not require ERK activation.

Combined use of a cytoprotectant and rehabilitation therapy after severe intracerebral hemorrhage in rats

After moderate intracerebral hemorrhage (ICH), both hypothermia (HYPO) and constraint-induced movement therapy (CIMT) improve recovery and reduce the volume of brain injury. We tested the hypothesis that more severe ICH requires both cytoprotection and rehabilitation to significantly improve recovery. Rats were subjected to a unilateral striatal ICH via collagenase infusion. Rats remained normothermic or were subjected to mild HYPO ( approximately 2 days) starting 12 h later. Fourteen days after ICH, half of the rats received CIMT (7 days of restraint of the less affected limb plus daily exercises); the remainder were untreated. Walking, limb use and skilled reaching were assessed up to 60 days, at which time animals were euthanized and the volume of tissue lost was determined. The HYPO treatment alone did not improve outcome, whereas CIMT alone provided significant benefit on the limb use asymmetry test. In the staircase test, the greatest benefit was achieved with the combination of HYPO and CIMT treatments. The volume of tissue lost after ICH was similar among groups arguing against cytoprotection as a mechanism of functional recovery. Finally, these findings suggest that, at least under the present circumstances (e.g., severe striatal ICH), CIMT provides superior benefit to HYPO and that combination therapy will sometimes further improve recovery.

Assessing behavioural function following a pyramidotomy lesion of the corticospinal tract in adult mice

We have developed a pyramidotomy model in mice to lesion the corticospinal tract at the level of the brainstem pyramidal tract, and evaluated the resultant impairments in motor function in a series of behavioural tests. Adult C57BL/6 mice received a unilateral pyramidotomy and a control group of mice underwent sham surgery. We studied the effects of this lesion on forepaw function using five behavioural paradigms, some of which have been widely used in rat studies but have not been fully explored in mice. The tests used were: a rearing test, which assesses forepaw use for weight support during spontaneous vertical exploration of a cylinder; a grid walking test, which assesses the ability to accurately place the forepaws during exploration of an elevated grid; a tape-removal test, which measures both sensory and motor function of the forepaw; a CatWalk automated gait analysis, which provides a number of quantitative measures including stride length and stride width during locomotion; and a staircase reaching task, which assesses skilled independent forepaw use. All tests revealed lesion effects on forepaw function with the tape removal, grid walking, rearing and CatWalk tests demonstrating robust effects throughout the testing period. The development of a pyramidotomy lesion model in mice, together with behavioural tests which can reliably measure functional impairments, will provide a valuable tool for assessing therapeutic strategies to promote regeneration and plasticity.

Mild to moderate hyperthermia does not worsen outcome after severe intracerebral hemorrhage in rats

Hyperthermia worsens outcome in clinical and experimental studies of ischemic stroke. Thus, we tested whether hyperthermia aggravates intracerebral hemorrhage (ICH) in rats. A striatal hemorrhage was produced via an infusion of bacterial collagenase. In a preliminary experiment, we compared brain and core temperatures (via telemetry) during heating (infrared lamp). The brain temperature rise exceeded that produced by enforced core hyperthermia, which was used subsequently. In these experiments up to three hyperthermia conditions (versus normothermia) were tested including: hyperthermia (>38.5 degrees C) over the first (HYP-1) or second 24 h period (HYP-2) after ICH and 3 h of 40 degrees C hyperthermia starting 12 h after ICH (HYP-3). The HYP-1, HYP-2, and HYP-3 treatments did not affect functional deficits (e.g., spontaneous forelimb use, skilled reaching) or the volume of injury at 30 days. Furthermore, the HYP-1 treatment did not aggravate injury or deficits at 7 days. Bleeding and inflammation, which contribute to pathology, were not significantly altered by HYP-1 and HYP-3 treatments. Bleeding was assessed at 1 day, and macrophages and neutrophils were counted at 2 and 4 days. Accordingly, hyperthermia, under the present conditions, did not worsen outcome after striatal ICH.

Post-ischemic modest hypothermia (35 degrees C) combined with intravenous magnesium is more effective at reducing CA1 neuronal death than either treatment used alone following global cerebral ischemia in rats

In this study, we investigated the efficacy of pre- and 2 h post-ischemic magnesium treatment with different durations of modest hypothermia (35 degrees C) induced immediately or 2 h following global cerebral ischemia in rats. In experimental group 1, rats received an intravenous loading dose (LD) of 360 micromol/kg MgSO4 immediately before ischemia followed by a 48 h intravenous infusion (IVI) at 120 micromol/kg/h. Immediately post-ischemia, body temperature was lowered to 35 degrees C for 6 h or maintained at 37 degrees C. In experimental group 2, 2 h after ischemia, rats received the MgSO4 LD/IVI and/or had their body temperature lowered to 35 degrees C for 6, 12 or 24 h. In experimental group 1, ischemic rats receiving 6 h of modest hypothermia demonstrated 9.4% CA1 neuronal survival, whereas rats treated with magnesium alone or magnesium and 6 h of modest hypothermia demonstrated 5.1% and 37.9% neuronal survival, respectively. In experimental group 2, ischemic rats receiving 6, 12 or 24 h of modest hypothermia demonstrated 6.1, 5 and 43% CA1 neuronal survival, respectively. Rats treated with magnesium and 6, 12 or 24 h of modest hypothermia demonstrated 8.1, 9 and 76% neuronal survival, respectively. Our findings demonstrate that post-ischemic treatment with a 24 h duration of modest hypothermia and magnesium is more effective than either treatment used alone.

Hypothermia in acute stroke

Moderate hypothermia (MH) is neuroprotective in animal models of focal ischemia when it is induced during, or within few hours after, onset of ischemia. In patients with acute stroke, several observational studies suggested normothermia or mild hypothermia as independent prognostic factors for favorable outcome. Currently, mild hypothermia was only examined in one clinical study that showed its feasibility and safety, but was not powered to examine efficacy. Limited clinical data on MH in humans suggest that this treatment probably reduces mortality in patients with malignant middle cerebral artery infarction. Still, MH in humans is associated with several side effects, intensive medical treatment, and a prolonged stay in the neurologic intensive care unit. Use of MH should be limited to specialized units, applying this treatment within research protocols or observational studies.

Therapeutic hypothermia after cardiac arrest

PURPOSE OF REVIEW

Most patients who suffer a cardiac arrest die after the event. Full neurological recovery occurs in only 6-23%. Until recently no specific post-arrest therapy was available to improve outcome. Application of therapeutic hypothermia (32-34 degrees C for 12-24 h) applied after cardiac arrest could help to improve this dreadful situation. This review covers the background of and recent clinical studies into hypothermia after cardiac arrest, and gives some insights into the future of resuscitation, namely suspended animation.

RECENT FINDINGS

Two randomized clinical trials of mild therapeutic hypothermia applied after successful resuscitation from cardiac arrest showed that hypothermia after cardiac arrest improves neurological outcome as well as overall mortality.

SUMMARY

The introduction of therapeutic hypothermia after cardiac arrest into routine intensive care practice could save thousands of lives worldwide, because only six patients must be treated to yield one additional patient with favourable neurological recovery. New developments in cooling techniques will make early induction of therapeutic hypothermia simple and convenient. The optimal duration and depth of hypothermia will be determined by future trials. Suspended animation is cooling during cardiac arrest to preserve the organism under conditions of prolonged controlled clinical death, followed by delayed resuscitation, resulting in survival without brain damage. This concept was initially introduced for trauma victims who rapidly bleed to death, and proved to be feasible in studies evaluating outcomes following exsanguination cardiac arrest in large animals. Whether the concept of suspended animation is applicable to normovolemic cardiac arrest is under investigation.

Middle cerebral artery (MCA) stroke produces dysfunction in adjacent motor cortex as detected by intracortical microstimulation in rats

Middle cerebral artery (MCA) stroke in the rat produces impairments in skilled movements. The lesion damages lateral neocortex but spares primary motor cortex (M1), raising the question of the origin of skilled movement deficits. Here, the behavioral deficits of MCA stroke were identified and then M1 was examined neurophysiologically and neuroanatomically. Rats were trained on a food skilled reaching task then the lateral frontal cortex was damaged by unilateral MCA electrocoagulation contralateral to the reaching forelimb. Reach testing and training on two tasks was conducted over 30 post-surgical days. Later, M1 and the corticospinal tract were investigated using intracortical microstimulation (ICMS), anterograde and retrograde axon tracing. A skilled reaching impairment was observed post-surgery, which partly recovered with time and training. ICMS revealed a diminished forelimb movement representation in MCA rats, but a face representation comparable in size to sham rats. Anterograde and retrograde tract tracing suggest that M1 efferents were intact. Although M1 appears to be in the main anatomically spared after MCA stroke its function as assessed electrophysiologically and behaviorally is disrupted.

Spreading depression expands traumatic injury in neocortical brain slices

Traumatic brain injury (TBI) is particularly common in young people, generating healthcare costs that can span decades. The cellular processes activated in the first minutes following injury are poorly understood, and the 3-4 h following trauma are crucial for reducing subsequent injury. Spreading depression (SD) is a profound inactivation of neurons and glia lasting 1-2 min that arises focally and migrates outward across gray matter. In the hours following focal stroke, the metabolic stress of energy reduction and recurring SD-like events (peri-infarct depolarizations, PIDs) interact to promote neuronal injury. Similar recurring depolarizations might evolve immediately following TBI and exacerbate neuronal damage peripheral to the impact site. To test this possibility and examine if certain drugs might limit damage by inhibiting what we term traumatic spreading depression (tSD), we developed a technique whereby a small weight was dropped onto a live slice of rat neocortex while imaging changes in light transmittance (LT). Imaging revealed a propagating front of increased LT arising at the border of the impact site. Traumatic SD significantly expanded the region of ensuing damage. Both tSD and subsequent damage were blocked by the NMDA receptor antagonist MK-801 (100 microM) or the sigma-1 receptor (sigma1R) ligands dextromethorphan (30 microM) or BD-1063 (100 microM). Co-application of the sigma1R antagonist (+)3-PPP with DM reversed the block as did lowering temperature from 35 degrees C to 32 degrees C. This study provides evidence that an event similar to peri-infarct depolarization can arise from an injury site in neocortex within seconds following impact and act to expand the region of acute neuronal damage.

Resuscitative mild hypothermia as a protective tool in brain damage: is there evidence?

Resuscitative mild hypothermia is and will increasingly be used in the emergency department as protection for the brain after an ischaemic insult. The clinical application of resuscitative mild hypothermia and its limitations will be summarized in this paper. The evidence for each application and its underlying mechanism will also be reviewed.

Lost in translation: taking neuroprotection from animal models to clinical trials

Caffeinol has been proposed as a neuroprotectant for human trials. This review covers a variety of animal models used and various attempts to take animal protocols to human trials. The accompanying paper discusses the rabbit model that was used to identify the efficacy of tissue plasminogen activator (tPA) treatment. To date, this is the only model that was able to achieve laboratory to clinical translational success. Use of caffeinol as a cytoprotective agent in rat models yielded exciting results, which led to clinical trials. However, caffeinol given with tPA in rabbits leads to increased hemorrhage. Caffeinol alone does not prove to be neuroprotective, as vasodilation by itself is not efficacious. However, vasodilation combined with thrombolysis (caffeinol with tPA) poses an increased risk of hemorrhage. For a more translational approach to study neuroprotection and neuroprotective agents in human trials, it is necessary to demonstrate the efficacy of the procedure and purported agents in several animal models.

Intravenous administration of magnesium is only neuroprotective following transient global ischemia when present with post-ischemic mild hypothermia

We hypothesized that post-ischemic hypothermia plays an important role in magnesium mediated neuroprotection following global cerebral ischemia. To test this hypothesis, we subjected rats to 8 min of global cerebral ischemia and magnesium treatment with and without post-ischemic body temperature maintenance. In Group 1, rats received an intravenously administered loading dose (LD) of 360 micromol/kg MgSO4 immediately before ischemia followed by a 48-h intravenous infusion (IVI) at either 60, 120 or 240 micromol/kg/h. Animal body temperature was kept at 37+/-0.2 degrees C during ischemia and between 36.6 and 37.8 degrees C for 6 h after ischemia. In Group 2, rats received a 360 micromol/kg MgSO4 LD followed by a 48-h IVI of either 120 or 240 micromol/kg/h MgSO4. In this group, body temperature following ischemia was monitored but not regulated. Control animals in Groups 1 and 2 received normal saline. Seven days after ischemia, hippocampal CA1 neurons were histologically examined. All Group 1 MgSO4-treated and control animals demonstrated less than 6% hippocampal CA1 neuronal survival. In Group 2, the rectal temperature of MgSO4-treated and control animals spontaneously dropped as low as 35.4 degrees C during the 6-h post-ischemia monitoring period. In addition, Group 2 animals that received the LD followed by an IVI of 120 or 240 micromol/kg/h MgSO4 demonstrated 34% (p<0.05) and 20% (p=0.936) CA1 neuronal survival, respectively. The CA1 neuronal survival in saline-treated control animals in both groups was less than 6%. Our data demonstrate only the combination of MgSO4 treatment and post-ischemic mild hypothermia is neuroprotective following global ischemia.

Temperature-regulated model of focal ischemia in the mouse: a study with histopathological and behavioral outcomes

BACKGROUND AND PURPOSE

The importance of mouse stroke models has increased with the development of genetically manipulated animals. We hypothesized that immediate postischemia hypothermia may attenuate ischemic brain injury in the mouse.

METHODS

Intraabdominal radio frequency probes were implanted in animals and core temperature monitored. Groups included: MCAO-45-REG (45 minutes middle cerebral artery occlusion [MCAO]) temperature-controlled in the postischemic period >34 degrees C for 24 hours; MCAO-45 (45 minutes MCAO) were allowed to self-regulate core temperature during recovery; MCAO-30-REG (30 minutes MCAO), with the same temperature protocol as MCAO-45-REG; MCAO-30 (30 minutes MCAO), with temperature protocol the same as MCAO-45. Behavior and histological score was assessed at 7 days. The qualitative histological score assessed for injury in 18 specified regions.

RESULTS

MCAO-45-REG core temperature (mean 34.94 degrees C+/-0.8 degrees C) was significantly different than the self-regulating (MCAO-45, mean 33.1 degrees C+/-2.3 degrees C) for the first 4 hours after anesthesia (P<0.01). There was a trend toward similar differences in temperatures for MCAO-30-REG and MCAO-30 (P=0.08). At 7 days, a greater improvement in behavior score was observed for MCAO-45 and MCAO-30 compared with MCAO-45-REG and MCAO-30-REG (P<0.001). The histological score confirmed reduced injury in unregulated temperature groups (MCAO-45-REG mean 38+/-10 and MCAO-45 30+/-5.1, P<0.05; MCAO-30-REG 41+/-10 and MCAO-30 30+/-9, P<0.05).

CONCLUSIONS

Hypothermia is an important confounder of stroke injury in the intraluminal filament mouse model. Future mouse stroke studies must use strict temperature regulation.

Therapeutic hypothermia for acute ischemic stroke: what do laboratory studies teach us?

BACKGROUND AND PURPOSE

The significance of brain temperature to outcome in cerebral ischemia is recognized. Numerous variations of depth, duration, and delay of cooling have been studied in animal models. It is important to become familiar with these studies to design appropriate clinical trials. With that in mind, a critical review of the pertinent literature is presented, taking into consideration potential limitations in translating such laboratory work to the clinical level.

METHODS

Hypothermia is an especially robust neuroprotectant in the laboratory and has been shown to alter many of the damaging effects of cerebral ischemia. Most laboratory research on therapeutic cooling in cerebral ischemia has been conducted in rodent models of temporary and permanent middle cerebral artery occlusion and report the effects of mild or moderate hypothermia arranged during or after ischemia.

RESULTS

Intraischemic cooling vastly reduces infarct size in most occlusion models. Tissue salvage with delayed onset of cooling is less dramatic but is commonly observed when cooling is begun within 60 minutes of stroke onset in permanent and 180 minutes of stroke onset in temporary occlusion models. Prolonged postischemic cooling further enhances efficacy.

CONCLUSIONS

Laboratory studies have shown that intraischemic hypothermia is more protective than postischemic hypothermia and more benefit is conferred with temporary occlusion than permanent occlusion models. The efficacy of postischemic hypothermia is critically dependent on the duration and depth of hypothermia and its timing relative to ischemia.

Delayed onset of prolonged hypothermia improves outcome after intracerebral hemorrhage in rats

Prolonged hypothermia reduces ischemic brain injury, but its efficacy after intracerebral hemorrhagic (ICH) stroke is unresolved. Rats were implanted with core temperature telemetry probes and subsequently subjected to an ICH, which was produced by infusing bacterial collagenase into the striatum. Animals were kept normothermic (NORMO), or were made mildly hypothermic (33-35 degrees C) for over 2 days starting 1 hour (HYP-1), 6 hours (HYP-6), or 12 hours (HYP-12) after collagenase infusion. Others were cooled for 7 hours beginning 1 hour after infusion (BRIEF). Skilled reaching, walking, and spontaneous forelimb use were assessed. Normothermic ICH rats sustained, on average, a 36.9-mm3 loss of tissue at 1 month. Only the HYP-12 group had a significantly smaller lesion (25.5 mm3). Some functional improvements were found with this and other hypothermia treatments. Cerebral edema was observed in NORMO rats, and was not lessened significantly by hypothermia (HYP-12). Blood pressure measurements, as determined by telemetry, in BRIEF rats showed that hypothermia increased blood pressure. This BRIEF treatment also resulted in significantly more bleeding at 12 hours after ICH (79.2 microL) versus NORMO-treated rats (58.4 microL) as determined by a spectrophotometric hemoglobin assay. Accordingly, these findings suggest that early hypothermia may fail to lessen lesion size owing to complications, such as elevated blood pressure, whereas much-delayed hypothermia is beneficial after ICH. Future experiments should assess whether counteracting the side effects of early hypothermia enhances protection.

Mild to moderate hypothermia prevents microvascular basal lamina antigen loss in experimental focal cerebral ischemia

BACKGROUND AND PURPOSE

Microvascular basal lamina damage occurs after cerebral ischemia and is important for the development of hemorrhage. The aim of this study was to determine whether hypothermia could maintain microvascular integrity in ischemic stroke.

METHODS

Using the suture model, we subjected 12 rats to 3 hours of focal ischemia and 24 hours of reperfusion. Six rats received postischemic normothermia (37 degrees C) and 6 received hypothermia (32 degrees C to 34 degrees C) for the reperfusion period; a group of 6 sham-operated animals without ischemia was used as control. Collagen type IV and hemoglobin were measured by Western blot analysis, matrix metalloproteinase (MMP)-2 and MMP-9 by gelatin zymography, and urokinase-type plasminogen activator (uPA) and tissue-type plasminogen activator (tPA) by plasminogen-casein zymography.

RESULTS

Hypothermia reduced basal lamina collagen type IV loss: 87+/-16% (hypothermia) versus 43+/-4% (normothermia) in basal ganglia and 74+/-16% versus 64+/-4% in cortex; hypothermia reduced hemorrhage from 431+/-65% (normothermia) to 241+/-28% (basal ganglia) (P<0.05). Hypothermia also reduced MMP-2, MMP-9, uPA, and tPA (basal ganglia: MMP-2: 71+/-20% [hypothermia] versus 109+/-3% [normothermia]; MMP-9: 38+/-12% versus 115+/-4%; uPA activity: 310+/-86% versus 1019+/-22%; tPA activity: 61+/-17% versus 111+/-13%; cortex: MMP-2: 53+/-6% versus 116+/-1%; MMP-9: 16+/-4% versus 123+/-3%; uPA: 180+/-27% versus 176+/-10%; tPA: 91+/-15% versus 101+/-8%; each difference: P<0.001) (nonischemic control side=100%).

CONCLUSIONS

Hypothermia maintains microvascular integrity and reduces hemorrhage and the activities of MMP-2, MMP-9, uPA, and tPA.

Motor enrichment and the induction of plasticity before or after brain injury

Voluntary exercise, treadmill activity, skills training, and forced limb use have been utilized in animal studies to promote brain plasticity and functional change. Motor enrichment may prime the brain to respond more adaptively to injury, in part by upregulating trophic factors such as GDNF, FGF-2, or BDNF. Discontinuation of exercise in advance of brain injury may cause levels of trophic factor expression to plummet below baseline, which may leave the brain more vulnerable to degeneration. Underfeeding and motor enrichment induce remarkably similar molecular and cellular changes that could underlie their beneficial effects in the aged or injured brain. Exercise begun before focal ischemic injury increases BDNF and other defenses against cell death and can maintain or expand motor representations defined by cortical microstimulation. Interfering with BDNF synthesis causes the motor representations to recede or disappear. Injury to the brain, even in sedentary rats, causes a small, gradual increase in astrocytic expression of neurotrophic factors in both local and remote brain regions. The neurotrophic factors may inoculate those areas against further damage and enable brain repair and use-dependent synaptogenesis associated with recovery of function or compensatory motor learning. Plasticity mechanisms are particularly active during time-windows early after focal cortical damage or exposure to dopamine neurotoxins. Motor and cognitive impairments may contribute to self-imposed behavioral impoverishment, leading to a reduced plasticity. For slow degenerative models, early forced forelimb use or exercise has been shown to halt cell loss, whereas delayed rehabilitation training is ineffective and disuse is prodegenerative. However, it is possible that, in the chronic stages after brain injury, a regimen of exercise would reactivate mechanisms of plasticity and thus enhance rehabilitation targeting residual functional deficits.

Hypothermic protection in rat focal ischemia models: strain differences and relevance to "reperfusion injury"

Hypothermic protection was compared in Long-Evans and spontaneously hypertensive rat (SHR) strains using transient focal ischemia, and in Wistar and SHR strains using permanent focal ischemia. Focal ischemia was produced by distal surgical occlusion of the middle cerebral artery and tandem occlusion of the ipsilateral common carotid artery (MCA/CCAO). Moderate hypothermia of 2 hours' duration was produced by systemic cooling to 32 degrees C, with further cooling of the brain achieved by reducing to 30 degrees C the temperature of the saline drip superfusing the exposed occlusion site. Infarct volume was determined from serial hematoxylin and eosin-stained frozen sections obtained routinely at 24 hours, or in some cases after 3 days' survival. In the SHR, moderate hypothermia was only effective when initiated before recirculation after a 90-minute occlusion period. In contrast, the same intervention was strikingly effective in the Long-Evans rat even when initiated after as long as 30-minute reperfusion after a 3-hour occlusion. This magnitude and duration of cooling was not protective in permanent MCA/CCAO in the SHR, but such transient hypothermia did effectively reduce infarct volume after permanent occlusions in Wistar rats. These results show striking differences in the temporal window for hypothermic protection among rat focal ischemia models. As expected, "reperfusion injury" in the Long-Evans strain is particularly responsive to delayed cooling. The finding that the SHR can be protected by hypothermia initiated immediately before recirculation suggests a rapidly evolving component of injury occurs subsequent to reperfusion in this model as well. Hypothermic protection after permanent occlusion in Wistar rats identifies a transient, temperature-sensitive phase of infarct evolution that is not evident in the unreperfused SHR. These observations confirm that distinct mechanisms can underlie the temporal progression of injury in rat stroke models, and emphasize the critical importance of considering model and strain differences in extrapolating results of hypothermic protection studies in animals to the design of interventions in clinical stroke.

Hypothermia and stroke: the pathophysiological background

Hypothermia to mitigate ischemic brain tissue damage has a history of about six decades. Both in clinical and experimental studies of hypothermia, two principal arbitrary patterns of core temperature lowering have been defined: mild (32-35 degrees C) and moderate hypothermia (30-33 degrees C). The neuroprotective effectiveness of postischemic hypothermia is typically viewed with skepticism because of conflicting experimental data. The questions to be resolved include the: (i) postischemic delay; (ii) depth; and (iii) duration of hypothermia. However, more recent experimental data have revealed that a protected reduction in brain temperature can provide sustained behavioral and histological neuroprotection, especially when thermoregulatory responses are suppressed by sedation or anesthesia. Conversely, brief or very mild hypothermia may only delay neuronal damage. Accordingly, protracted hypothermia of 32-34 degrees C may be beneficial following acute cerebral ischemia. But the pathophysiological mechanism of this protection remains yet unclear. Although reduction of metabolism could explain protection by deep hypothermia, it does not explain the robust protection connected with mild hypothermia. A thorough understanding of the experimental data of postischemic hypothermia would lead to a more selective and effective clinical therapy. For this reason, we here summarize recent experimental data on the application of hypothermia in cerebral ischemia, discuss problems to be solved in the experimental field, and try to draw parallels to therapeutic potentials and limitations.

Neuroprotective effect of the neurotensin analogue JMV-449 in a mouse model of permanent middle cerebral ischaemia

The neuroprotective effect of the neurotensin analogue H-Lys-psi(CH2NH)Lys-Pro-Tyr-Ile-Leu-OH (JMV-449) was assessed in a mouse model of permanent distal middle cerebral artery occlusion. Mice were injected with 0.6 nmol JMV-449 or vehicle i.c.v. immediately after ischaemia. The core temperature declined by 6-7 degrees C after 30 min and the hypothermia persisted for 4-5 h. JMV-449 treatment was able to reduce the infarct volume significantly both at 24 h and 14 days after onset of ischaemia. No neuroprotective effect could be seen if the mice were kept normothermic after the JMV-449 treatment suggesting that the neuroprotective effect is mediated via the hypothermia.

Long-term effects of clomethiazole in a model of global ischemia

The failure of neuroprotective drugs in clinical trials has raised questions about the predictive value of animal models. To address this issue we reexamined the efficacy of clomethiazole using functional and histological outcome measures in combination with long-term survival times. Gerbils were exposed to 5 min of global ischemia and received 400 mg/ml clomethiazole (via osmotic minipump) plus a bolus injection (60 mg/kg) 30 min after ischemia. Brain temperature was maintained at approximately 36.5 degrees C during ischemia and for the first 30 min after ischemia, and was monitored in all groups for 24 h. Subgroups of clomethiazole-treated gerbils had their temperatures regulated in the normothermic range while in other animals temperature was not controlled. Open-field habituation tests were conducted 5, 10, 30, and 60 days after occlusion. CA1 cell counts and CA1 slice recordings were done at the conclusion of behavioral testing. Clomethiazole significantly attenuated CA1 cell loss at 10-, 30-, and 60-day survival. A modest reduction in habituation deficits was evident only on Day 10 (P < 0.05). Similarly, field potential amplitude was not maintained in the rostral CA1 region. Clomethiazole produced mild hypothermia that developed over several hours. Based on short-term CA1 cell counts, clomethiazole provided significant histological protection with limited functional preservation. Neuroprotection disappeared when longer survival times (60 day) were employed and temperature confounds eliminated. These data demonstrate the necessity of utilizing more clinically relevant survival times and carefully monitoring/regulating postischemic temperature when assessing potential neuroprotective compounds.

Therapeutic hypothermia for acute stroke

Experimental evidence and clinical experience show that hypothermia protects the brain from damage during ischaemia. There is a growing hope that the prevention of fever in stroke will improve outcome and that hypothermia may be a therapeutic option for the treatment of stroke. Body temperature is directly related to stroke severity and outcome, and fever after stroke is associated with substantial increases in morbidity and mortality. Normalisation of temperature in acute stroke by antipyretics is generally recommended, although there is no direct evidence to support this treatment. Despite its obvious therapeutic potential, hypothermia as a form of neuroprotection for stroke has been investigated in only a few very small studies. Therapeutic hypothermia is feasible in acute stroke but owing to serious side-effects--such as hypotension, cardiac arrhythmia, and pneumonia--it is still thought of as experimental, and evidence of efficacy from clinical trials is needed.

Brain temperature measurement and regulation in awake and freely moving rodents

Temperature measurement and control are essential in most ischemia experiments. Hypothermia lessens ischemic brain injury whereas hyperthermia exacerbates it. A substantial number of ischemia studies rely solely on rectal temperature measurements during the insult. However, rectal temperature may not accurately reflect brain temperature especially during global ischemia. Furthermore, postischemic temperature changes are often inadequately monitored. Delayed cooling reduces injury, whereas delayed hyperthermia aggravates it. This review summarizes our experiences with core and brain telemetry probes to continually measure temperature in various ischemia models. Furthermore, we discuss methods to simultaneously measure and regulate temperature in the freely moving postischemic rodent, and the need for such control in ischemia research.

Experimental focal ischemic injury: behavior-brain interactions and issues of animal handling and housing

In experimental neurological models of brain injury, behavioral manipulations before and after the insult can have a major impact on molecular, anatomical, and functional outcome. Investigators using animals for preclinical research should keep in mind that people with brain injury have lived in, and will continue to live in, an environment that is far more complex than that of the typical laboratory rodent. To yield more reliable and relevant behavioral assessment, it may be appropriate in some cases to house animals in environments that allow for motor enrichment and to handle animals in ways that promote tameness. Experience can affect mechanisms of plasticity and degeneration beneficially or adversely. Behavioral interventions that have been found to modulate postinjury brain events are reviewed. The timing and interaction of biological and motor therapies and the potential contribution of experience-dependent and drug-induced trophic factor expression are discussed.