Improving the outcome of severe head injury with the oxygen radical scavenger polyethylene glycol-conjugated superoxide dismutase: a phase II trial

Superoxide dismutase improves posttraumatic cortical blood flow in rats

Oxygen free radicals, such as the superoxide anion, are known to mediate damage to the cerebral microcirculation following traumatic brain injury. The purpose of this study was to determine if superoxide dismutase (SOD), a scavenger of superoxide anion, could alter posttraumatic cortical blood flow. Following barbiturate anesthesia, rats were surgically prepared for moderate fluid percussion brain injury. Cortical blood flow contralateral to the site of injury was measured using laser-Doppler flowmetry. Laser-Doppler flowmetry assesses flow by measuring cell volume and velocity, which are multiplied electronically to give flow. Starting 10 min before injury, animals received either superoxide dismutase (24,000 U/kg bolus, followed by continuous infusion of 1600 U/kg/min) or an equal volume of saline. Blood pressure, heart rate, and cortical blood flow were measured up to 1 h posttrauma. Rats receiving superoxide dismutase had significantly higher cortical blood flow posttrauma (F = 6.91, p < 0.02). One hour posttrauma, the blood flow in SOD-treated rats was 89 +/- 8% of preinjury baseline, whereas this value was only 66 +/- 6% of control in saline-treated rats. SOD caused not only greater blood velocity but also less reduction in cortical blood volume after injury. There were no significant differences between the groups with respect to blood pressure or heart rate. This study further supports the role of oxygen radical-mediated cerebrovascular dysfunction following traumatic brain injury and is the first to show the beneficial effect of SOD on cortical blood flow following fluid percussion brain injury.

Hypothermia attenuates the normal increase in interleukin 1 beta RNA and nerve growth factor following traumatic brain injury in the rat

Significant morbidity and mortality associated with traumatic brain injury (TBI) are allied with secondary posttrauma inflammatory complications. Hypothermia has been suggested as a possible treatment to lessen or suppress these inflammatory reactions. We report here that interleukin 1 beta, a cytokine responsible for initiating inflammatory cascades, is elevated in rat cortex within 6 h of TBI in the rat. Nerve growth factor (NGF) RNA and protein also increased subsequently, and NGF protein remained elevated for up to 7 days. Four hours of whole body hypothermia (32 degrees C), applied immediately after the TBI, attenuated the posttrauma increase in IL-1 beta RNA and eliminated the increase in NGF RNA and protein observed in cerebral cortex following TBI. Thus, hypothermia may be an effective therapy to diminish the posttrauma inflammatory cascade in the brain (as suggested by the decrease in IL-1 beta). However, the same treatment may hinder the brain's intrinsic repair mechanisms. Optimal treatment may, therefore, require supplemental administration of neurotrophic factors or other agents along with hypothermia.

In vivo detection of superoxide anion production by the brain using a cytochrome c electrode

A cytochrome c-coated platinized carbon electrode was utilized to detect superoxide generated by the brain during hypoxia/hypercarbia, focal ischemia, and reperfusion and following fluid percussion brain injury with and without hemorrhagic hypotension and reperfusion in the rat. All three of these forms of brain injury were associated with an increase in the superoxide signal. The cytochrome c electrode proved to be sensitive and responsive enough for minute-by-minute measurement of superoxide generation by brain tissue.

An additional therapeutic effect of adequate hyperventilation in severe acute brain trauma: normalization of cerebral glucose uptake

In a total of 309 frequent serial studies, arteriojugular differences in glucose and oxygen levels were concurrently evaluated in 33 adult patients who were experiencing the most acute phase of severe brain trauma. Hyperventilation therapy was optimized to maintain both normalized intracranial pressure and cerebral extraction of oxygen. Under these circumstances, global cerebral glucose extraction was found to be closest to normal during profound optimized hyperventilation, with PaCO2 levels below 25 mm Hg. In contrast, during normocapnia global cerebral glucose extraction dropped below normal range, indicating impairment of cerebral glucose uptake. Findings from this study show that in severe acute brain injury, optimized hyperventilation exerts an additional metabolic effect with respect to cerebral glucose uptake.

[Pharmacologic brain protection: specific agents]

Dysfunctional sodium influx is the first step in the ischaemic cascade. It has been recently demonstrated that reducing ionic flux through voltagegated Na channels shortens the NMDA receptor activity of cultured hippocampal slices in which oxidative phosphorylation and glycolysis have been blocked. The implication of this finding is that blocking initial events in the ischaemic cascade, events which do not directly cause neuronal damage, will reduce the damage done by downstream events. It also seems intuitively reasonable to suppose that truncating initial steps of the ischaemic cascade, as distinct from blocking glutamate receptors and scavening free radicals, will reduce the probability of interfering with endogenous mechanisms of repair. Clinically useful, substantive, prophylactic, pharmacological cerebral protection will come from drugs that work upstream. And for pharmacological protection that can only be initiated subsequent to an ischaemic event, the more we learn about endogenous repair, or genetic pharmacology, the closer we will come to maximizing the benefits and minimizing the costs of downstream intervention.

Reduced blood-brain barrier permeability after cardiac arrest by conjugated superoxide dismutase and catalase in piglets

BACKGROUND AND PURPOSE

Cardiac arrest and resuscitation in immature piglets result in a delayed increase in blood-brain barrier permeability. We tested the hypothesis that pretreatment with oxygen radical scavengers reduces postischemic permeability.

METHODS

Permeability was assessed by measuring the plasma-to-brain transfer coefficient of the small amino acid, alpha-aminoisobutyric acid, in 2- to 3-week-old anesthetized piglets. Three groups were studied: (1) a nonischemic time control group (n = 5), (2) an ischemia group (n = 8) pretreated with 5 mL of polyethylene glycol vehicle, and (3) an ischemia group (n = 8) pretreated with polyethylene glycol conjugated to superoxide dismutase (10,000 U/kg) and to catalase (20,000 U/kg). The ischemia protocol consisted of 8 minutes of ventricular fibrillation, 6 minutes of cardiopulmonary resuscitation, defibrillation, and 4 hours of spontaneous circulation.

RESULTS

The mean +/- SEM of the transfer coefficient of alpha-aminoisobutyric acid in cerebrum was (in microL/g per minute): 1.54 +/- 0.37 in the nonischemic group, 2.04 +/- 0.26 in the ischemia group treated with vehicle, and 1.29 +/- 0.25 in the ischemia group treated with oxygen radical scavengers. Postischemic values with scavenger treatment were significantly lower than those with vehicle treatment in cerebrum, cerebellum, medulla and cervical spinal cord.

CONCLUSIONS

Pretreatment with oxygen radical scavengers reduces postischemic blood-brain barrier permeability by a small amino acid. These data are consistent with oxygen radical-mediated dysfunction of cerebral endothelium in a pediatric model of cardiopulmonary resuscitation.

Endogenous neuroprotection factors and traumatic brain injury: mechanisms of action and implications for therapy

Throughout evolution the brain has acquired elegant strategies to protect itself against a variety of environmental insults. Prominent among these are signals released from injured cells that are capable of initiating a cascade of events in neurons and glia designed to prevent further damage. Recent research has identified a remarkably large number of neuroprotection factors (NPFs), whose expression is increased in response to brain injury. Examples include the neurotrophins (NGF, NT-3, NT-5, and BDNF), bFGF, IGFs, TGFs, TNFs and secreted forms of the beta-amyloid precursor protein. Animal and cell culture studies have shown that NPFs can attenuate neuronal injury initiated by insults believed to be relevant to the pathophysiology of traumatic brain injury (TBI) including excitotoxins, ischemia, and free radicals. Studies of the mechanism of action of these NPFs indicate that they enhance cellular systems involved in maintenance of Ca2+ homeostasis and free radical metabolism. Recent work has identified several low-molecular-weight lipophilic compounds that appear to mimic the action of NPFs by activating signal transduction cascades involving tyrosine phosphorylation. Such compounds, alone or in combination with antioxidants and calcium-stabilizing agents, have proved beneficial in animal studies of ischemic brain injury and provide opportunities for development of preventative/therapeutic approaches for TBI.

Management of raised intracranial pressure

This review has been written at an unfortunate time. Novel questions are being asked of the old therapies and there is an abundance of new strategies both to lower ICP and protect the brain against cerebral ischaemia. In the United Kingdom, the problem is to ensure that appropriate patients continue to be referred to centres where clinical trials of high quality can be undertaken. One of the success stories of the past decade has been the decline in the number of road accidents as a result of seat belt legislation, improvements in car design and the drink/driving laws. Hence, fortunately there are fewer patients with head injuries to treat and it is even more important that patients are appropriately referred if studies to assess efficacy of the new strategies are not to be thwarted. The nihilistic concept that intensive investigation with ICP monitoring for patients with diffuse head injury or brain swelling following evacuation of a haematoma or a contusion has no proven beneficial effect on outcome, requires revision. A cocktail of therapies may be required that can be created only when patients are monitored in sufficient detail to reveal the mechanisms underlying their individual ICP problem. Ethical problems may arise over how aggressively therapy for intracranial hypertension should be pursued and for how long. There has always been the concern that cranial decompression or prolonged barbiturate coma may preserve patients but with unacceptably severe disability. Some patients may be salvaged from herniating with massive cerebral infarction with the use of osmotherapy but is the outcome acceptable? Similar considerations apply to some children with metabolic encephalopathies. Where such considerations have been scrutinised in patients with severe head injury, the whole spectrum of outcomes appears to be shifted so that the number of severe disabilities and persistent vegetative states are not increased. However, it is important to be sensitive to such issues based on experience of the particular cause of raised intracranial pressure in a given age group.

Cerebral ischemia-reperfusion injury after severe head injury and its possible treatment with polyethyleneglycol-superoxide dismutase

Oxygen radical-mediated mechanisms play a role both in cerebral ischemia-reperfusion injury and in traumatic brain injury. Moreover, my work with measurements of cerebral blood flow with the 133Xe method and the stable xenon-computed tomography method and through measurements of arteriovenous difference of oxygen indicates that ischemia and ischemia-reperfusion are also part of traumatic brain injury but only in the first few hours after injury. The contributions of the research laboratories at the Medical College of Virginia, Richmond, to the understanding of the role of oxygen free radicals in traumatic brain injury are discussed. Finally, a trial of the oxygen radical scavenger polyethyleneglycol-superoxide dismutase in human beings with severe head injuries show that death and vegetative state occurred twice as often in the 26 patients receiving placebo compared with the group of 26 patients receiving a 10,000 U/kg bolus of polyethyleneglycol-superoxide dismutase (43%, respectively; 20% at three months; P < .03).