Metabolic changes associated with altering blood glucose levels in short duration forebrain ischemia

Hyperglycemia, acute ischemic stroke, and thrombolytic therapy

Ischemic stroke is a leading cause of disability and is considered now the fourth leading cause of death. Many clinical trials have shown that stroke patients with acute elevation in blood glucose at onset of stroke suffer worse functional outcomes, longer in-hospital stay, and higher mortality rates. The only therapeutic hope for these patients is the rapid restoration of blood flow to the ischemic tissue through intravenous administration of the only currently proven effective therapy, tissue plasminogen activator (tPA). However, even this option is associated with the increased risk of intracerebral hemorrhage. Nonetheless, the underlying mechanisms through which hyperglycemia (HG) and tPA worsen the neurovascular injury after stroke are not fully understood. Accordingly, this review summarizes the latest updates and recommendations about the management of HG and coadministration of tPA in a clinical setting while focusing more on the various experimental models studying (1) the effect of HG on stroke outcomes, (2) the potential mechanisms involved in worsening the neurovascular injury, (3) the different therapeutic strategies employed to ameliorate the injury, and finally, (4) the interaction between HG and tPA. Developing therapeutic strategies to reduce the hemorrhage risk with tPA in hyperglycemic setting is of great clinical importance. This can best be achieved by conducting robust preclinical studies evaluating the interaction between tPA and other therapeutics in order to develop potential therapeutic strategies with high translational impact.

Insulin, synaptic function, and opportunities for neuroprotection

A steadily growing number of studies have begun to establish that the brain and insulin, while traditionally viewed as separate, do indeed have a relationship. The uptake of pancreatic insulin, along with neuronal biosynthesis, provides neural tissue with the hormone. As well, insulin acts upon a neuronal receptor that, although a close reflection of its peripheral counterpart, is characterized by unique structural and functional properties. One distinction is that the neural variant plays only a limited part in neuronal glucose transport. However, a number of other roles for neural insulin are gradually emerging; most significant among these is the modulation of ligand-gated ion channel (LGIC) trafficking. Notably, insulin has been shown to affect the tone of synaptic transmission by regulating cell-surface expression of inhibitory and excitatory receptors. The manner in which insulin regulates receptor movement may provide a cellular mechanism for insulin-mediated neuroprotection in the absence of hypoglycemia and stimulate the exploration of new therapeutic opportunities.

How Important is Hyperglycemia During Acute Brain Infarction?

BACKGROUND

Although well supported by animal studies, it remains unproven whether lowering hyperglycemia during acute cerebral infarction will improve outcomes. Further support for this therapeutic approach comes from clinical studies in acute myocardial infarction and in ventilated postsurgical patients, where lowering hyperglycemia improved outcomes.

REVIEW SUMMARY

Animal studies support the hypothesis that hyperglycemia during acute brain ischemia augments the brain injury, but only in models with reperfusion. The available human studies to date are all observational and they usually find an association between hyperglycemia during acute cerebral infarction and worse outcome. Also, there is evidence that hyperglycemia during acute cerebral infarction is detrimental only with reperfusion. This association appears to be linear in the glucose ranges tested (normal to high). In addition, there is an association between admission hyperglycemia and hemorrhagic conversion of an acute cerebral infarct when thrombolytics are used.

CONCLUSION

Sufficient evidence has accumulated to proceed to clinical efficacy trials to see if tight glycemic control compared with persistent hyperglycemia during acute cerebral infarction will improve outcomes. If such therapy proves beneficial, the increased cost, effort, and risk associated with tight glycemic control during acute cerebral infarction could be justified. Randomized clinical trials to test this hypothesis are currently in progress.

Effects of 2-deoxy-d-glucose on focal cerebral ischemia in hyperglycemic rats

The authors examined the effects of pretreatment with 2-deoxy-d-glucose (2DG) on the middle cerebral artery occlusion-reperfusion (MCAO/R) model in hyperglycemic rats. Proton magnetic resonance imaging and spectroscopy were used to measure the lesion size, the level of cerebral perfusion deficit, and ratio of lactate to N-acetyl aspartate (NAA) in brain regions. By performing sequential diffusion weighted imaging, gradient echo bolus tracking, steady-state spin echo imaging, and water-suppressed proton magnetic resonance spectroscopy techniques, the time course of the early changes of the lactate/NAA peak ratio and perfusion deficit was examined in hyperglycemic rats undergoing 90-minute MCAO followed by 24-h reperfusion. Compared with the saline-treated hyperglycemic rats, 2DG treatment at 10 minutes before MCAO significantly reduced diffusion weighted imaging hyperintensity by approximately 60% and the lactate/NAA peak ratio by approximately 70% at 4 h after MCAO/R. Both spin echo-measured cerebral blood volume and dynamic gradient echo-relative cerebral blood flow showed that the restoration of blood supply recovered and remained at approximately 80% of baseline during reperfusion in 2DG-treated hyperglycemic rats. These data suggest that inhibition of glucose metabolism by 2DG has a beneficial effect in reducing brain injury and minimizing the production of brain lactate during MCAO/R in hyperglycemic rats.

Inhibition of Na(+)/H(+) exchange by 5-(N-ethyl-N-isopropyl)-amiloride reduces free fatty acid efflux from the ischemic reperfused rat cerebral cortex

Brain tissue acidosis is considered to be a contributor to ischemic brain injury. The deleterious effects of marked acidosis may be associated with reperfusion and an excessive entry of Na(+) into cerebral neurons and glia as intracellular pH is restored by Na(+)/H(+) exchange. Normalization of pH, with activation of many calcium-dependent and other phospholipases and proteases with pH optima in the neutral or alkaline range, could account for the pronounced elevation in extracellular levels of free fatty acids which occurs during reperfusion following cerebral ischemia. In the present investigation we evaluated the effects of inhibition of Na(+)/H(+) exchange with N-(N-ethyl-N-isopropyl)-amiloride (EIPA; 25 microM) applied topically onto the rat cerebral cortex prior to and during ischemia. Free fatty acid levels in cortical superfusates, withdrawn at 10-min intervals from bilateral cortical windows, were analyzed by high pressure liquid chromatography. EIPA application effectively inhibited the increases in arachidonic and linoleic acid release observed in the control rats during reperfusion, and non-significantly depressed that of palmitic and oleic acids. Superfusate levels of glucose, which decline to near zero levels during ischemia and then rebound during reperfusion, were not affected by EIPA administration. Lactate levels in cortical superfusates from EIPA-treated animals rose more rapidly during reperfusion than did those in the control rats and then significantly declined towards basal levels. The data indicate that inhibition of Na(+)/H(+) exchange prevented the activation of phospholipases that usually occurs during reperfusion following a cerebral ischemic episode. These results are the first demonstration of such an effect and may provide an explanation for the cerebroprotective effects that have been observed in stroked animals following administration of Na(+)/H(+) exchange inhibitors.

Effect of nitric oxide synthase inhibitor on a hyperglycemic rat model of reversible focal ischemia: detection of excitatory amino acids release and hydroxyl radical formation

The purpose of this study was to investigate the mechanisms by which a nitric oxide synthase (NOS) inhibitor, NG-nitro-L-arginine methyl ester (L-NAME), is neuroprotective in the hyperglycemic rat model of 2 h of transient middle cerebral artery occlusion followed by 2 h of reperfusion (MCAO/R). The salicylate trapping method was used in conjunction with a microdialysis technique to continuously estimate hydroxyl radical (.OH) formation by measurement of the stable adducts 2,3- and 2,5-dihydroxybenzoic acid (DHBA). Extracellular excitatory amino acids (EAAs) were detected from the same microdialysis samples. Magnetic resonance imaging (MRI) techniques were used to measure neuronal and cerebrovascular injury. The magnitude of EAA release correlated with the levels of the .OH adducts. Treatment with L-NAME (3 mg/kg, i.p.) 1 min before MCAO, and again 1 min before reperfusion, reduced the levels of DHBA by 46. 4% and glutamate by 50.5% in the hyperglycemic rats compared to untreated hyperglycemic controls. MRI indicated that L-NAME reduced the no-reflow zone and the cytotoxic lesion volume to 22.5% and 21. 0%, respectively, that of hyperglycemic controls. Co-treatment with the nitric oxide (NO) donor L-arginine completely eliminated the protective effects of l-NAME with respect to .OH and EAA levels as well as MRI lesion volume. Our data suggest that hyperglycemic MCAO/R results in excessive glutamate excitotoxicity, leading to enhanced generation of .OH via a NO-mediated mechanism, in turn resulting in severe ischemia/reperfusion brain injury.

Hydroxyl radical formation in hyperglycemic rats during middle cerebral artery occlusion/reperfusion

Preexisting hyperglycemia is associated with enhanced reperfusion injury in the postischemic rat brain. The goal of this study was to evaluate whether the hyperglycemic exacerbation of brain injury is associated with enhanced generation of hydroxyl radicals in rats subjected to middle cerebral artery occlusion (2 h), followed by reperfusion (2 h). Magnetic resonance images revealed the exacerbation of focal brain injury in hyperglycemic rats. The salicylate trapping method was used in conjunction with microdialysis to continuously estimate hydroxyl radical production by measurement of the stable adducts 2,3- and 2,5-dihydroxybenzoic acid (DHBA) during ischemia/reperfusion. In normoglycemic rats, from a mean baseline level of 130 nmol/l, 2,3-DHBA levels surged to peak levels of 194 nmol/l 45 min into ischemia and to 197 nmol/l 15-30 min into the reperfusion period, returning to baseline by 2 h into reperfusion. A similar temporal profile was observed in hyperglycemic rats, except that absolute 2,3-DHBA levels were higher (165 nmol/l at baseline, 317 nmol/l peak during ischemia, 333 nmol/l peak during reperfusion), and levels remained significantly high (p < .05) throughout the reperfusion period. These results suggest that hydroxyl radical is an important contributor to the exacerbation of neuronal and cerebrovascular injury after focal ischemia/reperfusion in hyperglycemic rats.

The effect of hyperglycemia on cerebral metabolism during hypoxia-ischemia in the immature rat

Unlike adults, hyperglycemia with circulating glucose concentrations of 25-35 mM/L protects the immature brain from hypoxic-ischemic damage. To ascertain the effect of hyperglycemia on cerebral oxidative metabolism during the course of hypoxia-ischemia, 7-day postnatal rats underwent unilateral common carotid artery ligation followed by exposure to 8% O2 for 2 h at 37 degrees C. Experimental animals received 0.2 cc s.c. 50% glucose at the onset of hypoxia-ischemia, and 0.15 cc 25% glucose 1 h later to maintain blood glucose concentrations at 20-25 mM/L for 2 h. Control rat pups received equivalent concentrations or volumes of either mannitol or 1 N saline at the same intervals. The cerebral metabolic rate for glucose (CMRglc) increased from 7.1 (control) to 20.2 mumol 100 g-1 min-1 in hyperglycemic rats during the first hour of hypoxia-ischemia, 79 and 35% greater than the rates for saline-and mannitol-injected animals at the same interval, respectively (p < 0.01). Brain intracellular glucose concentrations were 5.2 and 3.0 mM/kg in the hyperglycemic rat pups at 1 and 2 h of hypoxia-ischemia, respectively; glucose levels were near negligible in mannitol- and saline-treated animals at the same intervals. Brain intracellular lactate concentrations averaged 13.4 and 23.3 mM/kg in hyperglycemic animals at 1 and 2 h of hypoxia-ischemia, respectively, more than twice the concentrations estimated for the saline- and mannitol-treated littermates. Phosphocreatine (PCr) and ATP decreased in all three experimental groups, but were preserved to the greatest extent in hyperglycemic animals. Results indicate that anaerobic glycolytic flux is increased to a greater extent in hyperglycemic immature rats than in normoglycemic littermates subjected to cerebral hypoxia-ischemia, and that the enhanced glycolysis leads to greater intracellular lactate accumulation. Despite cerebral lactosis, energy reserves were better preserved in hyperglycemic animals than in saline-treated controls, thus accounting for the greater resistance of hyperglycemic animals to hypoxic-ischemic brain damage.

Cerebrovascular disorders in patients with diabetes mellitus

Diabetes mellitus is a risk factor for ischemic, but not hemorrhagic stroke. The frequency of transient ischemic attacks is not increased in patients with diabetes compared to the general population. Diabetes mellitus is associated with higher mortality, worse functional outcome, more severe disability after stroke and a higher frequency of recurrent stroke. Diabetes is not associated with an increased size of cerebral infarction. Controversy exists regarding whether hyperglycemia adversely affects stroke outcome or primarily reflects stroke severity. Cerebral blood flow disturbances, impaired cerebrovascular reactivity, and damage to large and small extra- and intracranial cerebral vessels have been found in humans and animals with diabetes. Combinations of some or all of these factors may underlie the high incidence and worse outcome of stroke in patients with diabetes. Knowledge of these pathophysiologic factors will assist in the design of future intervention strategies.

pH-associated Brain Injury in Cerebral Ischemia and Circulatory Arrest

Neuronal injury remains a major limitation in therapies directed toward cardiopulmonary resuscitation and cerebral ischemia. We summarize clinical and experimental information regarding pH-modulated mechanisms of cerebral ischemic injury and the status of antiacidosis therapies relative to the brain. A large body of evidence in animals and humans indicates that cerebral pH can modulate, and perhaps mediate, ischemic brain pathology and influence functional outcome. The importance of low pH and brain bicarbonate levels during reperfusion as a secondary injury remains an open question of therapeutic importance. Under specific conditions, acidosis may be neuroprotective, but this is an area of current controversy. Effective antiacidosis therapy must address the possibility of synergism and competition among multiple injury mechanisms.

Glucose availability alters ischaemia-induced changes in intracellular pH and calcium of isolated rat spinal roots

Peripheral nerves in diabetic patients show an enhanced liability to ischaemic lesions. Using an in vitro model, we have now analysed the possible role of intracellular proton (pHi) and calcium concentrations ([Ca2+]i) for the pathophysiology of this phenomenon. Isolated rat spinal roots were preincubated for 3 to 6 h in either 5 or 25 mM of D-glucose before transient exposure to gaseous hypoxia or cyanide. Intracellular pH and Ca2+ concentrations were measured photometrically by means of the fluorescent dyes carboxy-SNARF-1 and a combination of Calcium Green-1 and Fura Red, respectively. The following observations were made. (a) The presence of 25 mM D-glucose resulted in stronger intracellular acidification and much slower post-hypoxic recovery of pHi as compared to 5 mM D-glucose. (b) Intracellular calcium increased during hypoxia and recovered quickly on reoxygenation. There were no statistically significant differences between the Ca2+ signals in either high or normal concentrations of D-glucose, although on average less rise was seen in high glucose. (c) Inhibition of glycolysis with iodoacetate reduced the acidification but amplified the rise in [Ca2+]i seen during transient hypoxia. These data suggest that hypoxia-induced nerve acidification rather than a rise in [Ca2+]i might contribute to ischaemic lesions found in diabetic neuropathy.

23Na nuclear magnetic resonance spectral changes during and after forebrain ischemia in hypoglycemic, normoglycemic, and hyperglycemic rats

BACKGROUND AND PURPOSE

The severity of brain injury in animal models of forebrain ischemia increases with blood glucose level. During ischemia, energy failure is slower and maintenance of ion gradients is prolonged as the level of glycemia increases. It is not clear how the level of glycemia influences recovery of ion homeostasis on reperfusion. It has been shown that changes in the intensity of the multiple-quantum 23Na nuclear magnetic resonance (NMR) signals reflect changes in intracellular Na+ levels. We have used 23Na NMR spectroscopy to evaluate the influence of the level of glycemia on changes in Na+ concentration during and after forebrain ischemia in rats.

METHODS

Single-quantum (SQ) and double-quantum (DQ) 23Na NMR spectra were measured before and during 10-minute forebrain ischemia and during reperfusion in hypoglycemic, normoglycemic, and hyperglycemic rats.

RESULTS

The DQ 23Na NMR signal increased to 210% of preischemia intensity in all rats, but a delay in this increase was observed in normoglycemic and hyperglycemic animals. The rate of the DQ 23Na NMR signal increase was fastest in hypoglycemic (apparent first-order rate constant 0.673 +/- 0.046 min-1, P < .002 compared with normoglycemic animals) and slowest in hyperglycemic (0.285 +/- 0.024 min-1, P < .03) rats. During reperfusion, the signal intensity recovered rapidly in hypoglycemic (0.385 +/- 0.050 min-1) and normoglycemic (0.464 +/- 0.047 min-1) rats, whereas in hyperglycemic animals recovery was slow (0.108 +/- 0.044 min-1, P < .0001 compared with normoglycemic animals). The SQ 23Na NMR signal intensity increased to 117% of preischemia level in hypoglycemic (P < .05 compared with normoglycemic animals) and to 107% in normoglycemic and hyperglycemic animals during reperfusion.

CONCLUSIONS

The slower increase in the 23Na DQ NMR signal intensity during forebrain ischemia in rats with higher blood glucose levels suggests that Na+ homeostasis is maintained longer in these animals. On reperfusion, the slower recovery of the DQ 23Na NMR signal intensity in hyperglycemic animals likely indicates a slower recovery of Na+ homeostasis, perhaps contributing to the increased neuronal injury after cerebral ischemia in hyperglycemic animals.

Rapid recovery of rat brain intracellular pH after cardiac arrest and resuscitation

We studied the intracellular pH in rat cerebral cortex of rats subjected to reversible total cerebral ischemia by cardiac arrest and resuscitation. Brain acidoses was more pronounced during ischemia in hyperglycemic rats (6.21 +/- 0.14) than in normoglycemic rats (6.56 +/- 0.07). Brain tissue lactate accumulated proportionally. Nevertheless, within 5 min of reperfusion, pHi in both normoglycemic and hyperglycemic groups had recovered to baseline levels, i.e. near 7.1-7.2, despite the fact that lactate concentrations were still elevated. These results demonstrate a rapid reversal of ischemic acidosis during recovery from 10 min of cardiac arrest, and suggest that acidosis, per se, may not be responsible for neuronal damage following cardiac arrest and resuscitation, even in hyperglycemic conditions.

The effects of hyperglycaemic hypoxia on rectification in rat dorsal root axons

1. Electrotonic responses to 150 ms current pulses were recorded from isolated rat dorsal roots incubated for at least 3 h with either normal (5 mM) or high (25 mM) D-glucose solutions, and with either normal (25 mM) or low (5 mM) bicarbonate concentrations. 2. On replacement of O2 by N2 for 50 min, all the roots depolarized, but the changes in electrotonus differed systematically. With normal glucose, the depolarization was accompanied by an increase in input conductance. In contrast, for the hyperglycaemic roots the depolarization was slower and accompanied by a fall in input conductance which was exacerbated in low bicarbonate concentrations. 3. The changes induced by hyperglycaemic hypoxia in low bicarbonate could be mimicked by exposure of the roots either to 100% CO2 or to a combination of 3 mM tetraethylammonium chloride and 3 mM 4-aminopyridine, to block both fast and slow potassium channels. 4. These results indicate that the primary mechanism of hypoxic depolarization of these sensory axons is altered by hyperglycaemia. In normoglycaemia, the changes in electrotonus are consistent with an increase in axonal potassium conductance. The block of potassium channels seen in hyperglycaemic hypoxia is attributed to intra-axonal acidification by anaerobic glycolysis and may contribute to the pathogenesis of diabetic neuropathy.