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Kang M, Min K, Jang J, Kim SC, Kang MS, Jang SJ, Lee JY, Kim SH, Kim MK, An SA, Kim M. Involvement of Immune Responses in the Efficacy of Cord Blood Cell Therapy for Cerebral Palsy. Stem Cells Dev 2015; 24:2259-68. [PMID: 25977995 DOI: 10.1089/scd.2015.0074] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
This study evaluated the efficacy of umbilical cord blood (UCB) cell for patients with cerebral palsy (CP) in a randomized, placebo-controlled, double-blind trial and also assessed factors and mechanisms related to the efficacy. Thirty-six children (ages 6 months to 20 years old) with CP were enrolled and treated with UCB or a placebo. Muscle strength and gross motor function were evaluated at baseline and 1, 3, and 6 months after treatment. Along with function measurements, each subject underwent (18)F-fluorodeoxyglucose positron emission tomography at baseline and 2 weeks after treatment. Cytokine and receptor levels were quantitated in serial blood samples. The UCB group showed greater improvements in muscle strength than the controls at 1 (0.94 vs. -0.35, respectively) and 3 months (2.71 vs. 0.65) after treatment (Ps<0.05). The UCB group also showed greater improvements in gross motor performance than the control group at 6 months (8.54 vs. 2.60) after treatment (P<0.01). Additionally, positron emission tomography scans revealed decreased periventricular inflammation in patients administered UCB, compared with those treated with a placebo. Correlating with enhanced gross motor function, elevations in plasma pentraxin 3 and interleukin-8 levels were observed for up to 12 days after treatment in the UCB group. Meanwhile, increases in blood cells expressing Toll-like receptor 4 were noted at 1 day after treatment in the UCB group, and they were correlated with increased muscle strength at 3 months post-treatment. In this trial, treatment with UCB alone improved motor outcomes and induced systemic immune reactions and anti-inflammatory changes in the brain. Generally, motor outcomes were positively correlated with the number of UCB cells administered: a higher number of cells resulted in better outcomes. Nevertheless, future trials are needed to confirm the long-term efficacy of UCB therapy, as the follow-up duration of the present trial was short.
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Affiliation(s)
- Mino Kang
- 1 Department of Bionanotechnology, Gachon Medical Research Institute, Gachon University , Seongnam, Republic of Korea
| | - Kyunghoon Min
- 2 Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University , Seongnam, Republic of Korea
| | - Joonyoung Jang
- 2 Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University , Seongnam, Republic of Korea
| | - Seung Chan Kim
- 1 Department of Bionanotechnology, Gachon Medical Research Institute, Gachon University , Seongnam, Republic of Korea
| | - Myung Seo Kang
- 3 Department of Laboratory Medicine, CHA Bundang Medical Center, CHA University and CHA Medical Center Cord Blood Bank , Seongnam, Republic of Korea
| | - Su Jin Jang
- 4 Department of Nuclear Medicine, CHA Bundang Medical Center, CHA University , Seongnam, Republic of Korea
| | - Ji Young Lee
- 4 Department of Nuclear Medicine, CHA Bundang Medical Center, CHA University , Seongnam, Republic of Korea
| | - Sang Heum Kim
- 5 Department of Radiology, CHA Bundang Medical Center, CHA University , Seongnam, Republic of Korea
| | - Moon Kyu Kim
- 6 Division of Hematology-Oncology, Department of Pediatrics, CHA Bundang Medical Center, CHA University , Seongnam, Republic of Korea
| | - SeongSoo A An
- 1 Department of Bionanotechnology, Gachon Medical Research Institute, Gachon University , Seongnam, Republic of Korea
| | - MinYoung Kim
- 2 Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University , Seongnam, Republic of Korea
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202
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Neutrophil and monocyte toll-like receptor 4, CD11b and reactive oxygen intermediates, and neuroimaging outcomes in preterm infants. Pediatr Res 2015; 78:82-90. [PMID: 25826119 DOI: 10.1038/pr.2015.66] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 01/05/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Activated leukocytes and infection are implicated in neonatal brain injury. Leukocyte surface receptors are increased in stroke models and may be targets for future adjunctive therapies. METHODS Serial blood samples were analyzed from preterm infants (n = 51; <32 wk gestation) on days 0, 1, 2, and 7 of life. Monocyte and neutrophil activation were evaluated via flow cytometry at baseline and following endotoxin stimulation ex vivo by measuring CD11b (activation), toll-like receptor 4 (TLR-4; endotoxin recognition) expression, and intracellular reactive oxygen intermediate (ROI) production (function). RESULTS Control preterm infants with normal neuroimaging had elevated baseline CD11b and TLR-4 expression and ROI production compared with adults as well as a robust immune response following endotoxin stimulation. Preterm infants with abnormal neuroimaging had increased neutrophil TLR-4 and ROI compared with all controls. CONCLUSION Preterm infants have a robust immune response compared with adults. Increased TLR-4 expression in preterm infants with abnormal neuroimaging is similar to findings in adult stroke. In addition, ROI production may cause tissue injury. The modulation of these responses may be beneficial in preterm inflammatory disorders.
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Vinnars MT, Vollmer B, Nasiell J, Papadogiannakis N, Westgren M. Association between cerebral palsy and microscopically verified placental infarction in extremely preterm infants. Acta Obstet Gynecol Scand 2015; 94:976-82. [PMID: 26054014 DOI: 10.1111/aogs.12688] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 06/01/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Previously, cerebral palsy has been associated with placental infarctions diagnosed macroscopically by midwifes. However, the risk of misclassification of infarctionsis is high without a histological verification. Therefore, the objective of this study was to study placental histopathology in relation to developmental outcome at 2.5 years corrected age in a population born extremely preterm. MATERIAL AND METHODS A prospective cohort study was carried out at Karolinska University Hospital, Stockholm, Sweden on a population of 139 live born infants delivered <27 gestational weeks during 2004-2007. A senior perinatal pathologist, who was blinded to outcome data, evaluated all placental slides microscopically. Neuromotor and sensory functions of the children were evaluated. Bayley Scales of Infant and Toddler Development-III (Bayley-III) were used to assess development at corrected age 2.5 years. The outcome data were evaluated without reference to obstetrical and pathology data. The primary outcome measure was neurological and developmental status at 2.5 years of corrected age. This was measured as diagnosis of cerebral palsy, visual impairment, hearing impairment as well as performance on Bayley-III scales evaluating cognitive, language and motor functions. RESULTS Two out of seven children with placental infarction were diagnosed with cerebral palsy compared with one child of 51 without placental infarction (p = 0.036). For developmental outcome according to Bayley-III at 2.5 years no statistically significant associations with placental pathology were found. CONCLUSION A possible association between placental infarction, verified by microscopic examination, and cerebral palsy has been identified in this extremely preterm population.
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Affiliation(s)
- Marie-Therese Vinnars
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden
| | - Brigitte Vollmer
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Clinical Neurosciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Josefine Nasiell
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden
| | - Nikos Papadogiannakis
- Department of Laboratory Medicine, Division of Pathology, Karolinska Institute, Stockholm, Sweden
| | - Magnus Westgren
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden
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204
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Brain damage of the preterm infant: new insights into the role of inflammation. Biochem Soc Trans 2015; 42:557-63. [PMID: 24646278 DOI: 10.1042/bst20130284] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Epidemiological studies have shown a strong association between perinatal infection/inflammation and brain damage in preterm infants and/or neurological handicap in survivors. Experimental studies have shown a causal effect of infection/inflammation on perinatal brain damage. Infection including inflammatory factors can disrupt programmes of brain development and, in particular, induce death and/or blockade of oligodendrocyte maturation, leading to myelin defects. Alternatively, in the so-called multiple-hit hypothesis, infection/inflammation can act as predisposing factors, making the brain more susceptible to a second stress (sensitization process), such as hypoxic-ischaemic or excitotoxic insults. Epidemiological data also suggest that perinatal exposure to inflammatory factors could predispose to long-term diseases including psychiatric disorders.
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205
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Cardoso FL, Herz J, Fernandes A, Rocha J, Sepodes B, Brito MA, McGavern DB, Brites D. Systemic inflammation in early neonatal mice induces transient and lasting neurodegenerative effects. J Neuroinflammation 2015; 12:82. [PMID: 25924675 PMCID: PMC4440597 DOI: 10.1186/s12974-015-0299-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 04/10/2015] [Indexed: 12/11/2022] Open
Abstract
Background The inflammatory mediator lipopolysaccharide (LPS) has been shown to induce acute gliosis in neonatal mice. However, the progressive effects on the murine neurodevelopmental program over the week that follows systemic inflammation are not known. Thus, we investigated the effects of repeated LPS administration in the first postnatal week in mice, a condition mimicking sepsis in late preterm infants, on the developing central nervous system (CNS). Methods Systemic inflammation was induced by daily intraperitoneal administration (i.p.) of LPS (6 mg/kg) in newborn mice from postnatal day (PND) 4 to PND6. The effects on neurodevelopment were examined by staining the white matter and neurons with Luxol Fast Blue and Cresyl Violet, respectively. The inflammatory response was assessed by quantifying the expression/activity of matrix metalloproteinases (MMP), toll-like receptor (TLR)-4, high mobility group box (HMGB)-1, and autotaxin (ATX). In addition, B6 CX3CR1gfp/+ mice combined with cryo-immunofluorescence were used to determine the acute, delayed, and lasting effects on myelination, microglia, and astrocytes. Results LPS administration led to acute body and brain weight loss as well as overt structural changes in the brain such as cerebellar hypoplasia, neuronal loss/shrinkage, and delayed myelination. The impaired myelination was associated with alterations in the proliferation and differentiation of NG2 progenitor cells early after LPS administration, rather than with excessive phagocytosis by CNS myeloid cells. In addition to disruptions in brain architecture, a robust inflammatory response to LPS was observed. Quantification of inflammatory biomarkers revealed decreased expression of ATX with concurrent increases in HMGB1, TLR-4, and MMP-9 expression levels. Acute astrogliosis (GFAP+ cells) in the brain parenchyma and at the microvasculature interface together with parenchymal microgliosis (CX3CR1+ cells) were also observed. These changes preceded the migration/proliferation of CX3CR1+ cells around the vessels at later time points and the subsequent loss of GFAP+ astrocytes. Conclusion Collectively, our study has uncovered a complex innate inflammatory reaction and associated structural changes in the brains of neonatal mice challenged peripherally with LPS. These findings may explain some of the neurobehavioral abnormalities that develop following neonatal sepsis.
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Affiliation(s)
- Filipa L Cardoso
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003, Lisbon, Portugal.
| | - Jasmin Herz
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Bethesda, MD, 20892-1430, USA.
| | - Adelaide Fernandes
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003, Lisbon, Portugal. .,Department of Biochemistry and Human Biology, Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003, Lisbon, Portugal.
| | - João Rocha
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003, Lisbon, Portugal.
| | - Bruno Sepodes
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003, Lisbon, Portugal.
| | - Maria A Brito
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003, Lisbon, Portugal. .,Department of Biochemistry and Human Biology, Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003, Lisbon, Portugal.
| | - Dorian B McGavern
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Bethesda, MD, 20892-1430, USA.
| | - Dora Brites
- Research Institute for Medicines (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003, Lisbon, Portugal. .,Department of Biochemistry and Human Biology, Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003, Lisbon, Portugal.
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206
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Hagberg H, Mallard C, Ferriero DM, Vannucci SJ, Levison SW, Vexler ZS, Gressens P. The role of inflammation in perinatal brain injury. Nat Rev Neurol 2015; 11:192-208. [PMID: 25686754 PMCID: PMC4664161 DOI: 10.1038/nrneurol.2015.13] [Citation(s) in RCA: 571] [Impact Index Per Article: 63.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Inflammation is increasingly recognized as being a critical contributor to both normal development and injury outcome in the immature brain. The focus of this Review is to highlight important differences in innate and adaptive immunity in immature versus adult brain, which support the notion that the consequences of inflammation will be entirely different depending on context and stage of CNS development. Perinatal brain injury can result from neonatal encephalopathy and perinatal arterial ischaemic stroke, usually at term, but also in preterm infants. Inflammation occurs before, during and after brain injury at term, and modulates vulnerability to and development of brain injury. Preterm birth, on the other hand, is often a result of exposure to inflammation at a very early developmental phase, which affects the brain not only during fetal life, but also over a protracted period of postnatal life in a neonatal intensive care setting, influencing critical phases of myelination and cortical plasticity. Neuroinflammation during the perinatal period can increase the risk of neurological and neuropsychiatric disease throughout childhood and adulthood, and is, therefore, of concern to the broader group of physicians who care for these individuals.
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Affiliation(s)
- Henrik Hagberg
- 1] Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, King's Health Partners, St Thomas' Hospital, London SE1 7EH, UK. [2] Perinatal Center, Institute of Physiology and Neurosciences and Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 435 43 Gothenburg, Sweden
| | - Carina Mallard
- Perinatal Center, Institute of Physiology and Neurosciences and Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 435 43 Gothenburg, Sweden
| | - Donna M Ferriero
- Departments of Neurology and Pediatrics, University of California San Francisco, San Francisco, CA 94158, USA
| | - Susan J Vannucci
- Department of Pediatrics/Newborn Medicine, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - Steven W Levison
- Department of Neurology and Neuroscience, Rutgers University, RBHS-New Jersey Medical School, Cancer Center, H-1226 205 South Orange Avenue, Newark, NJ 07103, USA
| | - Zinaida S Vexler
- Departments of Neurology and Pediatrics, University of California San Francisco, San Francisco, CA 94158, USA
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207
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Baburamani AA, Miyakuni Y, Vontell R, Supramaniam VG, Svedin P, Rutherford M, Gressens P, Mallard C, Takeda S, Thornton C, Hagberg H. Does Caspase-6 Have a Role in Perinatal Brain Injury? Dev Neurosci 2015; 37:321-37. [PMID: 25823427 PMCID: PMC4876595 DOI: 10.1159/000375368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 01/19/2015] [Indexed: 12/31/2022] Open
Abstract
Apoptotic mechanisms are centre stage for the development of injury in the immature brain, and caspases have been shown to play a pivotal role during brain development and in response to injury. The inhibition of caspases using broad-spectrum agents such as Q-VD-OPh is neuroprotective in the immature brain. Caspase-6, an effector caspase, has been widely researched in neurodevelopmental disorders and found to be important following adult stroke, but its function in the neonatal brain has yet to be detailed. Furthermore, caspases may be important in microglial activation; microglia are required for optimal brain development and following injury, and their close involvement during neuronal cell death suggests that apoptotic cues such as caspase activation may be important in microglial activation. Therefore, in this study we aimed to investigate the possible apoptotic and non-apoptotic functions caspase-6 may have in the immature brain in response to hypoxia-ischaemia. We examined whether caspases are involved in microglial activation. We assessed cleaved caspase-6 expression following hypoxia-ischaemia and conducted primary microglial cultures to assess whether the broad-spectrum inhibitor Q-VD-OPh or caspase-6 gene deletion affected lipopolysaccharide (LPS)-mediated microglial activation and phenotype. We observed cleaved caspase-6 expression to be low but present in the cell body and cell processes in both a human case of white matter injury and 72 h following hypoxia-ischaemia in the rat. Gene deletion of caspase-6 did not affect the outcome of brain injury following mild (50 min) or severe (60 min) hypoxia-ischaemia. Interestingly, we did note that cleaved caspase-6 was co-localised with microglia that were not of apoptotic morphology. We observed that mRNA of a number of caspases was modulated by low-dose LPS stimulation of primary microglia. Q-VD-OPh treatment and caspase-6 gene deletion did not affect microglial activation but modified slightly the M2b phenotype response by changing the time course of SOCS3 expression after LPS administration. Our results suggest that the impact of active caspase-6 in the developing brain is subtle, and we believe there are predominantly other caspases (caspase-2, −3, −8, −9) that are essential for the cell death processes in the immature brain.
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Affiliation(s)
- Ana A Baburamani
- Perinatal Center, Institute of Neuroscience and Physiology, Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Roux C, Aligny C, Lesueur C, Girault V, Brunel V, Ramdani Y, Genty D, Driouich A, Laquerrière A, Marret S, Brasse-Lagnel C, Gonzalez BJ, Bekri S. NMDA receptor blockade in the developing cortex induces autophagy-mediated death of immature cortical GABAergic interneurons: An ex vivo and in vivo study in Gad67-GFP mice. Exp Neurol 2015; 267:177-93. [PMID: 25795167 DOI: 10.1016/j.expneurol.2015.02.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 01/14/2015] [Accepted: 02/05/2015] [Indexed: 01/16/2023]
Abstract
In neonates, excitotoxicity is a major process involved in hypoxic-ischemic brain lesions, and several research groups have suggested the use of NMDA antagonists for neuroprotection. However, despite their clinical interest, there is more and more evidence suggesting that, in the immature brain, these molecules exert deleterious actions on migrating GABAergic interneurons by suppressing glutamatergic trophic inputs. Consequently, preventing the side effects of NMDA antagonists would be therapeutically useful. Because macroautophagy is involved in the adaptive response to trophic deprivation, the aim of the present study was to investigate the impact of autophagy modulators on the MK801-induced death of immature GABAergic interneurons and to characterize the crosstalk between autophagic and apoptotic mechanisms in this cell type. Ex vivo, using cortical slices from NMRI and Gad67-GFP mice, we show that blockade of the NMDA receptor results in an accumulation of autophagosomes due to the disruption of the autophagic flux. This effect precedes the activation of the mitochondrial apoptotic pathway, and the degeneration of immature GABAergic neurons present in developing cortical layers II-IV and is prevented by 3-MA, an autophagy inhibitor. In contrast, modulators of autophagy (3-MA, rapamycin) do not interfere with the anti-excitotoxic and neuroprotective effect of MK801 observed in deep layers V and VI. In vivo, 3-MA blocks the rapid increase in caspase-3 cleavage induced by the blockade of NMDA receptors and prevents the resulting long-term decrease in Gad67-GFP neurons in layers II-IV. Together, these data suggest that, in the developing cortex, the suppression of glutamatergic inputs through NMDA receptor inhibition results in the impairment of the autophagic flux and the subsequent switch to apoptotic death of immature GABAergic interneurons. The concomitant inhibition of autophagy prevents this pro-apoptotic action of the NMDA blocker and favors the long-term rescue of GABAergic interneurons without interfering with its neuroprotective actions. The use of autophagy modulators in the developing brain would create new opportunities to prevent the side effects of NMDA antagonists used for neuroprotection or anesthesia.
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Affiliation(s)
- Christian Roux
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France
| | - Caroline Aligny
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France
| | - Céline Lesueur
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France; Department of Medical Biochemistry, Rouen University Hospital, Rouen, France
| | - Virginie Girault
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France
| | - Valery Brunel
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France; Department of Medical Biochemistry, Rouen University Hospital, Rouen, France
| | - Yasmina Ramdani
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France
| | - Damien Genty
- Department of Pathology, Rouen University Hospital, Rouen, France
| | - Azeddine Driouich
- Research Platform of Cell Imagery (PRIMACEN), France; Laboratory of Glycobiology and Plant Extracellular Matrix (GLYCOMEV) EA 4358, France
| | - Annie Laquerrière
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France; Department of Pathology, Rouen University Hospital, Rouen, France
| | - Stéphane Marret
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France; Department of Neonatal Paediatrics and Intensive Care, Rouen University Hospital, Rouen, France
| | - Carole Brasse-Lagnel
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France; Department of Medical Biochemistry, Rouen University Hospital, Rouen, France
| | - Bruno J Gonzalez
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France.
| | - Soumeya Bekri
- Region-Inserm Team NeoVasc ERI28, Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Institute of Research for Innovation in Biomedicine, Normandy University, Rouen, France; Department of Medical Biochemistry, Rouen University Hospital, Rouen, France
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Moretti R, Pansiot J, Bettati D, Strazielle N, Ghersi-Egea JF, Damante G, Fleiss B, Titomanlio L, Gressens P. Blood-brain barrier dysfunction in disorders of the developing brain. Front Neurosci 2015; 9:40. [PMID: 25741233 PMCID: PMC4330788 DOI: 10.3389/fnins.2015.00040] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 01/27/2015] [Indexed: 12/22/2022] Open
Abstract
Disorders of the developing brain represent a major health problem. The neurological manifestations of brain lesions can range from severe clinical deficits to more subtle neurological signs or behavioral problems and learning disabilities, which often become evident many years after the initial damage. These long-term sequelae are due at least in part to central nervous system immaturity at the time of the insult. The blood-brain barrier (BBB) protects the brain and maintains homeostasis. BBB alterations are observed during both acute and chronic brain insults. After an insult, excitatory amino acid neurotransmitters are released, causing reactive oxygen species (ROS)-dependent changes in BBB permeability that allow immune cells to enter and stimulate an inflammatory response. The cytokines, chemokines and other molecules released as well as peripheral and local immune cells can activate an inflammatory cascade in the brain, leading to secondary neurodegeneration that can continue for months or even years and finally contribute to post-insult neuronal deficits. The role of the BBB in perinatal disorders is poorly understood. The inflammatory response, which can be either acute (e.g., perinatal stroke, traumatic brain injury) or chronic (e.g., perinatal infectious diseases) actively modulates the pathophysiological processes underlying brain injury. We present an overview of current knowledge about BBB dysfunction in the developing brain during acute and chronic insults, along with clinical and experimental data.
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Affiliation(s)
- Raffaella Moretti
- INSERM U1141, Robert Debre's Hospital Paris, France ; Université Paris Diderot, Sorbonne Paris Cité, UMRS 1141-PROTECT Paris, France ; PremUP Paris, France ; S. Maria della Misericordia Hospital, Università degli Studi di Udine Udine, Italy
| | - Julien Pansiot
- INSERM U1141, Robert Debre's Hospital Paris, France ; Université Paris Diderot, Sorbonne Paris Cité, UMRS 1141-PROTECT Paris, France ; PremUP Paris, France
| | - Donatella Bettati
- INSERM U1141, Robert Debre's Hospital Paris, France ; Université Paris Diderot, Sorbonne Paris Cité, UMRS 1141-PROTECT Paris, France ; PremUP Paris, France
| | - Nathalie Strazielle
- Lyon Neurosciences Research Center, INSERM U1028, CNRS UMR5292 - Lyon University Lyon, France ; Brain-i Lyon, France
| | | | - Giuseppe Damante
- S. Maria della Misericordia Hospital, Università degli Studi di Udine Udine, Italy
| | - Bobbi Fleiss
- INSERM U1141, Robert Debre's Hospital Paris, France ; Université Paris Diderot, Sorbonne Paris Cité, UMRS 1141-PROTECT Paris, France ; PremUP Paris, France ; Department of Division of Imaging Sciences and Biomedical Engineering, Centre for the Developing Brain, St. Thomas' Hospital London, UK
| | - Luigi Titomanlio
- INSERM U1141, Robert Debre's Hospital Paris, France ; Université Paris Diderot, Sorbonne Paris Cité, UMRS 1141-PROTECT Paris, France ; PremUP Paris, France ; Pediatric Emergency Department, APHP, Robert Debré Hospital Paris, France
| | - Pierre Gressens
- INSERM U1141, Robert Debre's Hospital Paris, France ; Université Paris Diderot, Sorbonne Paris Cité, UMRS 1141-PROTECT Paris, France ; PremUP Paris, France ; Department of Division of Imaging Sciences and Biomedical Engineering, Centre for the Developing Brain, St. Thomas' Hospital London, UK
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Kuban KCK, O’Shea TM, Allred EN, Fichorova RN, Heeren T, Paneth N, Hirtz D, Dammann O, Leviton A. The breadth and type of systemic inflammation and the risk of adverse neurological outcomes in extremely low gestation newborns. Pediatr Neurol 2015; 52:42-8. [PMID: 25459361 PMCID: PMC4276530 DOI: 10.1016/j.pediatrneurol.2014.10.005] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 10/07/2014] [Accepted: 10/08/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND We hypothesized that the risk of brain damage in extremely preterm neonates increases with the breadth and type of systemic inflammation, indexed by the number of elevated inflammation-related proteins and the number of functional categories of inflammation-related proteins exhibiting an elevated concentration. METHODS In blood from 881 infants born before 28 weeks gestation, we measured the concentrations of 25 inflammation-related proteins, representing six functional categories (cytokines, chemokines, growth factors, adhesion molecules, metalloproteinases, and liver-produced acute phase reactant proteins) on postnatal days 1, 7, and 14. We evaluated associations between the number and type of proteins whose concentrations were elevated on two separate occasions a week apart and the diagnoses of ventriculomegaly as a neonate, and at 2 years, microcephaly, impaired early cognitive functioning, cerebral palsy, and autism risk as assessed with the Modified Checklist for Autism in Toddlers screen, and in a subset of these children from 12 of 14 sites (n = 826), an attention problem identified with the Child Behavior Checklist. RESULTS The risk of abnormal brain structure and function overall was increased among children who had recurrent and/or persistent elevations of the 25 proteins. The risk for most outcomes did not rise until at least four proteins in at least two functional categories were elevated. When we focused our analysis on 10 proteins previously found to be associated consistently with neurological outcomes, we found the risk of low Mental Development Index on the Bayley Scales of Infant Development-II, microcephaly, and a Child Behavior Checklist-defined attention problem increased with higher numbers of these recurrently and/or persistently elevated proteins. INTERPRETATION Increasing breadth of early neonatal inflammation, indexed by the number of protein elevations or the number of protein functional classes elevated, is associated with increasing risk of disorders of brain structure and function among infants born extremely preterm.
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Affiliation(s)
- Karl C. K. Kuban
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | | | - Elizabeth N. Allred
- Harvard Medical School, Boston, MA, USA,Boston Children’s Hospital, Boston, MA, USA,Harvard School of Public Health, Boston, MA, USA
| | - Raina N. Fichorova
- Harvard Medical School, Boston, MA, USA,Department of Obstetrics, Gynecology & Reproductive Biology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Tim Heeren
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Nigel Paneth
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
| | - Deborah Hirtz
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Olaf Dammann
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston MA, USA
| | - Alan Leviton
- Harvard Medical School, Boston, MA, USA,Boston Children’s Hospital, Boston, MA, USA
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DAMIANO DIANEL. Meaningfulness of mean group results for determining the optimal motor rehabilitation program for an individual child with cerebral palsy. Dev Med Child Neurol 2014; 56:1141-1146. [PMID: 24919877 PMCID: PMC4229436 DOI: 10.1111/dmcn.12505] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 02/04/2023]
Abstract
As research on the efficacy or effectiveness of interventions to improve motor functioning in cerebral palsy (CP) has accumulated and been incorporated into systematic reviews, the foundation for evidence-based practice in CP is growing. To determine whether an intervention is effective, clinical trials report mean group differences. However, even if a statistically significant mean group effect is found, this does not imply that this intervention was effective for each study participant or ensure positive outcomes for all with CP. A personalized approach to medical care is currently being advocated based primarily on increasingly recognized genetic variations in individual responses to medications and other therapies. A similar approach is also warranted, and perhaps more justifiable, in CP which includes a heterogeneous group of disorders. Even interventions deemed highly effective in CP demonstrate a range of individual responses along a continuum from a negative or negligible response to a strong positive effect, the bases for which remain incompletely understood. This narrative review recommends that the next critical step in advancing evidence-based practice is to implement research strategies to identify patient factors that predict treatment responses so we can not only answer the question 'what works', but also 'what works best, for whom'.
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Affiliation(s)
- DIANE L. DAMIANO
- Rehabilitation Medicine Department/Clinical Center, National Institutes of Health, Bethesda, MD, USA
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212
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Kuban KCK, O'Shea TM, Allred EN, Paneth N, Hirtz D, Fichorova RN, Leviton A. Systemic inflammation and cerebral palsy risk in extremely preterm infants. J Child Neurol 2014; 29:1692-8. [PMID: 24646503 PMCID: PMC4167987 DOI: 10.1177/0883073813513335] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The authors hypothesized that among extremely preterm infants, elevated concentrations of inflammation-related proteins in neonatal blood are associated with cerebral palsy at 24 months. In 939 infants born before 28 weeks gestation, the authors measured blood concentrations of 25 proteins on postnatal days 1, 7, and 14 and evaluated associations between elevated protein concentrations and cerebral palsy diagnosis. Protein elevations within 3 days of birth were not associated with cerebral palsy. Elevations of tumor necrosis factor-α, tumor necrosis factor-α-receptor-1, interleukin-8, and intercellular adhesion molecule-1 on at least 2 days were associated with diparesis. Recurrent-persistent elevations of interleukin-6, E-selectin, or insulin-like growth factor binding protein-1 were associated with hemiparesis. Diparesis and hemiparesis were more likely among infants who had at least 4 of 9 protein elevations that previously have been associated with cognitive impairment and microcephaly. Repeated elevations of inflammation-related proteins during the first 2 postnatal weeks are associated with increased risk of cerebral palsy.
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Affiliation(s)
- Karl C K Kuban
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - T Michael O'Shea
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Elizabeth N Allred
- Harvard Medical School, Boston, MA, USA Boston Children's Hospital, Boston, MA, USA Harvard School of Public Health, Boston, MA, USA
| | - Nigel Paneth
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
| | - Deborah Hirtz
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Raina N Fichorova
- Harvard Medical School, Boston, MA, USA Department of Obstetrics Gynecology & Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA
| | - Alan Leviton
- Harvard Medical School, Boston, MA, USA Boston Children's Hospital, Boston, MA, USA
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Korzeniewski SJ, Romero R, Cortez J, Pappas A, Schwartz AG, Kim CJ, Kim JS, Kim YM, Yoon BH, Chaiworapongsa T, Hassan SS. A "multi-hit" model of neonatal white matter injury: cumulative contributions of chronic placental inflammation, acute fetal inflammation and postnatal inflammatory events. J Perinat Med 2014; 42:731-43. [PMID: 25205706 PMCID: PMC5987202 DOI: 10.1515/jpm-2014-0250] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 08/11/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We sought to determine whether cumulative evidence of perinatal inflammation was associated with increased risk in a "multi-hit" model of neonatal white matter injury (WMI). METHODS This retrospective cohort study included very preterm (gestational ages at delivery <32 weeks) live-born singleton neonates delivered at Hutzel Women's Hospital, Detroit, MI, from 2006 to 2011. Four pathologists blinded to clinical diagnoses and outcomes performed histological examinations according to standardized protocols. Neurosonography was obtained per routine clinical care. The primary indicator of WMI was ventriculomegaly (VE). Neonatal inflammation-initiating illnesses included bacteremia, surgical necrotizing enterocolitis, other infections, and those requiring mechanical ventilation. RESULTS A total of 425 live-born singleton neonates delivered before the 32nd week of gestation were included. Newborns delivered of pregnancies affected by chronic chorioamnionitis who had histologic evidence of an acute fetal inflammatory response were at increased risk of VE, unlike those without funisitis, relative to referent newborns without either condition, adjusting for gestational age [odds ratio (OR) 4.7; 95% confidence interval (CI) 1.4-15.8 vs. OR 1.3; 95% CI 0.7-2.6]. Similarly, newborns with funisitis who developed neonatal inflammation-initiating illness were at increased risk of VE, unlike those who did not develop such illness, compared to the referent group without either condition [OR 3.6 (95% CI 1.5-8.3) vs. OR 1.7 (95% CI 0.5-5.5)]. The greater the number of these three types of inflammation documented, the higher the risk of VE (P<0.0001). CONCLUSION Chronic placental inflammation, acute fetal inflammation, and neonatal inflammation-initiating illness seem to interact in contributing risk information and/or directly damaging the developing brain of newborns delivered very preterm.
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Hagberg H, Ek C. Targeting the vasculature for cerebroprotection in the immature brain. Exp Neurol 2014; 261:551-2. [DOI: 10.1016/j.expneurol.2014.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 08/05/2014] [Indexed: 11/29/2022]
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Maternal immune activation and abnormal brain development across CNS disorders. Nat Rev Neurol 2014; 10:643-60. [PMID: 25311587 DOI: 10.1038/nrneurol.2014.187] [Citation(s) in RCA: 604] [Impact Index Per Article: 60.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Epidemiological studies have shown a clear association between maternal infection and schizophrenia or autism in the progeny. Animal models have revealed maternal immune activation (mIA) to be a profound risk factor for neurochemical and behavioural abnormalities in the offspring. Microglial priming has been proposed as a major consequence of mIA, and represents a critical link in a causal chain that leads to the wide spectrum of neuronal dysfunctions and behavioural phenotypes observed in the juvenile, adult or aged offspring. Such diversity of phenotypic outcomes in the mIA model are mirrored by recent clinical evidence suggesting that infectious exposure during pregnancy is also associated with epilepsy and, to a lesser extent, cerebral palsy in children. Preclinical research also suggests that mIA might precipitate the development of Alzheimer and Parkinson diseases. Here, we summarize and critically review the emerging evidence that mIA is a shared environmental risk factor across CNS disorders that varies as a function of interactions between genetic and additional environmental factors. We also review ongoing clinical trials targeting immune pathways affected by mIA that may play a part in disease manifestation. In addition, future directions and outstanding questions are discussed, including potential symptomatic, disease-modifying and preventive treatment strategies.
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Short-term effects of erythropoietin on neurodevelopment in infants with cerebral palsy: a pilot study. Brain Dev 2014; 36:764-9. [PMID: 24314853 DOI: 10.1016/j.braindev.2013.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 11/01/2013] [Accepted: 11/10/2013] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Cerebral palsy (CP) is a disabling condition characterized by the motor impairment, which is difficult to be ameliorated. In the brain of infants with CP, there are persistent pathomechanisms including accentuated neuroinflammation. Since erythropoietin was demonstrated to have neuroprotective effect via anti-inflammatory and anti-apoptotic properties, we hypothesized that the administration of recombinant human EPO (rhEPO) could help children with CP, especially young infants. MATERIALS AND METHOD We investigated the therapeutic efficacy of rhEPO for infants with CP, who had been undergoing active rehabilitation in hospitalized setting to eliminate treatment bias. Twenty infants with CP were randomly divided into EPO or control group equally. We compared the changes in the Gross Motor Function Measure (GMFM) and the Bayley Scales of Infant Development-II (BSID-II) scores during one month of hospitalization between two groups. RESULTS The improvements after 1 month on the GMFM A and GMFM total scores differed significantly between the groups (p = 0.003, p = 0.04, respectively). However, the changes after 6 months were not different between the two groups. The scores of BSID-II did not show any differences at 1-month and 6-months post-treatment. CONCLUSION These results indicated that rhEPO could have therapeutic efficacy for infants with CP during the active rehabilitation and anti-inflammation was suggested to be one of its therapeutic mechanisms.
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217
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Hadders-Algra M. Early diagnosis and early intervention in cerebral palsy. Front Neurol 2014; 5:185. [PMID: 25309506 PMCID: PMC4173665 DOI: 10.3389/fneur.2014.00185] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 09/09/2014] [Indexed: 01/06/2023] Open
Abstract
This paper reviews the opportunities and challenges for early diagnosis and early intervention in cerebral palsy (CP). CP describes a group of disorders of the development of movement and posture, causing activity limitation that is attributed to disturbances that occurred in the fetal or infant brain. Therefore, the paper starts with a summary of relevant information from developmental neuroscience. Most lesions underlying CP occur in the second half of gestation, when developmental activity in the brain reaches its summit. Variations in timing of the damage not only result in different lesions but also in different neuroplastic reactions and different associated neuropathologies. This turns CP into a heterogeneous entity. This may mean that the best early diagnostics and the best intervention methods may differ for various subgroups of children with CP. Next, the paper addresses possibilities for early diagnosis. It discusses the predictive value of neuromotor and neurological exams, neuroimaging techniques, and neurophysiological assessments. Prediction is best when complementary techniques are used in longitudinal series. Possibilities for early prediction of CP differ for infants admitted to neonatal intensive care and other infants. In the former group, best prediction is achieved with the combination of neuroimaging and the assessment of general movements, in the latter group, best prediction is based on carefully documented milestones and neurological assessment. The last part reviews early intervention in infants developing CP. Most knowledge on early intervention is based on studies in high-risk infants without CP. In these infants, early intervention programs promote cognitive development until preschool age; motor development profits less. The few studies on early intervention in infants developing CP suggest that programs that stimulate all aspects of infant development by means of family coaching are most promising. More research is urgently needed.
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Affiliation(s)
- Mijna Hadders-Algra
- Department of Pediatrics - Developmental Neurology, University Medical Center Groningen, University of Groningen , Groningen , Netherlands
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218
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Xie C, Zhou K, Wang X, Blomgren K, Zhu C. Therapeutic benefits of delayed lithium administration in the neonatal rat after cerebral hypoxia-ischemia. PLoS One 2014; 9:e107192. [PMID: 25211332 PMCID: PMC4161387 DOI: 10.1371/journal.pone.0107192] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/07/2014] [Indexed: 01/02/2023] Open
Abstract
Aim We have previously shown that lithium treatment immediately after hypoxia-ischemia (HI) in neonatal rats affords both short- and long-term neuroprotection. The aim of this study was to evaluate possible therapeutic benefits when lithium treatment was delayed 5 days, a time point when most cell death is over. Methods Eight-day-old male rats were subjected to unilateral HI and 2 mmol/kg lithium chloride was injected intraperitoneally 5 days after the insult. Additional lithium injections of 1 mmol/kg were administered at 24 h intervals for the next 14 days. Brain injury was evaluated 12 weeks after HI. Serum cytokine measurements and behavioral analysis were performed before sacrificing the animals. Results Brain injury, as indicated by tissue loss, was reduced by 38.7%, from 276.5±27.4 mm3 in the vehicle-treated group to 169.3±25.9 mm3 in the lithium-treated group 12 weeks after HI (p<0.01). Motor hyperactivity and anxiety-like behavior after HI were normalized by lithium treatment. Lithium treatment increased neurogenesis in the dentate gyrus as indicated by doublecortin labeling. Serum cytokine levels, including IL-1α, IL-1β, and IL-6, were still elevated as late as 5 weeks after HI, but lithium treatment normalized these cytokine levels. Conclusions Delayed lithium treatment conferred long-term neuroprotection in neonatal rats after HI, and this opens a new avenue for future development of treatment strategies for neonatal brain injury that can be administered after the acute injury phase.
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Affiliation(s)
- Cuicui Xie
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
- Department of Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Kai Zhou
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
- Department of Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Xiaoyang Wang
- Perinatal Center, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
- Department of Pediatrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Klas Blomgren
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
- Department of Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden
- Department of Pediatrics, University of Gothenburg, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Changlian Zhu
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Göteborg, Sweden
- Department of Pediatrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Pediatrics, Zhengzhou Children's Hospital, Zhengzhou, China
- * E-mail:
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Albertsson AM, Bi D, Duan L, Zhang X, Leavenworth JW, Qiao L, Zhu C, Cardell S, Cantor H, Hagberg H, Mallard C, Wang X. The immune response after hypoxia-ischemia in a mouse model of preterm brain injury. J Neuroinflammation 2014; 11:153. [PMID: 25187205 PMCID: PMC4172879 DOI: 10.1186/s12974-014-0153-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 08/14/2014] [Indexed: 01/04/2023] Open
Abstract
Background Preterm brain injury consists primarily of periventricular leukomalacia accompanied by elements of gray-matter injury, and these injuries are associated with cerebral palsy and cognitive impairments. Inflammation is believed to be an important contributing factor to these injuries. The aim of this study was to examine the immune response in a postnatal day (PND) 5 mouse model of preterm brain injury induced by hypoxia-ischemia (HI) that is characterized by focal white and gray-matter injury. Methods C57Bl/6 mice at PND 5 were subjected to unilateral HI induced by left carotid artery ligation and subsequent exposure to 10% O2 for 50 minutes, 70 minutes, or 80 minutes. At seven days post-HI, the white/gray-matter injury was examined. The immune responses in the brain after HI were examined at different time points after HI using RT-PCR and immunohistochemical staining. Results HI for 70 minutes in PND 5 mice induced local white-matter injury with focal cortical injury and hippocampal atrophy, features that are similar to those seen in preterm brain injury in human infants. HI for 50 minutes resulted in a small percentage of animals being injured, and HI for 80 minutes produced extensive infarction in multiple brain areas. Various immune responses, including changes in transcription factors and cytokines that are associated with a T-helper (Th)1/Th17-type response, an increased number of CD4+ T-cells, and elevated levels of triggering receptor expressed on myeloid cells 2 (TREM-2) and its adaptor protein DNAX activation protein of 12 kDa (DAP12) were observed using the HI 70 minute preterm brain injury model. Conclusions We have established a reproducible model of HI in PND 5 mice that produces consistent local white/gray-matter brain damage that is relevant to preterm brain injury in human infants. This model provides a useful tool for studying preterm brain injury. Both innate and adaptive immune responses are observed after HI, and these show a strong pro-inflammatory Th1/Th17-type bias. Such findings provide a critical foundation for future studies on the mechanism of preterm brain injury and suggest that blocking the Th1/Th17-type immune response might provide neuroprotection after preterm brain injury.
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220
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Marret S, Jadas V, Kieffer A, Chollat C, Rondeau S, Chadie A. [Treatment of encephalopathy by hypothermia in the term newborn]. Arch Pediatr 2014; 21:1026-34. [PMID: 25080834 DOI: 10.1016/j.arcped.2014.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 05/31/2014] [Accepted: 06/17/2014] [Indexed: 11/25/2022]
Abstract
Criteria defining the involvement of severe perinatal anoxia in neonatal encephalopathy in at-term newborns at birth are stringent and are rarely all present. The simultaneous action of pre- and intrapartum factors preceding neonatal hypoxic-ischemic encephalopathy are often observed. Cooling is recommended as there is evidence that it reduces mortality without increasing major disability in survivors. It must be conducted following strict clinical and electroencephalographic criteria. Other strategies for brain protection remain difficult to establish. Follow-up must be long enough to detect cognitive deficiencies, which are frequent, even if cerebral palsy is not observed.
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Affiliation(s)
- S Marret
- Service de pédiatrie néonatale et réanimation, neuropédiatrie, centre de référence des troubles apprentissages, Camsp, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France; Équipe Inserm, région (ERI28), Neovasc handicap périnatal, faculté de médecine et de pharmacie, université de Normandie, institut de recherche et d'innovation biomédicale, 76183 Rouen cedex, France.
| | - V Jadas
- Service de pédiatrie néonatale et réanimation, neuropédiatrie, centre de référence des troubles apprentissages, Camsp, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France; Équipe Inserm, région (ERI28), Neovasc handicap périnatal, faculté de médecine et de pharmacie, université de Normandie, institut de recherche et d'innovation biomédicale, 76183 Rouen cedex, France
| | - A Kieffer
- Service de pédiatrie néonatale et réanimation, neuropédiatrie, centre de référence des troubles apprentissages, Camsp, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France; Équipe Inserm, région (ERI28), Neovasc handicap périnatal, faculté de médecine et de pharmacie, université de Normandie, institut de recherche et d'innovation biomédicale, 76183 Rouen cedex, France
| | - C Chollat
- Service de pédiatrie néonatale et réanimation, neuropédiatrie, centre de référence des troubles apprentissages, Camsp, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France; Équipe Inserm, région (ERI28), Neovasc handicap périnatal, faculté de médecine et de pharmacie, université de Normandie, institut de recherche et d'innovation biomédicale, 76183 Rouen cedex, France
| | - S Rondeau
- Service de pédiatrie néonatale et réanimation, neuropédiatrie, centre de référence des troubles apprentissages, Camsp, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France; Équipe Inserm, région (ERI28), Neovasc handicap périnatal, faculté de médecine et de pharmacie, université de Normandie, institut de recherche et d'innovation biomédicale, 76183 Rouen cedex, France
| | - A Chadie
- Service de pédiatrie néonatale et réanimation, neuropédiatrie, centre de référence des troubles apprentissages, Camsp, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France; Équipe Inserm, région (ERI28), Neovasc handicap périnatal, faculté de médecine et de pharmacie, université de Normandie, institut de recherche et d'innovation biomédicale, 76183 Rouen cedex, France
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Furukawa S, Yang L, Sameshima H. Galantamine, an acetylcholinesterase inhibitor, reduces brain damage induced by hypoxia-ischemia in newborn rats. Int J Dev Neurosci 2014; 37:52-7. [PMID: 24972037 DOI: 10.1016/j.ijdevneu.2014.06.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/17/2014] [Accepted: 06/17/2014] [Indexed: 12/30/2022] Open
Abstract
AIM Our aim is to elucidate whether galantamine, known as an acetylcholinesterase inhibitor, reduces brain damage induced by hypoxia-ischemia (HI). STUDY DESIGN 7-day-old Wistar rats were used. Rats were subjected to left carotid artery ligation followed by 2 h of hypoxia (8% oxygen). We injected galantamine intraperitoneally just before hypoxia (5.0 mg/kg, n=14; 2.5 mg/kg, n=9; 1.0mg/kg, n=11) and after hypoxia (5.0mg/kg, n=7) to determine its neuroprotective effect. An equivalent volume of saline was administered as a control before (n=31) and after hypoxic load (n=7). We also examined the production of IL-1β in the ligated hemisphere side after injection of galantamine (prior hypoxia; 5.0 mg/kg, n=7) or saline (n=8). Brains were analyzed 7 days after HI. RESULTS Two of the 5.0 mg/kg galantamine pre-treated rats and a post-treated rat died during experiments. The remaining survived and 5.0mg/kg galantamine pre-treated rats showed a marked reduction of brain damage (p<0.01) compared with the control. The other galantamine groups had severe brain damage similar to controls. Microglial accumulation was significantly reduced in rats pre-treated with 5.0 mg/kg of galantamine compared to control rats on both the hippocampus (p=0.02) and cortex (p<0.01). In contrast, the other galantamine groups showed a lower suppressive effect on microglial accumulation compared to the control. Galantamine significantly reduced IL-1β productions when compared to the control (p<0.01). CONCLUSION Pre-treatment of galantamine reduced brain damage with a suppressive effect on microglial accumulation and IL-1β production in a newborn rat model of HI.
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Affiliation(s)
- Seishi Furukawa
- Department of Obstetrics & Gynecology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.
| | - Li Yang
- Department of Obstetrics & Gynecology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Hiroshi Sameshima
- Department of Obstetrics & Gynecology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Working Therapeutically with Parents after the Diagnosis of a Child's Cerebral Palsy: Issues and Practice Guidelines. AUSTRALIAN JOURNAL OF REHABILITATION COUNSELLING 2014. [DOI: 10.1017/jrc.2014.6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Little is known about the effectiveness of psychoeducational support groups on positive adaptation in parents and families after a child has been diagnosed with cerebral palsy. A systematic literature review adopting the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to gain an understanding of the process of adaptation in parents with a child with cerebral palsy and the effects psychoeducational support programs have on this process. The databases searched were psychINFO, Taylor and Francis Online, PsychARTICLES, Medline and ProQuest. A total of 1083 papers were found and 19 of those papers were analysed. A narrative approach was used to synthesise the data extracted. A number of factors that influence adaption within a family after the diagnosis of cerebral palsy in a family member were identified in the review. These factors include, but are not limited to, providing appropriate and relevant information to parents and families, identifying community services and resources available to the family, assisting in the reduction of psychosocial distress, and encouraging the facilitation and collaboration of a strong parent-professional partnership throughout the process. Based on this information guidelines for psychoeducation programs for this client group were proposed.
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Osterstock G, El Yandouzi T, Romanò N, Carmignac D, Langlet F, Coutry N, Guillou A, Schaeffer M, Chauvet N, Vanacker C, Galibert E, Dehouck B, Robinson ICAF, Prévot V, Mollard P, Plesnila N, Méry PF. Sustained alterations of hypothalamic tanycytes during posttraumatic hypopituitarism in male mice. Endocrinology 2014; 155:1887-98. [PMID: 24601879 DOI: 10.1210/en.2013-1336] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Traumatic brain injury is a leading cause of hypopituitarism, which compromises patients' recovery, quality of life, and life span. To date, there are no means other than standardized animal studies to provide insights into the mechanisms of posttraumatic hypopituitarism. We have found that GH levels were impaired after inducing a controlled cortical impact (CCI) in mice. Furthermore, GHRH stimulation enhanced GH to lower level in injured than in control or sham mice. Because many characteristics were unchanged in the pituitary glands of CCI mice, we looked for changes at the hypothalamic level. Hypertrophied astrocytes were seen both within the arcuate nucleus and the median eminence, two pivotal structures of the GH axis, spatially remote to the injury site. In the arcuate nucleus, GHRH neurons were unaltered. In the median eminence, injured mice exhibited unexpected alterations. First, the distributions of claudin-1 and zonula occludens-1 between tanycytes were disorganized, suggesting tight junction disruptions. Second, endogenous IgG was increased in the vicinity of the third ventricle, suggesting abnormal barrier properties after CCI. Third, intracerebroventricular injection of a fluorescent-dextran derivative highly stained the hypothalamic parenchyma only after CCI, demonstrating an increased permeability of the third ventricle edges. This alteration of the third ventricle might jeopardize the communication between the hypothalamus and the pituitary gland. In conclusion, the phenotype of CCI mice had similarities to the posttraumatic hypopituitarism seen in humans with intact pituitary gland and pituitary stalk. It is the first report of a pathological status in which tanycyte dysfunctions appear as a major acquired syndrome.
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Affiliation(s)
- Guillaume Osterstock
- INSERM Unité 661 (G.O., T.E.Y., N.Co., N.R., A.G., M.S., N.Ch., E.G., P.M., P.-F.M.), Centre National de la Recherche Scientifique Unité Mixte de Recherche 5203 (G.O., T.E.Y., N.R., N.Co., A.G., M.S., N.Ch., E.G., P.M., P.-F.M.), Institut de Génomique Fonctionelle, 34094 Montpellier, France; Université Montpellier 1, 2 (G.O., T.E.Y., N.R., N.Co., A.G., M.S., N.Ch., E.G., P.M., P.-F.M.), 34967 Montpellier, France; Division of Molecular Neuroendocrinology (D.C., I.C.A.F.R.), Medical Research Council National Institute for Medical Research, The Ridgeway, Mill Hill, London NW7 1AA, United Kingdom; Royal College of Surgeons in Ireland (G.O., T.E.Y., M.S., N.P.), Dublin 2, Ireland; INSERM Unité 837 (F.L., C.V., B.D., V.P.), Department of Development and Plasticity of the Postnatal Brain, Jean-Pierre Aubert Research Center, 59045 Lille, France; and University of Lille 2 (F.L., C.V., B.D., V.P.), 59000 Lille, France
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Abstract
The syndrome of cerebral palsy encompasses a large group of childhood movement and posture disorders. Severity, patterns of motor involvement, and associated impairments such as those of communication, intellectual ability, and epilepsy vary widely. Overall prevalence has remained stable in the past 40 years at 2-3·5 cases per 1000 livebirths, despite changes in antenatal and perinatal care. The few studies available from developing countries suggest prevalence of comparable magnitude. Cerebral palsy is a lifelong disorder; approaches to intervention, whether at an individual or environmental level, should recognise that quality of life and social participation throughout life are what individuals with cerebral palsy seek, not improved physical function for its own sake. In the past few years, the cerebral palsy community has learned that the evidence of benefit for the numerous drugs, surgery, and therapies used over previous decades is weak. Improved understanding of the role of multiple gestation in pathogenesis, of gene environment interaction, and how to influence brain plasticity could yield significant advances in treatment of the disorder. Reduction in the prevalence of post-neonatal cerebral palsy, especially in developing countries, should be possible through improved nutrition, infection control, and accident prevention.
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Affiliation(s)
- Allan Colver
- Institute of Health and Society, Newcastle University, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Charles Fairhurst
- Department of Paediatric Neurosciences, Evelina Children's Hospital, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
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225
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Hagberg H, Mallard C, Rousset CI, Thornton C. Mitochondria: hub of injury responses in the developing brain. Lancet Neurol 2014; 13:217-32. [PMID: 24457191 DOI: 10.1016/s1474-4422(13)70261-8] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Progress in the field of mitochondrial biology in the past few years has shown that mitochondrial activities go beyond bioenergetics. These new aspects of mitochondrial physiology and pathophysiology have important implications for the immature brain. A picture emerges in which mitochondrial biogenesis, mitophagy, migration, and morphogenesis are crucial for brain development and synaptic pruning, and play a part in recovery after acute insults. Mitochondria also affect brain susceptibility to injury, and mitochondria-directed interventions can make the immature brain highly resistant to acute injury. Finally, the mitochondrion is a platform for innate immunity, contributes to inflammation in response to infection and acute damage, and participates in antiviral and antibacterial defence. Understanding of these new aspects of mitochondrial function will provide insights into brain development and neurological disease, and enable discovery and development of new strategies for treatment.
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Affiliation(s)
- Henrik Hagberg
- Centre for the Developing Brain, Perinatal Imaging & Health, King's College London, St Thomas' Hospital, London, UK; Perinatal Center, Departments of Clinical Sciences and Physiology & Neurosciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Carina Mallard
- Perinatal Center, Departments of Clinical Sciences and Physiology & Neurosciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Catherine I Rousset
- Centre for the Developing Brain, Perinatal Imaging & Health, King's College London, St Thomas' Hospital, London, UK
| | - Claire Thornton
- Centre for the Developing Brain, Perinatal Imaging & Health, King's College London, St Thomas' Hospital, London, UK
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226
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Long-term functional consequences and ongoing cerebral inflammation after subarachnoid hemorrhage in the rat. PLoS One 2014; 9:e90584. [PMID: 24603553 PMCID: PMC3946189 DOI: 10.1371/journal.pone.0090584] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 02/04/2014] [Indexed: 01/15/2023] Open
Abstract
Subarachnoid hemorrhage (SAH) represents a considerable health problem with an incidence of 6–7 per 100.000 individuals per year in Western society. We investigated the long-term consequences of SAH on behavior, neuroinflammation and gray- and white-matter damage using an endovascular puncture model in Wistar rats. Rats were divided into a mild or severe SAH group based on their acute neurological score at 24 h post-SAH. The degree of hemorrhage determined in post-mortem brains at 48 h strongly correlated with the acute neurological score. Severe SAH induced increased TNF-α, IL-1β, IL-10, MCP-1, MIP2, CINC-1 mRNA expression and cortical neutrophil influx at 48 h post-insult. Neuroinflammation after SAH was very long-lasting and still present at day 21 as determined by Iba-1 staining (microglia/macrophages) and GFAP (astrocytes). Long-term neuroinflammation was strongly associated with the degree of severity of SAH. Cerebral damage to gray- and white-matter was visualized by immunohistochemistry for MAP2 and MBP at 21 days after SAH. Severe SAH induced significant gray- and white-matter damage. MAP2 loss at day 21 correlated significantly with the acute neurological score determined at 24 h post-SAH. Sensorimotor behavior, determined by the adhesive removal task and von Frey test, was affected after severe SAH at day 21. In conclusion, we are the first to show that SAH induces ongoing cortical inflammation. Moreover, SAH induces mainly cortical long-term brain damage, which is associated with long-term sensorimotor damage.
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227
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Intermittent or sustained systemic inflammation and the preterm brain. Pediatr Res 2014; 75:376-80. [PMID: 24429547 PMCID: PMC3943674 DOI: 10.1038/pr.2013.238] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 09/13/2013] [Indexed: 12/22/2022]
Abstract
Exposure to perinatal infection and inflammation is associated with an increased risk for neonatal brain damage and developmental disabilities. In this integrated mechanism review, we discuss evidence in support of the contention that the preterm newborn is capable of intermittent or sustained systemic inflammation (ISSI), which appears to contribute more to adverse neurodevelopmental outcomes in preterm infants than does shorter duration inflammation.
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228
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Abstract
This article explains the mechanisms underlying choices of pharmacotherapy for hypoxic-ischemic insults of both preterm and term babies. Some preclinical data are strong enough that clinical trials are now underway. Challenges remain in deciding the best combination therapies for each age and insult.
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Affiliation(s)
- Sandra E. Juul
- University of Washington, Department of Pediatrics, 1959 NE Pacific St, Box 356320, Seattle, Washington 98195, Telephone: (206) 221-6814; Fax: (206) 543-8926
| | - Donna M. Ferriero
- Neonatal Brain Disorders Laboratory, University of California, San Francisco, 675 Nelson Rising Lane, Room 494, Box 0663, San Francisco, California 94143, Phone: (415) 502-7319, Fax: (415) 486-2297
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229
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Astrocytes and microglia in acute cerebral injury underlying cerebral palsy associated with preterm birth. Pediatr Res 2014; 75:234-40. [PMID: 24336433 DOI: 10.1038/pr.2013.188] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Accepted: 07/11/2013] [Indexed: 02/06/2023]
Abstract
Cerebral palsy is one of the most devastating consequences of brain injury around the time of birth, and nearly a third of cases are now associated with premature birth. Compared with term babies, preterm babies have an increased incidence of complications that may increase the risk of disability, such as intraventricular hemorrhage, periventricular leukomalacia, sepsis, and necrotizing enterocolitis. The response to injury is highly dependent on brain maturity, and although cellular vulnerability is well documented, there is now evidence that premyelinating axons are also particularly sensitive to ischemic injury. In this review, we will explore recent evidence highlighting a central role for glia in mediating increased risk of disability in premature infants, including excessive activation of microglia and opening of astrocytic gap junction hemichannels in spreading injury after brain ischemia, in part likely involving release of adenosine triphosphate (ATP) and overactivation of purinergic receptors, particularly in white matter. We propose the hypothesis that inflammation-induced opening of connexin hemichannels is a key regulating event that initiates a vicious circle of excessive ATP release, which in turn propagates activation of purinergic receptors on microglia and astrocytes. This suggests that developing effective neuroprotective strategies for preterm infants requires a detailed understanding of glial responses.
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230
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Chicha L, Smith T, Guzman R. Stem cells for brain repair in neonatal hypoxia-ischemia. Childs Nerv Syst 2014; 30:37-46. [PMID: 24178233 DOI: 10.1007/s00381-013-2304-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/08/2013] [Indexed: 12/15/2022]
Abstract
Neonatal hypoxic-ischemic insults are a significant cause of pediatric encephalopathy, developmental delays, and spastic cerebral palsy. Although the developing brain's plasticity allows for remarkable self-repair, severe disruption of normal myelination and cortical development upon neonatal brain injury are likely to generate life-persisting sensory-motor and cognitive deficits in the growing child. Currently, no treatments are available that can address the long-term consequences. Thus, regenerative medicine appears as a promising avenue to help restore normal developmental processes in affected infants. Stem cell therapy has proven effective in promoting functional recovery in animal models of neonatal hypoxic-ischemic injury and therefore represents a hopeful therapy for this unmet medical condition. Neural stem cells derived from pluripotent stem cells or fetal tissues as well as umbilical cord blood and mesenchymal stem cells have all shown initial success in improving functional outcomes. However, much still remains to be understood about how those stem cells can safely be administered to infants and what their repair mechanisms in the brain are. In this review, we discuss updated research into pathophysiological mechanisms of neonatal brain injury, the types of stem cell therapies currently being tested in this context, and the potential mechanisms through which exogenous stem cells might interact with and influence the developing brain.
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Affiliation(s)
- L Chicha
- Department of Biomedicine, University of Basel, Basel, Switzerland
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231
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White matter loss in a mouse model of periventricular leukomalacia is rescued by trophic factors. Brain Sci 2013; 3:1461-82. [PMID: 24961618 PMCID: PMC4061895 DOI: 10.3390/brainsci3041461] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 10/15/2013] [Accepted: 10/28/2013] [Indexed: 11/16/2022] Open
Abstract
Periventricular leukomalacia (PVL) is the most frequent cause of cerebral palsy and other intellectual disabilities, and currently there is no treatment. In PVL, glutamate excitotoxicity (GME) leads to abnormal oligodendrocytes (OLs), myelin deficiency, and ventriculomegaly. We have previously identified that the combination of transferrin and insulin growth factors (TSC1) promotes endogenous OL regeneration and remyelination in the postnatal and adult rodent brain. Here, we produced a periventricular white matter lesion with a single intracerebral injection of N-methyl-d-aspartate (NMDA). Comparing lesions produced by NMDA alone and those produced by NMDA + TSC1 we found that: NMDA affected survival and reduced migration of OL progenitors (OLPs). In contrast, mice injected with NMDA + TSC1 proliferated twice as much indicating that TSC1 supported regeneration of the OLP population after the insult. Olig2-mRNA expression showed 52% OLP survival in mice receiving a NMDA injection and increased to 78% when TSC1 + NMDA were injected simultaneously and ventricular size was reduced by TSC1. Furthermore, in striatal slices TSC1 reduced the inward currents induced by NMDA in medium-sized spiny neurons, demonstrating neuroprotection. Thus, white matter loss after excitotoxicity can be partially rescued as TSC1 conferred neuroprotection to preexisting OLP and regeneration via OLP proliferation. Furthermore, we showed that early TSC1 administration maximizes neuroprotection.
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232
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Wang X, Hu D, Zhang L, Lian G, Zhao S, Wang C, Yin J, Wu C, Yang J. Gomisin A inhibits lipopolysaccharide-induced inflammatory responses in N9 microglia via blocking the NF-κB/MAPKs pathway. Food Chem Toxicol 2013; 63:119-27. [PMID: 24211520 DOI: 10.1016/j.fct.2013.10.048] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 10/11/2013] [Accepted: 10/29/2013] [Indexed: 01/30/2023]
Abstract
Gomisin A, one of the major dibenzocyclooctadiene lignans isolated from Schisandra chinensis Baill., has proved to possess a variety of pharmacological effects. The aim of the present study was to investigate the anti-inflammatory and neuroprotective effects of gomisin A as well as its potential molecular mechanisms. It was found that gomisin A not only inhibited the production of NO and PGE2 in a concentration-dependent manner but also suppressed the expressions of iNOS and COX-2 in LPS-stimulated N9 microglia without observable cytotoxicity. Gomisin A was also able to attenuate the mRNA expression and the production of pro-inflammatory factors TNF-α, IL-1β and IL-6. Moreover, LPS induced reactive oxygen species (ROS) production, NADPH oxidase activation, and gp91phox expression, which were markedly inhibited by gomisin A in microglia. Furthermore, the data showed that gomisin A significantly down-regulated the TLR4 protein expression, and inhibited nuclear transcription factor (NF)-κB and mitogen-activated protein kinases (MAPKs) signaling pathways. Additionally, gomisin A alleviated the cell death of SH-SY5Y neuroblastoma, rat primary cortical and hippocampal neurons induced by the conditioned-media from activated microglia. In summary, gomisin A may exert neuroprotective effects by attenuating the microglia-mediated neuroinflammatory response via inhibiting the TLR4-mediated NF-κB and MAPKs signaling pathways.
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Affiliation(s)
- Xiaoxiao Wang
- Department of Pharmacology, Shenyang Pharmaceutical University, 103 Wenhua Road, 110016 Shenyang, PR China
| | - Di Hu
- Development and Utilization Key Laboratory of Northeast Plant Materials of Liaoning Province, Department of Pharmacognosy, Shenyang Pharmaceutical University, 103 Wenhua Road, 110016 Shenyang, PR China
| | - Lijia Zhang
- Department of Pharmacology, Shenyang Pharmaceutical University, 103 Wenhua Road, 110016 Shenyang, PR China
| | - Guoning Lian
- Department of Pharmacology, Shenyang Pharmaceutical University, 103 Wenhua Road, 110016 Shenyang, PR China
| | - Siqi Zhao
- Department of Pharmacology, Shenyang Pharmaceutical University, 103 Wenhua Road, 110016 Shenyang, PR China.
| | - Chunming Wang
- Department of Pharmacology, Shenyang Pharmaceutical University, 103 Wenhua Road, 110016 Shenyang, PR China
| | - Jun Yin
- Development and Utilization Key Laboratory of Northeast Plant Materials of Liaoning Province, Department of Pharmacognosy, Shenyang Pharmaceutical University, 103 Wenhua Road, 110016 Shenyang, PR China.
| | - Chunfu Wu
- Department of Pharmacology, Shenyang Pharmaceutical University, 103 Wenhua Road, 110016 Shenyang, PR China.
| | - Jingyu Yang
- Department of Pharmacology, Shenyang Pharmaceutical University, 103 Wenhua Road, 110016 Shenyang, PR China.
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233
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O'Shea TM, Downey LC, Kuban KKC. Extreme prematurity and attention deficit: epidemiology and prevention. Front Hum Neurosci 2013; 7:578. [PMID: 24065904 PMCID: PMC3776954 DOI: 10.3389/fnhum.2013.00578] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 08/28/2013] [Indexed: 01/01/2023] Open
Affiliation(s)
- T. Michael O'Shea
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, Winston-SalemNC, USA
| | - L. Corbin Downey
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, Winston-SalemNC, USA
| | - Karl K. C. Kuban
- Division of Pediatric Neurology, Department of Pediatrics, Boston UniversityBoston, MA, USA
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234
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Characterization of phenotype markers and neuronotoxic potential of polarised primary microglia in vitro. Brain Behav Immun 2013; 32:70-85. [PMID: 23454862 PMCID: PMC3694309 DOI: 10.1016/j.bbi.2013.02.005] [Citation(s) in RCA: 482] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 02/04/2013] [Accepted: 02/15/2013] [Indexed: 12/11/2022] Open
Abstract
Microglia mediate multiple facets of neuroinflammation, including cytotoxicity, repair, regeneration, and immunosuppression due to their ability to acquire diverse activation states, or phenotypes. Modulation of microglial phenotype is an appealing neurotherapeutic strategy but a comprehensive study of classical and more novel microglial phenotypic markers in vitro is lacking. The aim of this study was to outline the temporal expression of a battery of phenotype markers from polarised microglia to generate an in vitro tool for screening the immunomodulatory potential of novel compounds. We characterised expression of thirty-one macrophage/microglial phenotype markers in primary microglia over time (4, 12, 36, and 72 h), using RT-qPCR or multiplex protein assay. Firstly, we selected Interleukin-4 (IL-4) and lipopolysaccharide (LPS) as the strongest M1-M2 polarising stimuli, from six stimuli tested. At each time point, markers useful to identify that microglia were M1 included iNOS, Cox-2 and IL-6 and a loss of M2a markers. Markers useful for quantifying M2b-immunomodulatory microglia included, increased IL-1RA and SOCS3 and for M2a-repair and regeneration, included increased arginase-1, and a loss of the M1 and M2b markers were discriminatory. Additional markers were regulated at fewer time points, but are still likely important to monitor when assessing the immunomodulatory potential of novel therapies. Further, to facilitate identification of how novel immunomodulatory treatments alter the functional affects of microglia, we characterised how the soluble products from polarised microglia affected the type and rate of neuronal death; M1/2b induced increasing and M2a-induced decreasing neuronal loss. We also assessed any effects of prior activation state, to provide a way to identify how a novel compound may alter phenotype depending on the stage of injury/insult progression. We identified generally that a prior M1/2b reduced the ability of microglia to switch to M2a. Altogether, we have characterised a profile of phenotype markers and a mechanism of assessing functional outcome that we can use as a reference guide for first-line screening of novel immunomodulatory therapies in vitro in the search for viable neuroprotectants.
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235
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Mitha A, Foix-L'Hélias L, Arnaud C, Marret S, Vieux R, Aujard Y, Thiriez G, Larroque B, Cambonie G, Burguet A, Boileau P, Rozé JC, Kaminski M, Truffert P, Ancel PY. Neonatal infection and 5-year neurodevelopmental outcome of very preterm infants. Pediatrics 2013; 132:e372-80. [PMID: 23878051 DOI: 10.1542/peds.2012-3979] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine whether neonatal infections are associated with a higher risk of adverse neurodevelopment at 5 years of age in a population-based cohort of very preterm children. METHODS We included all live births between 22 and 32 weeks of gestation, from 9 regions in France, in 1997 (EPIPAGE study). Of the 2665 live births, 2277 were eligible for a follow-up evaluation at 5 years of age: 1769 had a medical examination and 1495 underwent cognitive assessment. Cerebral palsy and cognitive impairment were studied as a function of early-onset sepsis (EOS) and late-onset sepsis (LOS), after adjustment for potential confounding factors, in multivariate logistic regression models. RESULTS A total of 139 (5%) of the 2665 live births included in the study presented with EOS alone (without associated LOS), 752 (28%) had LOS alone (without associated EOS), and 64 (2%) displayed both EOS and LOS. At 5 years of age, the frequency of cerebral palsy was 9% (157 of 1769) and that of cognitive impairment was 12% (177 of 1495). The frequency of cerebral palsy was higher in infants with isolated EOS (odds ratio [OR]: 1.70 [95% confidence interval (CI): 0.84-3.45]) or isolated LOS (OR: 1.71 [95% CI: 1.14-2.56]) than in uninfected infants, and this risk was even higher in cases of combined EOS and LOS (OR: 2.33 [95% CI: 1.02-5.33]). There was no association between neonatal infection and cognitive impairment. CONCLUSIONS Neonatal infections in these very preterm infants were associated with a higher risk of cerebral palsy at the age of 5 years, particularly in infants presenting with both EOS and LOS.
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Affiliation(s)
- Ayoub Mitha
- Neonatal Unit Hôpital Jeanne de Flandre, Lille, France.
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236
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O'Shea TM, Shah B, Allred EN, Fichorova RN, Kuban KCK, Dammann O, Leviton A. Inflammation-initiating illnesses, inflammation-related proteins, and cognitive impairment in extremely preterm infants. Brain Behav Immun 2013; 29:104-112. [PMID: 23295265 PMCID: PMC3582030 DOI: 10.1016/j.bbi.2012.12.012] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 12/17/2012] [Accepted: 12/19/2012] [Indexed: 12/11/2022] Open
Abstract
Neonatal inflammation is associated with perinatal brain damage. We evaluated to what extent elevated blood levels of inflammation-related proteins supplement information about the risk of impaired early cognitive function provided by inflammation-related illnesses. From 800 infants born before the 28th week of gestation, we collected blood spots on days 1, 7 and 14, for analysis of 25 inflammation-related proteins, and data about culture-positive bacteremia, necrotizing enterocolitis (Bell stage IIIb), and isolated perforation of the intestine, during the first two weeks, and whether they were ventilated on postnatal day 14. We considered a protein to be persistently or recurrently elevated if its concentration was in the top quartile (for gestational age and day blood was collected) on two separate days one week apart. We assessed the children at 2 years of age with the Bayley Mental Development Index (MDI). The combinations of NEC and ventilation on day 14, and of bacteremia and ventilation on day 14 consistently provided information about elevated risk of MDI <55, regardless of whether or not a variable for an elevated protein concentration was included in the model. A variable for a persistently or recurrently elevated concentration of each of the following proteins provided additional information about an increased risk of MDI <55: CRP, SAA, IL-6, TNF-alpha, IL-8, MIP-1beta, ICAM-1, E-SEL, and IGFBP-1. We conclude that elevated blood concentrations of inflammation-related proteins provide information about the risk of impaired cognitive function at age 2 years that supplements information provided by inflammation-associated illnesses.
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Affiliation(s)
- T Michael O'Shea
- Division of Neonatology, Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
| | - Bhavesh Shah
- Department of Pediatrics, Baystate Children's Hospital, Springfield, MA 01199, USA
| | - Elizabeth N Allred
- Department of Neurology, Children's Hospital Boston, and Harvard Medical School, Boston, MA 02115, USA
| | - Raina N Fichorova
- Laboratory of Genital Tract Biology, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Karl C K Kuban
- Division of Pediatric Neurology, Department of Pediatrics, Boston University, Boston, MA 02118, USA
| | - Olaf Dammann
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA 02111, USA; Perinatal Epidemiology Unit, Hannover Medical School, 30623 Hannover, Germany
| | - Alan Leviton
- Department of Neurology, Children's Hospital Boston, and Harvard Medical School, Boston, MA 02115, USA
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237
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Falahati S, Breu M, Waickman AT, Phillips AW, Arauz EJ, Snyder S, Porambo M, Goeral K, Comi AM, Wilson MA, Johnston MV, Fatemi A. Ischemia-induced neuroinflammation is associated with disrupted development of oligodendrocyte progenitors in a model of periventricular leukomalacia. Dev Neurosci 2013; 35:182-96. [PMID: 23445614 DOI: 10.1159/000346682] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 12/19/2012] [Indexed: 01/08/2023] Open
Abstract
Microglial activation in crossing white matter tracts is a hallmark of noncystic periventricular leukomalacia (PVL), the leading pathology underlying cerebral palsy in prematurely born infants. Recent studies indicate that neuroinflammation within an early time window can produce long-lasting defects in oligodendroglial maturation, myelination deficit, as well as disruption of transcription factors important in oligodendroglial maturation. We recently reported an ischemic mouse model of PVL, induced by unilateral neonatal carotid artery ligation, leading to selective long-lasting bilateral myelination deficits, ipsilateral thinning of the corpus callosum, ventriculomegaly, as well as evidence of axonopathy. Here, we report that permanent unilateral carotid ligation on postnatal day 5 in CD-1 mice induces an inflammatory response, as defined by microglial activation and recruitment, as well as significant changes in cytokine expression (increased IL-1β, IL-6, TGF-β1, and TNF-α) following ischemia. Transient reduction in counts of oligodendrocyte progenitor cells (OPCs) at 24 and 48 h after ischemia, a shift in OPC cell size and morphology towards the more immature form, as well as likely migration of OPCs were found. These OPC changes were topographically associated with areas showing microglial activation, and OPC counts negatively correlated with increased microglial staining. The presented data show a striking neuroinflammatory response in an ischemia-induced model of PVL, associated with oligodendroglial injury. Future studies modulating the neuroinflammatory response in this model may contribute to a better understanding of the interaction between microglia and OPCs in PVL and open opportunities for future therapies.
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Affiliation(s)
- Sina Falahati
- The Hugo W. Moser Research Institute at Kennedy Krieger Institute, Baltimore, MD 21205, USA
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Peterson MD, Gordon PM, Hurvitz EA. Chronic disease risk among adults with cerebral palsy: the role of premature sarcopoenia, obesity and sedentary behaviour. Obes Rev 2013; 14:171-82. [PMID: 23094988 DOI: 10.1111/j.1467-789x.2012.01052.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 09/18/2012] [Accepted: 09/19/2012] [Indexed: 12/15/2022]
Abstract
Premature declines in function among adults with cerebral palsy (CP) are generally attributed to weakness, spasticity and orthopaedic abnormalities, as well as chronic pain and fatigue. Very little research or clinical attention has been devoted to the confluence and consequences of early muscle wasting and obesity as mediators of secondary comorbidity in this population, and perhaps more importantly, to the role of lifestyle to potentiate these outcomes. At present, there are no national surveillance programmes that monitor chronic health in adults with CP; however, mortality records have demonstrated a greater prevalence of coronary heart disease as compared with the general population. Although by definition, CP is a 'non-progressive' condition, secondary factors such as habitual sedentary behaviour, obesity, and premature sarcoepenia may increase the severity of functional impairment throughout adulthood, and lead to cardiometabolic disease, fragility and/or early mortality. Herein we describe the heightened health risk represented in adults with CP, and discuss the hallmark phenotypic features that coincide with ageing, obesity and cardiometabolic disorders. Moreover, we provide discussion regarding the protective role of habitual physical activity to stimulate anti-inflammatory pathways and to ameliorate global risk. Although physical therapeutic modalities are already widely acknowledged as a vital component to improve movement quality in CP, the purpose of this review was to present a compelling case for the value of lifelong physical activity participation for both function and cardiometabolic health preservation.
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Affiliation(s)
- M D Peterson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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239
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Ramanantsoa N, Fleiss B, Bouslama M, Matrot B, Schwendimann L, Cohen-Salmon C, Gressens P, Gallego J. Bench to cribside: the path for developing a neuroprotectant. Transl Stroke Res 2012; 4:258-77. [PMID: 24323277 DOI: 10.1007/s12975-012-0233-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 11/06/2012] [Accepted: 11/29/2012] [Indexed: 12/29/2022]
Abstract
The consequences of perinatal brain injury include immeasurable anguish for families and substantial ongoing costs for care and support of effected children. Factors associated with perinatal brain injury in the preterm infant include inflammation and infection, and with increasing gestational age, a higher proportion is related to hypoxic-ischemic events, such as stroke and placental abruption. Over the past decade, we have acquired new insights in the mechanisms underpinning injury and many new tools to monitor outcome in perinatal brain injury in our experimental models. By embracing these new technologies, we can expedite the screening of novel therapies. This is critical as despite enormous efforts of the research community, hypothermia is the only viable neurotherapeutic, and this procedure is limited to term birth and postcardiac arrest hypoxic-ischemic events. Importantly, experimental and preliminary data in humans also indicate a considerable therapeutic potential for melatonin against perinatal brain injury. However, even if this suggested potential is proven, the complexity of the human condition means we are likely to need additional neuroprotective and regenerative strategies. Thus, within this review, we will outline what we consider the key stages of preclinical testing and development for a neuroprotectant or regenerative neurotherapy for perinatal brain injury. We will also highlight examples of novel small animal physiological and behavioral testing that gives small animal preclinical models greater clinical relevance. We hope these new tools and an integrated bench to cribside strategic plan will facilitate the fulfillment of our overarching goal, improving the long-term brain health and quality of life for infants suffering perinatal brain injury.
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Affiliation(s)
- Nelina Ramanantsoa
- Inserm U676, Hopital Robert Debre, 48 Blvd Serurier, 75019, Paris, France
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240
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Baburamani AA, Ek CJ, Walker DW, Castillo-Melendez M. Vulnerability of the developing brain to hypoxic-ischemic damage: contribution of the cerebral vasculature to injury and repair? Front Physiol 2012; 3:424. [PMID: 23162470 PMCID: PMC3493883 DOI: 10.3389/fphys.2012.00424] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/17/2012] [Indexed: 11/13/2022] Open
Abstract
As clinicians attempt to understand the underlying reasons for the vulnerability of different regions of the developing brain to injury, it is apparent that little is known as to how hypoxia-ischemia may affect the cerebrovasculature in the developing infant. Most of the research investigating the pathogenesis of perinatal brain injury following hypoxia-ischemia has focused on excitotoxicity, oxidative stress and an inflammatory response, with the response of the developing cerebrovasculature receiving less attention. This is surprising as the presentation of devastating and permanent injury such as germinal matrix-intraventricular haemorrhage (GM-IVH) and perinatal stroke are of vascular origin, and the origin of periventricular leukomalacia (PVL) may also arise from poor perfusion of the white matter. This highlights that cerebrovasculature injury following hypoxia could primarily be responsible for the injury seen in the brain of many infants diagnosed with hypoxic-ischemic encephalopathy (HIE). Interestingly the highly dynamic nature of the cerebral blood vessels in the fetus, and the fluctuations of cerebral blood flow and metabolic demand that occur following hypoxia suggest that the response of blood vessels could explain both regional protection and vulnerability in the developing brain. However, research into how blood vessels respond following hypoxia-ischemia have mostly been conducted in adult models of ischemia or stroke, further highlighting the need to investigate how the developing cerebrovasculature responds and the possible contribution to perinatal brain injury following hypoxia. This review discusses the current concepts on the pathogenesis of perinatal brain injury, the development of the fetal cerebrovasculature and the blood brain barrier (BBB), and key mediators involved with the response of cerebral blood vessels to hypoxia.
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Affiliation(s)
- Ana A Baburamani
- The Ritchie Centre, Monash Medical Centre, Monash Institute of Medical Research, Clayton Melbourne, VIC, Australia ; Sahlgrenska Academy, Gothenburg University Göteborg, Sweden
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Peterson MD, Gordon PM, Hurvitz EA, Burant CF. Secondary muscle pathology and metabolic dysregulation in adults with cerebral palsy. Am J Physiol Endocrinol Metab 2012; 303:E1085-93. [PMID: 22912367 PMCID: PMC3492860 DOI: 10.1152/ajpendo.00338.2012] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cerebral palsy (CP) is caused by an insult to or malformation of the developing brain which affects motor control centers and causes alterations in growth, development, and overall health throughout the life span. In addition to the disruption in development caused by the primary neurological insult, CP is associated with exaggerated sedentary behaviors and a hallmark accelerated progression of muscle pathology compared with typically developing children and adults. Factors such as excess adipose tissue deposition and altered partitioning, insulin resistance, and chronic inflammation may increase the severity of muscle pathology throughout adulthood and lead to cardiometabolic disease risk and/or early mortality. We describe a model of exaggerated health risk represented in adults with CP and discuss the mechanisms and secondary consequences associated with chronic sedentary behavior, obesity, aging, and muscle spasticity. Moreover, we highlight novel evidence that implicates aberrant inflammation in CP as a potential mechanism linking both metabolic and cognitive dysregulation in a cyclical pattern.
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Affiliation(s)
- Mark D Peterson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA.
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