Post-ischemic regional changes in acetylcholine synthesis following transient forebrain ischemia in gerbils

Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure

BACKGROUND

Delirium is the most common neuropsychiatric syndrome encountered by clinicians dealing with older adults and the medically ill and is best characterized by 5 core domains: cognitive deficits, attentional deficits, circadian rhythm dysregulation, emotional dysregulation, and alteration in psychomotor functioning.

DESIGN

An extensive literature review and consolidation of published data into a novel interpretation of known pathophysiological causes of delirium.

RESULTS

Available data suggest that numerous pathological factors may serve as precipitants for delirium, each having differential effects depending on patient-specific patient physiological characteristics (substrate). On the basis of an extensive literature search, a newly proposed theory, the systems integration failure hypothesis, was developed to bring together the most salient previously described theories, by describing the various contributions from each into a complex web of pathways-highlighting areas of intersection and commonalities and explaining how the variable contribution of these may lead to the development of various cognitive and behavioral dysfunctions characteristic of delirium. The specific cognitive and behavioral manifestations of the specific delirium picture result from a combination of neurotransmitter function and availability, variability in integration and processing of sensory information, motor responses to both external and internal cues, and the degree of breakdown in neuronal network connectivity, hence the term acute brain failure.

CONCLUSIONS

The systems integration failure hypothesis attempts to explain how the various proposed delirium pathophysiologic theories interact with each other, causing various clinically observed delirium phenotypes. A better understanding of the underlying pathophysiology of delirium may eventually assist in designing better prevention and management approaches.

Neuropathogenesis of delirium: review of current etiologic theories and common pathways

Delirium is a neurobehavioral syndrome caused by dysregulation of neuronal activity secondary to systemic disturbances. Over time, a number of theories have been proposed in an attempt to explain the processes leading to the development of delirium. Each proposed theory has focused on a specific mechanism or pathologic process (e.g., dopamine excess or acetylcholine deficiency theories), observational and experiential evidence (e.g., sleep deprivation, aging), or empirical data (e.g., specific pharmacologic agents' association with postoperative delirium, intraoperative hypoxia). This article represents a review of published literature and summarizes the top seven proposed theories and their interrelation. This review includes the "neuroinflammatory," "neuronal aging," "oxidative stress," "neurotransmitter deficiency," "neuroendocrine," "diurnal dysregulation," and "network disconnectivity" hypotheses. Most of these theories are complementary, rather than competing, with many areas of intersection and reciprocal influence. The literature suggests that many factors or mechanisms included in these theories lead to a final common outcome associated with an alteration in neurotransmitter synthesis, function, and/or availability that mediates the complex behavioral and cognitive changes observed in delirium. In general, the most commonly described neurotransmitter changes associated with delirium include deficiencies in acetylcholine and/or melatonin availability; excess in dopamine, norepinephrine, and/or glutamate release; and variable alterations (e.g., either a decreased or increased activity, depending on delirium presentation and cause) in serotonin, histamine, and/or γ-aminobutyric acid. In the end, it is unlikely that any one of these theories is fully capable of explaining the etiology or phenomenologic manifestations of delirium but rather that two or more of these, if not all, act together to lead to the biochemical derangement and, ultimately, to the complex cognitive and behavioral changes characteristic of delirium.

Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment

Delirium is the most common complication found in the general hospital setting. Yet, we know relatively little about its actual pathophysiology. This article contains a summary of what we know to date and how different proposed intrinsic and external factors may work together or by themselves to elicit the cascade of neurochemical events that leads to the development delirium. Given how devastating delirium can be, it is imperative that we better understand the causes and underlying pathophysiology. Elaborating a pathoetiology-based cohesive model to better grasp the basic mechanisms that mediate this syndrome will serve clinicians well in aspiring to find ways to correct these cascades, instituting rational treatment modalities, and developing effective preventive techniques.

Mechanisms of neurologic failure in critical illness

Critical illness frequently is associated with neurologic failure that may involve the central and peripheral nervous systems. Central nervous system failure is associated with a spectrum of neurobehavioral changes including delirium, coma, and long-term cognitive dysfunction. Peripheral neurologic failure, or critical illness neuromuscular abnormalities, is suggested by diffuse arreflexic weakness and protracted respiratory insufficiency, and may also persist long after the acute hospitalization. While the burden of neurological disease complicating critical illness is considerable, preventive or therapeutic options are limited. This article provides an overview of research evaluating the relationship between critical illness and neurologic function, with a special emphasis on underlying mechanisms.

Cerebral ischemia combined with β-amyloid impairs spatial memory in the eight-arm radial maze task in rats

beta-Amyloid (Abeta), a major component of senile plaques in Alzheimer's disease, has been implicated in neuronal cell death, a characteristic feature of this condition. In our previous experiments using primary cultures of hippocampal neurons, Abeta treatment induced neuronal cell death, displaying morphological characteristics of apoptosis that was significantly enhanced by hypoxia. Based on these results, we developed a simple in vivo rat model of Alzheimer's disease using cerebral ischemia, instead of hypoxia, combined with continuous intracerebroventricular administration of Abeta. The combination of cerebral ischemia and Abeta administration, but not either treatment alone, significantly impaired spatial memory in an eight-arm radial maze. A microdialysis study showed that spontaneous release of acetylcholine (ACh) from the dorsal hippocampus had a tendency to decrease in response to Abeta treatment alone or the combination of ischemia and Abeta. High K(+)-evoked increase in ACh release had a tendency to be inhibited by either ischemia or Abeta treatment alone and was significantly inhibited by the combination of both. Moreover, combination of ischemia and Abeta induced apoptosis of pyramidal neurons in the CA1 region of the hippocampus. Donepezil, a drug currently in clinical use for Alzheimer's disease, improved the impairment of spatial memory induced by cerebral ischemia combined with Abeta. These findings suggest that ischemia is an important factor facilitating the symptoms of Alzheimer's disease, and this model may be useful for developing new drugs for the treatment of Alzheimer's disease.

The role of taurine in cerebral ischemia: studies in transient forebrain ischemia and embolic focal ischemia in rodents

Sudden cessation of blood flow to the brain results in a series of events that either result in rapid loss of brain cells or delayed neuronal injury in certain vulnerable regions of the brain. Research over the last three decades has allowed for a better understanding of how neurons and other brain cells die from the effects of ischemia and hypoxia in the central nervous system. Excitatory and inhibitory neurotransmitters exist in a very precise balance for normal function of the brain. Ischemia very rapidly disrupts this balance resulting in a rapid build-up of excitatory neurotransmitters, especially glutamate in the extracellular space. The increased glutamate together with energy loss opens a number of different types of calcium and sodium channels resulting in the build-up of these ions in neurons, leading to cellular dysfunction and death. While most ischemia research has focused on antagonism of excitatory amino acids, there are some reports on enhancement and amplification of inhibitory responses in focal and global ischemia. The majority of work relates to potentiation of GABA, either endogenous or through GABA potentiating medications. Taurine has neuroinhibitory properties and may also have potential for neuroprotection in cerebral ischemia. This present review focuses on the role of taurine as a neuroprotective agent, possibly acting through several different inhibitory mechanisms. Taurine may inhibit neurotransmitter release and may result in normal intracellular osmolality. In transient global ischemia in gerbils, we studied in vivo microdialysis of amino acids before, during and after ischemia. We were able to show that taurine resulted in attenuation of glutamate during ischemia (however did not reach significance). In similar experiments, neuronal damage was assessed in the hippocampus. Our results show 48% damage in taurine treated animals, 60% in alanine treated animals and 69% in control groups (trend towards protection but again did not reach significance) Focal ischemia was induced by embolizing a thrombus into the distal internal carotid artery and origin of the middle cerebral artery. Again, in studies where we compared taurine to a placebo treated animal, there was no significant decrease in the amount of damage with taurine. There are reports in the literature that taurine may attenuate neuronal injury during ischemia. Our studies in two models of cerebral ischemia in rodents did not reveal neuronal protection. It is possible that higher doses or possibly prolonged use of taurine may show better results. Taurine may also potentially offer additive protective effects when used in combination with thrombolysis or other neuroprotective agents. Further studies are necessary to better understand the potential for taurine as a neuroprotective agent in cerebral ischemia.

A unifying hypothesis of Alzheimer's disease. IV. Causation and sequence of events

Contrary to common concepts, the brain in Alzheimer's disease (AD) does not follow a suicide but a rescue program. Widely shared features of metabolism in starvation, hibernation and various conditions of energy deprivation, e.g. ischemia, allow the definition of a deprivation syndrome which is a phylogenetically conserved adaptive response to energetic stress. It is characterized by hypometabolism, oxidative stress and adjustments of the glucose-fatty acid cycle. Cumulative evidence suggests that the brain in aging and AD actively adapts to the progressive fuel deprivation. The counterregulatory mechanisms aim to preserve glucose for anabolic needs and promote the oxidative utilization of ketone bodies. The agent mediating the metabolic switch is soluble Abeta which inhibits glucose utilization and stimulates ketone body utilization at various levels. These processes, which are initiated during normal aging, include inhibition of pro-glycolytic neurohormones, cholinergic transmission, and pyruvate dehydrogenase, the key transmitter and effector systems regulating glucose metabolism. Hormonal and effector systems which promote ketone body utilization, such as glucocorticosteroid and galanin activity, GABAergic transmission, nitric oxide, lipid transport, Ca2+ elevation, and ketone body metabolizing enzymes, are enhanced. A multitude of risk factors feed into this pathophysiological cascade at a variety of levels. Taking into account its pleiotropic regulatory actions in the deprivation response, a new name for Abeta is suggested: deprivin. On the other hand, cumulative evidence, taken together compelling, suggests that senile plaques are the dump rather than the driving force of AD. Moreover, the neurotoxic action of fibrillar Abeta is a likely in vitro artifact but does not contribute significantly to the in vivo pathophysiological events. This archaic program, conserved from bacteria to man, aims to ensure the survival of a deprived organism and controls such divergent processes as sporulation, hibernation, aging and aging-related diseases. In contrast to the immature brain, ketone body utilization of the aged brain is no longer sufficient to meet the energetic demands and is later supplemented by lactate, thus recapitulating in reverse order the sequential fuel utilization of the immature brain. The transduction pathways which operate to switch metabolism also convey the programming and balancing of the de-/redifferentiation/apoptosis cell cycle decisions. This encompasses the reiteration of developmental processes such as transcription factor activation, tau hyperphosphorylation, and establishment of growth factor independence by means of Ca2+ set point shift. Thus, the increasing energetic insufficiency results in the progressive centralization of metabolic activity to the neuronal soma, leading to pruning of the axonal/dendritic trees, loss of neuronal polarity, downregulation of neuronal plasticity and, eventually, depending on the Ca2+ -energy-redox homeostasis, degeneration of vulnerable neurons. Finally, it is outlined that genetic (e.g. Down's syndrome, APP and presenilin mutations and apoE4) and environmental risk factors represent progeroid factors which accelerate the aging process and precipitate the manifestation of AD as a progeroid systemic disease. Aging and AD are related to each other by threshold phenomena, corresponding to stage 2, the stage of resistance, and stage 3, exhaustion, of a metabolic stress response.

Cerebral ischemia in young and adult gerbils: effects on cholinergic metabolism

The effect of transient cerebral ischemia on cholinergic metabolism was investigated in adult and young gerbils subjected to bilateral carotid artery occlusion (15 min) alone or with release. Ischemia decreased brain acetylcholine (ACh) and increased choline (Ch) levels, affecting the young to a lesser degree than the adult gerbils. Blood recirculation induced a rapid early restoration of brain ACh levels in young animals, whereas a tremendous rebound of ACh was observed in the adults. After 2 h of reflow, Ch levels normalized in the adult brain, whereas a decreased choline level was seen in the young brain. This is the first study demonstrating an age-dependent susceptibility of cholinergic neurotransmission to cerebral ischemia.

Muscarinic receptors in rat cortex, hippocampus, hypothalamus and brainstem following transient forebrain ischemia and hemorrhagic shock

[3H]Quinuclidinyl benzilate binding properties of cerebral cortex, hippocampus, hypothalamus and brainstem of rats subjected to transient forebrain ischemia or severe hemorrhagic shock were investigated. Maximal binding capacities (Bmax) were not significantly different from control animals in either model. On the other hand, significant increases in binding affinities at all four brain regions in the ischemia-reperfusion group and at hypothalamic and brainstem membranes in the hemorrhagic shock group were observed. Kd values obtained in cortex and hippocampus of animals in shock were similar to control values. It was concluded that in brain ischemia models, the number of brain muscarinic receptors do not change at early stages, but binding affinities increase most likely due to systemic hypotension rather than reperfusion. The well-developed circle of Willis seems to protect cortical and hippocampal muscarinic receptors from hypoxia-induced changes.

Time course of decline of radiolabeled acetylcholine formed following intracerebroventricular administration of tritiated choline: effects of oxotremorine and scopolamine

Rats were injected intracerebroventricularly with 5 microCi of [methyl-3H]choline. The time course of decline of the radiolabeled acetylcholine (ACh) formed was estimated in the ipsilateral cerebral cortex and striatum. The [3H]ACh levels declined biphasically from the cerebral tissue. The initial decline proceeded rapidly, after which labeled ACh declined more slowly. Scopolamine (1 mg/kg, i.v.) caused a significant increase in the rate of [3H]ACh disappearance, which can be interpreted as an enhancement of ACh release. By contrast, oxotremorine (0.8 mg/kg, i.v.) markedly reduced the [3H]ACh disappearance. The results show that drug-induced changes in cholinergic neuronal activities can be estimated from the disappearance of radioactive ACh after labeling the endogenous transmitter through intracerebroventricular administration of labeled choline.