301
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Kirov II, Whitlow CT, Zamora C. Susceptibility-Weighted Imaging and Magnetic Resonance Spectroscopy in Concussion. Neuroimaging Clin N Am 2018; 28:91-105. [DOI: 10.1016/j.nic.2017.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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302
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Traumatic Brain Injury and Alzheimer's Disease: The Cerebrovascular Link. EBioMedicine 2018; 28:21-30. [PMID: 29396300 PMCID: PMC5835563 DOI: 10.1016/j.ebiom.2018.01.021] [Citation(s) in RCA: 226] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/19/2018] [Accepted: 01/19/2018] [Indexed: 12/12/2022] Open
Abstract
Traumatic brain injury (TBI) and Alzheimer's disease (AD) are devastating neurological disorders, whose complex relationship is not completely understood. Cerebrovascular pathology, a key element in both conditions, could represent a mechanistic link between Aβ/tau deposition after TBI and the development of post concussive syndrome, dementia and chronic traumatic encephalopathy (CTE). In addition to debilitating acute effects, TBI-induced neurovascular injuries accelerate amyloid β (Aβ) production and perivascular accumulation, arterial stiffness, tau hyperphosphorylation and tau/Aβ-induced blood brain barrier damage, giving rise to a deleterious feed-forward loop. We postulate that TBI can initiate cerebrovascular pathology, which is causally involved in the development of multiple forms of neurodegeneration including AD-like dementias. In this review, we will explore how novel biomarkers, animal and human studies with a focus on cerebrovascular dysfunction are contributing to the understanding of the consequences of TBI on the development of AD-like pathology. Cerebrovascular dysfunction (CVD) is emerging as a key element in the development of neurodegeneration after TBI. We propose that TBI initiates CVD, accelerating Aβ/tau deposition and leading to neurodegeneration and dementias. Clarifying this connection will support the development of novel biomarkers and therapeutic approaches for both TBI and AD.
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303
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Kim HJ, Tsao JW, Stanfill AG. The current state of biomarkers of mild traumatic brain injury. JCI Insight 2018; 3:97105. [PMID: 29321373 DOI: 10.1172/jci.insight.97105] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Mild traumatic brain injury (mTBI) is a common occurrence, with over 3 million cases reported every year in the United States. While research into the underlying pathophysiology is ongoing, there is an urgent need for better clinical guidelines that allow more consistent diagnosis of mTBI and ensure safe return-to-play timelines for athletes, nonathletes, and military personnel. The development of a suite of biomarkers that indicate the pathogenicity of mTBI could lead to clinically useful tools for establishing both diagnosis and prognosis. Here, we review the current evidence for mTBI biomarkers derived from investigations of the multifactorial pathology of mTBI. While the current literature lacks the scope and size for clarification of these biomarkers' clinical utility, early studies have identified some promising candidates.
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Affiliation(s)
- Han Jun Kim
- Department of Neurology, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jack W Tsao
- Department of Neurology, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurology, Memphis Veterans Affairs Medical Center, Memphis, Tennessee, USA.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Ansley Grimes Stanfill
- Department of Acute and Tertiary Care, College of Nursing, and.,Department of Genetics, Genomics, and Informatics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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304
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Moyron RB, Wall NR. Differential protein expression in exosomal samples taken from trauma patients. Proteomics Clin Appl 2018; 11. [PMID: 28734082 DOI: 10.1002/prca.201700095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 06/18/2017] [Accepted: 07/14/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Ron B Moyron
- Center for Health Disparities Research and Molecular Medicine, Loma Linda University, Loma Linda, CA, USA.,Department of Basic Sciences, Division of Biochemistry, Loma Linda University, Loma Linda, CA, USA
| | - Nathan R Wall
- Center for Health Disparities Research and Molecular Medicine, Loma Linda University, Loma Linda, CA, USA.,Department of Basic Sciences, Division of Biochemistry, Loma Linda University, Loma Linda, CA, USA
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305
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Zetterberg H, Blennow K. Chronic traumatic encephalopathy: fluid biomarkers. HANDBOOK OF CLINICAL NEUROLOGY 2018; 158:323-333. [PMID: 30482360 DOI: 10.1016/b978-0-444-63954-7.00030-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chronic traumatic encephalopathy (CTE) is a neuropathologic condition that has been described in individuals who have been exposed to repetitive head impacts, including concussions and subconcussive trauma. CTE cannot currently be diagnosed during life. Clinical symptoms of CTE (including changes in mood, behavior, and cognition) are nonspecific and may develop after a latency phase following the injuries. Differential diagnosis based solely on clinical features is, therefore, difficult. For example, some younger patients who do not experience the latency phase (i.e., symptoms of CTE may begin while still being exposed to the repetitive head impacts) may be clinically diagnosed with postconcussive syndrome, a vaguely defined condition that is described in a minority of concussed patients. Some older patients whose initial features of CTE include memory and executive dysfunction and progress to impaired activities of daily living may be clinically diagnosed with Alzheimer disease or another dementia. Although concussions are common in athletes and nonathletes, contact/collision sport athletes, such as boxers, American football players, and ice hockey players, are at greater risk of exposure to both concussion and repetitive subconcussive head impacts. Biomarkers for CTE pathophysiology would be of great value to study and improve our understanding of when and how the disease process starts and develops, as well as how it can be prevented or treated. Here, we review the literature regarding fluid biomarkers for repetitive subconcussive impacts, concussion, postconcussive syndrome, and CTE. We also discuss technical issues and potential pathways forward regarding how to move the most promising biomarker candidates into clinical laboratory practice.
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Affiliation(s)
- Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom; UK Dementia Research Institute, UCL, London, United Kingdom.
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
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306
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Bodnar CN, Morganti JM, Bachstetter AD. Depression following a traumatic brain injury: uncovering cytokine dysregulation as a pathogenic mechanism. Neural Regen Res 2018; 13:1693-1704. [PMID: 30136679 PMCID: PMC6128046 DOI: 10.4103/1673-5374.238604] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A substantial number of individuals have long-lasting adverse effects from a traumatic brain injury (TBI). Depression is one of these long-term complications that influences many aspects of life. Depression can limit the ability to return to work, and even worsen cognitive function and contribute to dementia. The mechanistic cause for the increased depression risk associated with a TBI remains to be defined. As TBI results in chronic neuroinflammation, and priming of glia to a secondary challenge, the inflammatory theory of depression provides a promising framework for investigating the cause of depression following a TBI. Increases in cytokines similar to those seen in depression in the general population are also increased following a TBI. Biomarker levels of cytokines peak within hours-to-days after the injury, yet pro-inflammatory cytokines may still be elevated above physiological levels months-to-years following TBI, which is the time frame in which post-TBI depression can persist. As tumor necrosis factor α and interleukin 1 can signal directly at the neuronal synapse, pathophysiological levels of these cytokines can detrimentally alter neuronal synaptic physiology. The purpose of this review is to outline the current evidence for the inflammatory hypothesis of depression specifically as it relates to depression following a TBI. Moreover, we will illustrate the potential synaptic mechanisms by which tumor necrosis factor α and interleukin 1 could contribute to depression. The association of inflammation with the development of depression is compelling; however, in the context of post-TBI depression, the role of inflammation is understudied. This review attempts to highlight the need to understand and treat the psychological complications of a TBI, potentially by neuroimmune modulation, as the neuropsychiatric disabilities can have a great impact on the rehabilitation from the injury, and overall quality of life.
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Affiliation(s)
- Colleen N Bodnar
- Spinal Cord & Brain Injury Research Center, University of Kentucky; Department of Neuroscience, University of Kentucky, Lexington, KY, USA
| | - Josh M Morganti
- Department of Neuroscience, University of Kentucky; Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA
| | - Adam D Bachstetter
- Spinal Cord & Brain Injury Research Center, University of Kentucky; Department of Neuroscience, University of Kentucky, Lexington, KY, USA
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307
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Jackson TC, Kotermanski SE, Jackson EK, Kochanek PM. BrainPhys® increases neurofilament levels in CNS cultures, and facilitates investigation of axonal damage after a mechanical stretch-injury in vitro. Exp Neurol 2017; 300:232-246. [PMID: 29199132 DOI: 10.1016/j.expneurol.2017.11.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/25/2017] [Accepted: 11/29/2017] [Indexed: 01/18/2023]
Abstract
Neurobasal®/B27 is a gold standard culture media used to study primary neurons in vitro. An alternative media (BrainPhys®/SM1) was recently developed which robustly enhances neuronal activity vs. Neurobasal® or DMEM. To the best of our knowledge BrainPhys® has not been explored in the setting of neuronal injury. Here we characterized the utility of BrainPhys® in a model of in vitro mechanical-stretch injury. METHODS/RESULTS Primary rat cortical neurons were maintained in classic Neurobasal®, or sequentially maintained in Neurocult® followed by BrainPhys® (hereafter simply referred to as "BrainPhys® maintained neurons"). The levels of axonal markers and proteins involved in neurotransmission were compared on day in vitro 10 (DIV10). BrainPhys® maintained neurons had higher levels of GluN2B, GluR1, Neurofilament light/heavy chain (NF-L & NF-H), and protein phosphatase 2 A (PP2A) vs. neurons in Neurobasal®. Mechanical stretch-injury (50ms/54% biaxial stretch) to BrainPhys® maintained neurons modestly (albeit significantly) increased 24h lactate dehydrogenase (LDH) levels but markedly decreased axonal NF-L levels post-injury vs. uninjured controls or neurons given a milder 38% stretch-injury. Furthermore, two 54% stretch-injuries (in tandem) exacerbated 24h LDH release, increased α-spectrin breakdown products (SBDPs), and decreased Tau levels. Also, BrainPhys® maintained cultures had decreased markers of cell damage 24h after a single 54% stretch-injury vs. neurons in Neurobasal®. Finally, we tested the hypothesis that lentivirus mediated overexpression of the pro-death protein RBM5 exacerbates neuronal and/or axonal injury in primary CNS cultures. RBM5 overexpression vs. empty-vector controls increased 24h LDH release, and SBDP levels, after a single 54% stretch-injury but did not affect NF-L levels or Tau. CONCLUSION BrainPhys® is a promising new reagent which facilities the investigation of molecular targets involved in axonal and/or neuronal injury in vitro.
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Affiliation(s)
- Travis C Jackson
- University of Pittsburgh School of Medicine, Safar Center for Resuscitation Research, Children's Hospital of Pittsburgh of UPMC, John G. Rangos Research Center, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA 15224, United States; University of Pittsburgh School of Medicine, Department of Critical Care Medicine, Scaife Hall, 3550 Terrace Street, United States.
| | - Shawn E Kotermanski
- University of Pittsburgh School of Medicine, Department of Pharmacology and Chemical Biology, Bridgeside Point Building 1, 100 Technology Drive, United States
| | - Edwin K Jackson
- University of Pittsburgh School of Medicine, Department of Pharmacology and Chemical Biology, Bridgeside Point Building 1, 100 Technology Drive, United States
| | - Patrick M Kochanek
- University of Pittsburgh School of Medicine, Safar Center for Resuscitation Research, Children's Hospital of Pittsburgh of UPMC, John G. Rangos Research Center, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA 15224, United States; University of Pittsburgh School of Medicine, Department of Critical Care Medicine, Scaife Hall, 3550 Terrace Street, United States
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308
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Tsitsopoulos PP, Abu Hamdeh S, Marklund N. Current Opportunities for Clinical Monitoring of Axonal Pathology in Traumatic Brain Injury. Front Neurol 2017; 8:599. [PMID: 29209266 PMCID: PMC5702013 DOI: 10.3389/fneur.2017.00599] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 10/25/2017] [Indexed: 01/14/2023] Open
Abstract
Traumatic brain injury (TBI) is a multidimensional and highly complex disease commonly resulting in widespread injury to axons, due to rapid inertial acceleration/deceleration forces transmitted to the brain during impact. Axonal injury leads to brain network dysfunction, significantly contributing to cognitive and functional impairments frequently observed in TBI survivors. Diffuse axonal injury (DAI) is a clinical entity suggested by impaired level of consciousness and coma on clinical examination and characterized by widespread injury to the hemispheric white matter tracts, the corpus callosum and the brain stem. The clinical course of DAI is commonly unpredictable and it remains a challenging entity with limited therapeutic options, to date. Although axonal integrity may be disrupted at impact, the majority of axonal pathology evolves over time, resulting from delayed activation of complex intracellular biochemical cascades. Activation of these secondary biochemical pathways may lead to axonal transection, named secondary axotomy, and be responsible for the clinical decline of DAI patients. Advances in the neurocritical care of TBI patients have been achieved by refinements in multimodality monitoring for prevention and early detection of secondary injury factors, which can be applied also to DAI. There is an emerging role for biomarkers in blood, cerebrospinal fluid, and interstitial fluid using microdialysis in the evaluation of axonal injury in TBI. These biomarker studies have assessed various axonal and neuroglial markers as well as inflammatory mediators, such as cytokines and chemokines. Moreover, modern neuroimaging can detect subtle or overt DAI/white matter changes in diffuse TBI patients across all injury severities using magnetic resonance spectroscopy, diffusion tensor imaging, and positron emission tomography. Importantly, serial neuroimaging studies provide evidence for evolving axonal injury. Since axonal injury may be a key risk factor for neurodegeneration and dementias at long-term following TBI, the secondary injury processes may require prolonged monitoring. The aim of the present review is to summarize the clinical short- and long-term monitoring possibilities of axonal injury in TBI. Increased knowledge of the underlying pathophysiology achieved by advanced clinical monitoring raises hope for the development of novel treatment strategies for axonal injury in TBI.
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Affiliation(s)
- Parmenion P Tsitsopoulos
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden.,Hippokratio General Hospital, Aristotle University, Thessaloniki, Greece
| | - Sami Abu Hamdeh
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Niklas Marklund
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden.,Department of Clinical Sciences Lund, Neurosurgery, Skåne University Hospital, Lund University, Lund, Sweden
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309
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Hamblin MR. Photobiomodulation for traumatic brain injury and stroke. J Neurosci Res 2017; 96:731-743. [PMID: 29131369 DOI: 10.1002/jnr.24190] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 10/04/2017] [Accepted: 10/04/2017] [Indexed: 12/12/2022]
Abstract
There is a notable lack of therapeutic alternatives for what is fast becoming a global epidemic of traumatic brain injury (TBI). Photobiomodulation (PBM) employs red or near-infrared (NIR) light (600-1100nm) to stimulate healing, protect tissue from dying, increase mitochondrial function, improve blood flow, and tissue oxygenation. PBM can also act to reduce swelling, increase antioxidants, decrease inflammation, protect against apoptosis, and modulate microglial activation state. All these mechanisms of action strongly suggest that PBM delivered to the head should be beneficial in cases of both acute and chronic TBI. Most reports have used NIR light either from lasers or from light-emitting diodes (LEDs). Many studies in small animal models of acute TBI have found positive effects on neurological function, learning and memory, and reduced inflammation and cell death in the brain. There is evidence that PBM can help the brain repair itself by stimulating neurogenesis, upregulating BDNF synthesis, and encouraging synaptogenesis. In healthy human volunteers (including students and healthy elderly women), PBM has been shown to increase regional cerebral blood flow, tissue oxygenation, and improve memory, mood, and cognitive function. Clinical studies have been conducted in patients suffering from the chronic effects of TBI. There have been reports showing improvement in executive function, working memory, and sleep. Functional magnetic resonance imaging has shown modulation of activation in intrinsic brain networks likely to be damaged in TBI (default mode network and salience network).
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Affiliation(s)
- Michael R Hamblin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA.,Department of Dermatology, Harvard Medical School, Boston, MA.,Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA
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310
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Ciuffreda KJ, Joshi NR, Truong JQ. Understanding the effects of mild traumatic brain injury on the pupillary light reflex. Concussion 2017; 2:CNC36. [PMID: 30202579 PMCID: PMC6094691 DOI: 10.2217/cnc-2016-0029] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/15/2017] [Indexed: 11/21/2022] Open
Abstract
The pupillary light reflex represents an optimal visual system to investigate and exploit in the mild traumatic brain injury (mTBI) population. Static and dynamic aspects of the pupillary light reflex were investigated objectively and quantitatively in the mTBI population. Pupillary responsivity was found to be significantly delayed, slowed and reduced, but symmetrical in nature, and with a smaller baseline diameter, as compared with normals. Several pupillary parameters also discriminated between those with versus without photosensitivity. Thus, dynamic pupillometry provides several objective biomarkers for the presence of mTBI and photosensitivity, gives insight into the global sites of neurological dysfunction and possible related mechanisms, and should result in improved patient care.
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Affiliation(s)
- Kenneth J Ciuffreda
- Brain Injury Research Clinic, SUNY/State College of Optometry, 33 West 42nd Street, New York City, NY 10036, USA
| | - Nabin R Joshi
- Brain Injury Research Clinic, SUNY/State College of Optometry, 33 West 42nd Street, New York City, NY 10036, USA
| | - James Q Truong
- Brain Injury Research Clinic, SUNY/State College of Optometry, 33 West 42nd Street, New York City, NY 10036, USA
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311
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Kneynsberg A, Combs B, Christensen K, Morfini G, Kanaan NM. Axonal Degeneration in Tauopathies: Disease Relevance and Underlying Mechanisms. Front Neurosci 2017; 11:572. [PMID: 29089864 PMCID: PMC5651019 DOI: 10.3389/fnins.2017.00572] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/29/2017] [Indexed: 12/14/2022] Open
Abstract
Tauopathies are a diverse group of diseases featuring progressive dying-back neurodegeneration of specific neuronal populations in association with accumulation of abnormal forms of the microtubule-associated protein tau. It is well-established that the clinical symptoms characteristic of tauopathies correlate with deficits in synaptic function and neuritic connectivity early in the course of disease, but mechanisms underlying these critical pathogenic events are not fully understood. Biochemical in vitro evidence fueled the widespread notion that microtubule stabilization represents tau's primary biological role and that the marked atrophy of neurites observed in tauopathies results from loss of microtubule stability. However, this notion contrasts with the mild phenotype associated with tau deletion. Instead, an analysis of cellular hallmarks common to different tauopathies, including aberrant patterns of protein phosphorylation and early degeneration of axons, suggests that alterations in kinase-based signaling pathways and deficits in axonal transport (AT) associated with such alterations contribute to the loss of neuronal connectivity triggered by pathogenic forms of tau. Here, we review a body of literature providing evidence that axonal pathology represents an early and common pathogenic event among human tauopathies. Observations of axonal degeneration in animal models of specific tauopathies are discussed and similarities to human disease highlighted. Finally, we discuss potential mechanistic pathways other than microtubule destabilization by which disease-related forms of tau may promote axonopathy.
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Affiliation(s)
- Andrew Kneynsberg
- Neuroscience Program, Michigan State University, East Lansing, MI, United States.,Department of Translational Science and Molecular Medicine, College of Human Medicine, Michigan State University, Grand Rapids, MI, United States
| | - Benjamin Combs
- Department of Translational Science and Molecular Medicine, College of Human Medicine, Michigan State University, Grand Rapids, MI, United States
| | - Kyle Christensen
- Neuroscience Program, Michigan State University, East Lansing, MI, United States.,Department of Translational Science and Molecular Medicine, College of Human Medicine, Michigan State University, Grand Rapids, MI, United States
| | - Gerardo Morfini
- Department of Anatomy and Cell Biology, University of Illinois at Chicago, Chicago, IL, United States
| | - Nicholas M Kanaan
- Neuroscience Program, Michigan State University, East Lansing, MI, United States.,Department of Translational Science and Molecular Medicine, College of Human Medicine, Michigan State University, Grand Rapids, MI, United States.,Hauenstein Neuroscience Center, Mercy Health Saint Mary's, Grand Rapids, MI, United States
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312
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Pre-clinical models in pediatric traumatic brain injury-challenges and lessons learned. Childs Nerv Syst 2017; 33:1693-1701. [PMID: 29149385 PMCID: PMC5909721 DOI: 10.1007/s00381-017-3474-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 05/30/2017] [Indexed: 12/31/2022]
Abstract
PURPOSE Despite the enormity of the problem and the lack of new therapies, research in the pre-clinical arena specifically using pediatric traumatic brain injury (TBI) models is limited. In this review, some of the key models addressing both the age spectrum of pediatric TBI and its unique injury mechanisms will be highlighted. Four topics will be addressed, namely, (1) unique facets of the developing brain important to TBI model development, (2) a description of some of the most commonly used pre-clinical models of severe pediatric TBI including work in both rodents and large animals, (3) a description of the pediatric models of mild TBI and repetitive mild TBI that are relatively new, and finally (4) a discussion of challenges, gaps, and potential future directions to further advance work in pediatric TBI models. METHODS This narrative review on the topic of pediatric TBI models was based on review of PUBMED/Medline along with a synthesis of information on key factors in pre-clinical and clinical developmental brain injury that influence TBI modeling. RESULTS In the contemporary literature, six types of models have been used in rats including weight drop, fluid percussion injury (FPI), impact acceleration, controlled cortical impact (CCI), mechanical shaking, and closed head modifications of CCI. In mice, studies are largely restricted to CCI. In large animals, FPI and rotational injury have been used in piglets and shake injury has also been used in lambs. Most of the studies have been in severe injury models, although more recently, studies have begun to explore mild and repetitive mild injuries to study concussion. CONCLUSIONS Given the emerging importance of TBI in infants and children, the morbidity and mortality that is produced, along with its purported link to the development of chronic neurodegenerative diseases, studies in these models merit greater systematic investigations along with consortium-type approaches and long-term follow-up to translate new therapies to the bedside.
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313
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Cherry JD, Stein TD, Tripodis Y, Alvarez VE, Huber BR, Au R, Kiernan PT, Daneshvar DH, Mez J, Solomon TM, Alosco ML, McKee AC. CCL11 is increased in the CNS in chronic traumatic encephalopathy but not in Alzheimer's disease. PLoS One 2017; 12:e0185541. [PMID: 28950005 PMCID: PMC5614644 DOI: 10.1371/journal.pone.0185541] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 09/14/2017] [Indexed: 12/14/2022] Open
Abstract
CCL11, a protein previously associated with age-associated cognitive decline, is observed to be increased in the brain and cerebrospinal fluid (CSF) in chronic traumatic encephalopathy (CTE) compared to Alzheimer's disease (AD). Using a cohort of 23 deceased American football players with neuropathologically verified CTE, 50 subjects with neuropathologically diagnosed AD, and 18 non-athlete controls, CCL11 was measured with ELISA in the dorsolateral frontal cortex (DLFC) and CSF. CCL11 levels were significantly increased in the DLFC in subjects with CTE (fold change = 1.234, p < 0.050) compared to non-athlete controls and AD subjects with out a history of head trauma. This increase was also seen to correlate with years of exposure to American football (β = 0.426, p = 0.048) independent of age (β = -0.046, p = 0.824). Preliminary analyses of a subset of subjects with available post-mortem CSF showed a trend for increased CCL11 among individuals with CTE (p = 0.069) mirroring the increase in the DLFC. Furthermore, an association between CSF CCL11 levels and the number of years exposed to football (β = 0.685, p = 0.040) was observed independent of age (β = -0.103, p = 0.716). Finally, a receiver operating characteristic (ROC) curve analysis demonstrated CSF CCL11 accurately distinguished CTE subjects from non-athlete controls and AD subjects (AUC = 0.839, 95% CI 0.62-1.058, p = 0.028). Overall, the current findings provide preliminary evidence that CCL11 may be a novel target for future CTE biomarker studies.
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Affiliation(s)
- Jonathan D. Cherry
- Boston University Alzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, United States of America
- Department of Neurology, Boston University School of Medicine, Boston, MA. United States of America
- VA Boston Healthcare System, Boston, MA, United States of America
- * E-mail:
| | - Thor D. Stein
- Boston University Alzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, United States of America
- Department of Neurology, Boston University School of Medicine, Boston, MA. United States of America
- Department of Veterans Affairs Medical Center, Bedford, MA, United States of America
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America
| | - Victor E. Alvarez
- Boston University Alzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, United States of America
- Department of Neurology, Boston University School of Medicine, Boston, MA. United States of America
- VA Boston Healthcare System, Boston, MA, United States of America
- Department of Veterans Affairs Medical Center, Bedford, MA, United States of America
| | - Bertrand R. Huber
- Boston University Alzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, United States of America
- Department of Neurology, Boston University School of Medicine, Boston, MA. United States of America
- VA Boston Healthcare System, Boston, MA, United States of America
| | - Rhoda Au
- Department of Neurology, Boston University School of Medicine, Boston, MA. United States of America
- Framingham Heart Study, Boston University School of Medicine, Boston, MA, United States of America
| | - Patrick T. Kiernan
- Boston University Alzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, United States of America
| | - Daniel H. Daneshvar
- Boston University Alzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, United States of America
| | - Jesse Mez
- Boston University Alzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, United States of America
- Department of Neurology, Boston University School of Medicine, Boston, MA. United States of America
| | - Todd M. Solomon
- Boston University Alzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, United States of America
| | - Michael L. Alosco
- Boston University Alzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, United States of America
- Department of Neurology, Boston University School of Medicine, Boston, MA. United States of America
| | - Ann C. McKee
- Boston University Alzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, United States of America
- Department of Neurology, Boston University School of Medicine, Boston, MA. United States of America
- VA Boston Healthcare System, Boston, MA, United States of America
- Department of Veterans Affairs Medical Center, Bedford, MA, United States of America
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, United States of America
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314
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Shahim P, Holleran L, Kim JH, Brody DL. Test-retest reliability of high spatial resolution diffusion tensor and diffusion kurtosis imaging. Sci Rep 2017; 7:11141. [PMID: 28894296 PMCID: PMC5593980 DOI: 10.1038/s41598-017-11747-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/30/2017] [Indexed: 02/03/2023] Open
Abstract
We assessed the test-retest reliability of high spatial resolution diffusion tensor imaging (DTI) and diffusion kurtosis imaging (DKI). Diffusion MRI was acquired using a Siemens 3 Tesla Prisma scanner with 80 mT/m gradients and a 32-channel head coil from each of 3 concussive traumatic brain injury (cTBI) patients and 4 controls twice 0 to 24 days apart. Coefficients of variation (CoV) for DTI parameters were calculated in each DTI Studio parcellated white matter tract at 1.25 mm and 1.75 mm isotropic voxel resolution, as well as DKI parameters at 1.75 mm isotropic. Overall, fractional anisotropy had the best reliability, with mean CoV at 5% for 1.25 mm and 3.5% for 1.75 mm isotropic voxels. Mean CoV for the other DTI metrics were <7.0% for both 1.25 and 1.75 mm isotropic voxels. The mean CoV was ≤4.5% across the DKI metrics. In the commonly injured orbitofrontal and temporal pole regions CoV was <3.5% for all parameters. Thus, with appropriate processing, high spatial resolution advanced diffusion MRI has good to excellent test-retest reproducibility in both human cTBI patients and controls. However, further technical improvements will be needed to reliably discern the most subtle diffusion abnormalities, especially at high spatial resolution.
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Affiliation(s)
- Pashtun Shahim
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA. .,Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden. .,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Laurena Holleran
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joong H Kim
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - David L Brody
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, Missouri, USA
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315
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Yu T, Tensaouti Y, Bagha ZM, Davidson R, Kim A, Kernie SG. Adult newborn neurons interfere with fear discrimination in a protocol-dependent manner. Brain Behav 2017; 7:e00796. [PMID: 28948089 PMCID: PMC5607558 DOI: 10.1002/brb3.796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 06/27/2017] [Accepted: 07/02/2017] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Significant enhancement of neurogenesis is known to occur in response to a variety of brain insults such as traumatic brain injury. Previous studies have demonstrated that injury-induced newborn neurons are required for hippocampus-dependent spatial learning and memory tasks like the Morris water maze, but not in contextual fear conditioning that requires both the hippocampus and amygdala. Recently, the dentate gyrus, where adult hippocampal neurogenesis occurs, has been implicated in processing information to form specific memory under specific environmental stimuli in a process known as pattern separation. METHODS To test whether injury-induced newborn neurons facilitate pattern separation, hippocampus-dependent contextual fear discrimination was performed using delta-HSV-TK transgenic mice, which can temporally inhibit injury-induced neurogenesis under the control of ganciclovir. RESULTS We observed that impaired neurogenesis enhanced the ability to distinguish aversive from naïve environments. In addition, this occurs most significantly following injury, but only in a context-dependent manner whereby the sequence of introducing the naïve environment from the aversive one affected the performance differentially. CONCLUSIONS Temporal impairment of both baseline and injury-induced adult neurogenesis enhances performance in fear discrimination in a context-dependent manner.
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Affiliation(s)
- Tzong‐Shiue Yu
- Department of PediatricsColumbia University College of Physicians and SurgeonsNew YorkNYUSA
| | - Yacine Tensaouti
- Department of PediatricsColumbia University College of Physicians and SurgeonsNew YorkNYUSA
| | - Zohaib M. Bagha
- Department of PediatricsColumbia University College of Physicians and SurgeonsNew YorkNYUSA
| | - Rina Davidson
- Department of PediatricsColumbia University College of Physicians and SurgeonsNew YorkNYUSA
| | - Ahleum Kim
- Department of PediatricsColumbia University College of Physicians and SurgeonsNew YorkNYUSA
| | - Steven G. Kernie
- Department of PediatricsColumbia University College of Physicians and SurgeonsNew YorkNYUSA
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316
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Toorell H, Zetterberg H, Blennow K, Sävman K, Hagberg H. Increase of neuronal injury markers Tau and neurofilament light proteins in umbilical blood after intrapartum asphyxia. J Matern Fetal Neonatal Med 2017. [PMID: 28629249 DOI: 10.1080/14767058.2017.1344964] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
AIM Compare the levels of the brain injury biomarkers Tau and neurofilament light protein (NFL) in cases of asphyxia with those in controls. MATERIALS AND METHODS We analyzed the neuronal proteins Tau and NFL in umbilical blood of 10 cases of severe-moderate intrapartum asphyxia and in 18 control cases. RESULTS The levels of both Tau and neurofilament were significantly higher after asphyxia and it appeared to be a correlation between the levels of the biomarkers and the severity of the insult. DISCUSSION Future studies are warranted to support or refute the value of Tau/NFLin clinical practice. CONCLUSION Fetal asphyxia remains a clinical problem resulting in life-long neurological disabilities. We urgently need more accurate early predictive markers to direct the clinician when to provide neuroprotective therapy.
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Affiliation(s)
- Hanna Toorell
- a Perinatal Center, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Henrik Zetterberg
- b Clinical Neurochemistry Laboratory , Mölndal , Sweden.,c Department of Psychiatry and Neurochemistry , Institute of Neuroscience and Physiology , Mölndal , Sweden.,d Department of Molecular Neuroscience , UCL Institute of Neurology, University College London , London , UK
| | - Kaj Blennow
- b Clinical Neurochemistry Laboratory , Mölndal , Sweden.,c Department of Psychiatry and Neurochemistry , Institute of Neuroscience and Physiology , Mölndal , Sweden
| | - Karin Sävman
- e Department of Pediatrics , Institute of Clinical Sciences, University of Gothenburg , Gothenburg , Sweden
| | - Henrik Hagberg
- a Perinatal Center, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska University Hospital , Gothenburg , Sweden.,f Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering , King's College London, St. Thomas' Hospital , London , UK
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317
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Conde V, Andreasen SH, Petersen TH, Larsen KB, Madsen K, Andersen KW, Akopian I, Madsen KH, Hansen CP, Poulsen I, Kammersgaard LP, Siebner HR. Alterations in the brain's connectome during recovery from severe traumatic brain injury: protocol for a longitudinal prospective study. BMJ Open 2017; 7:e016286. [PMID: 28615277 PMCID: PMC5541610 DOI: 10.1136/bmjopen-2017-016286] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is considered one of the most pervasive causes of disability in people under the age of 45. TBI often results in disorders of consciousness, and clinical assessment of the state of consciousness in these patients is challenging due to the lack of behavioural responsiveness. Functional neuroimaging offers a means to assess these patients without the need for behavioural signs, indicating that brain connectivity plays a major role in consciousness emergence and maintenance. However, little is known regarding how changes in connectivity during recovery from TBI accompany changes in the level of consciousness. Here, we aim to combine cutting-edge neuroimaging techniques to follow changes in brain connectivity in patients recovering from severe TBI. METHODS AND ANALYSIS A multimodal, longitudinal assessment of 30 patients in the subacute stage after severe TBI will be made comprising an MRI session combined with electroencephalography (EEG), a positron emission tomography session and a transcranial magnetic stimulation (TMS) combined with EEG (TMS/EEG) session. A group of 20 healthy participants will be included for comparison. Four sessions for patients and two sessions for healthy participants will be planned. Data analysis techniques will focus on whole-brain, both data-driven and hypothesis-driven, connectivity measures that will be specific to the imaging modality. ETHICS AND DISSEMINATION The project has received ethical approval by the local ethics committee of the Capital Region of Denmark and by the Danish Data Protection. Results will be published as original research articles in peer-reviewed journals and disseminated in international conferences. None of the measurements will have any direct clinical impact on the patients included in the study but may benefit future patients through a better understanding of the mechanisms underlying the recovery process after TBI. TRIAL REGISTRATION NUMBER NCT02424656; PRE-RESULTS.
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Affiliation(s)
- Virginia Conde
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Sara Hesby Andreasen
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Tue Hvass Petersen
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Karen Busted Larsen
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Karine Madsen
- Department of Clinical Physiology and Nuclear Medicine, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Kasper Winther Andersen
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Irina Akopian
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Kristoffer Hougaard Madsen
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Section for Cognitive Systems, DTU Compute, Technical University of Denmark, Copenhagen, Denmark
| | - Christian Pilebæk Hansen
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ingrid Poulsen
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lars Peter Kammersgaard
- Department of Neurorehabilitation, Traumatic Brain Injury, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Hartwig Roman Siebner
- Danish Research Centre for Magnetic Resonance, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Department of Neurology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
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318
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In vivo transduction of neurons with TAT-UCH-L1 protects brain against controlled cortical impact injury. PLoS One 2017; 12:e0178049. [PMID: 28542502 PMCID: PMC5443532 DOI: 10.1371/journal.pone.0178049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 05/07/2017] [Indexed: 12/17/2022] Open
Abstract
Many mechanisms or pathways are involved in secondary post-traumatic brain injury, such as the ubiquitin-proteasome pathway (UPP), axonal degeneration and neuronal cell apoptosis. UCH-L1 is a protein that is expressed in high levels in neurons and may have important roles in the UPP, autophagy and axonal integrity. The current study aims to evaluate the role of UCH-L1 in post-traumatic brain injury (TBI) and its potential therapeutic effects. A novel protein was constructed that fused the protein transduction domain (PTD) of trans-activating transduction (TAT) protein with UCH-L1 (TAT-UCH-L1) in order to promote neuronal transduction. The TAT-UCH-L1 protein was readily detected in brain by immunoblotting and immunohistochemistry after i.p. administration in mice. TBI was induced in mice using the controlled cortical impact (CCI) model. TAT-UCH-L1 treatment significantly attenuated K48-linkage polyubiquitin (polyUb)-protein accumulation in hippocampus after CCI compared to vehicle controls, but had no effects on K65-linkage polyUb-protein. TAT-UCH-L1 treatment also attenuated expression of Beclin-1 and LC3BII after CCI. TAT-UCH-L1-treated mice had significantly increased spared tissue volumes and increased survival of CA3 neurons 21 d after CCI compared to control vehicle-treated mice. Axonal injury, detected by APP immunohistochemistry, was reduced in thalamus 24 h and 21 d after CCI in TAT-UCH-L1-treated mice. These results suggest that TAT-UCH-L1 treatment improves function of the UPP and decreases activation of autophagy after CCI. Furthermore, TAT-UCH-L1 treatment also attenuates axonal injury and increases hippocampal neuronal survival after CCI. Taken together these results suggest that UCH-L1 may play an important role in the pathogenesis of cell death and axonal injury after TBI.
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319
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The Effects of Blast Exposure on Protein Deimination in the Brain. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017. [PMID: 28626499 PMCID: PMC5463117 DOI: 10.1155/2017/8398072] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Oxidative stress and calcium excitotoxicity are hallmarks of traumatic brain injury (TBI). While these early disruptions may be corrected over a relatively short period of time, long-lasting consequences of TBI including impaired cognition and mood imbalances can persist for years, even in the absence of any evidence of overt injury based on neuroimaging. This investigation examined the possibility that disordered protein deimination occurs as a result of TBI and may thus contribute to the long-term pathologies of TBI. Protein deimination is a calcium-activated, posttranslational modification implicated in the autoimmune diseases rheumatoid arthritis and multiple sclerosis, where aberrant deimination creates antigenic epitopes that elicit an autoimmune attack. The present study utilized proteomic analyses to show that blast TBI alters the deimination status of proteins in the porcine cerebral cortex. The affected proteins represent a small subset of the entire brain proteome and include glial fibrillary acidic protein and vimentin, proteins reported to be involved in autoimmune-based pathologies. The data also indicate that blast injury is associated with an increase in immunoglobulins in the brain, possibly representing autoantibodies directed against novel protein epitopes. These findings indicate that aberrant protein deimination is a biomarker for blast TBI and may therefore underlie chronic neuropathologies of head injury.
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320
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Khan M, Khan H, Singh I, Singh AK. Hypoxia inducible factor-1 alpha stabilization for regenerative therapy in traumatic brain injury. Neural Regen Res 2017; 12:696-701. [PMID: 28616019 PMCID: PMC5461600 DOI: 10.4103/1673-5374.206632] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Mild traumatic brain injury (TBI), also called concussion, initiates sequelae leading to motor deficits, cognitive impairments and subtly compromised neurobehaviors. While the acute phase of TBI is associated with neuroinflammation and nitroxidative burst, the chronic phase shows a lack of stimulation of the neurorepair process and regeneration. The deficiency of nitric oxide (NO), the consequent disturbed NO metabolome, and imbalanced mechanisms of S-nitrosylation are implicated in blocking the mechanisms of neurorepair processes and functional recovery in the both phases. Hypoxia inducible factor-1 alpha (HIF-1α), a master regulator of hypoxia/ischemia, stimulates the process of neurorepair and thus aids in functional recovery after brain trauma. The activity of HIF-1α is regulated by NO via the mechanism of S-nitrosylation of HIF-1α. S-nitrosylation is dynamically regulated by NO metabolites such as S-nitrosoglutathione (GSNO) and peroxynitrite. GSNO stabilizes, and peroxynitrite destabilizes HIF-1α. Exogenously administered GSNO was found not only to stabilize HIF-1α and to induce HIF-1α-dependent genes but also to stimulate the regeneration process and to aid in functional recovery in TBI animals.
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Affiliation(s)
- Mushfiquddin Khan
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Hamza Khan
- College of Medicine, University of South Carolina, Columbia, SC, USA
| | - Inderjit Singh
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Avtar K Singh
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, USA.,Ralph H. Johnson VA Medical Center, Charleston, SC, USA
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