Modification of the N-methyl-D-aspartate (NMDA) receptor in the brain of newborn piglets following hyperventilation induced ischemia

Spontaneous Hyperventilation Is Common in Patients with Spontaneous Cerebellar Hemorrhage, and Its Severity Is Associated with Outcome

Background: The spontaneous hyperventilation (SHV) accompanying spontaneous cerebellar hemorrhage has yet to attract a sufficient amount of attention. This study aimed to analyze the incidence of SHV in spontaneous cerebellar hemorrhage patients and its risk factors as well as its association with the outcome. Methods: We retrospectively reviewed the medical records of all spontaneous cerebellar hemorrhage patients who underwent surgical treatment at Tongji Hospital from July 2018 to December 2020. Arterial blood gas (ABG) test results and clinical characteristics, including demographics, comorbidities, imaging features, laboratory tests, and therapy choices, were collected. The Glasgow Outcome Scale was used to assess the outcome at two weeks and six months after admission. Results: A total of 147 patients were included, and of these patients 44.9% had spontaneous hyperventilation. Hypertension (OR, 3.175; CI, 1.332–7.569), usage of sedation drugs (OR, 3.693; CI, 1.0563–8.724), and hypernatremia (OR, 2.803; CI, 1.070–7.340) seemed to positively correlate to SHV occurrence. Hematoma removal had an inverse association with SHV (OR, 0.176; CI, 0.068–0.460). Patients with poor and good outcomes had significant differences in pH, PaCO₂, and HCO₃⁻ values, and the severity of SHV was associated with the PaCO₂ level. Conclusions: Spontaneous hyperventilation is common in patients with spontaneous cerebellar hemorrhage, and its severity is associated with the outcome.

Hyperventilation in Adult TBI Patients: How to Approach It?

Hyperventilation is a commonly used therapy to treat intracranial hypertension (ICTH) in traumatic brain injury patients (TBI). Hyperventilation promotes hypocapnia, which causes vasoconstriction in the cerebral arterioles and thus reduces cerebral blood flow and, to a lesser extent, cerebral blood volume effectively, decreasing temporarily intracranial pressure. However, hyperventilation can have serious systemic and cerebral deleterious effects, such as ventilator-induced lung injury or cerebral ischemia. The routine use of this therapy is therefore not recommended. Conversely, in specific conditions, such as refractory ICHT and imminent brain herniation, it can be an effective life-saving rescue therapy. The aim of this review is to describe the impact of hyperventilation on extra-cerebral organs and cerebral hemodynamics or metabolism, as well as to discuss the side effects and how to implement it to manage TBI patients.

Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension

During traumatic brain injury, intracranial hypertension (ICH) can become a life-threatening condition if it is not managed quickly and adequately. Physicians use therapeutic hyperventilation to reduce elevated intracranial pressure (ICP) by manipulating autoregulatory functions connected to cerebrovascular CO₂ reactivity. Inducing hypocapnia via hyperventilation reduces the partial pressure of arterial carbon dioxide (PaCO₂), which incites vasoconstriction in the cerebral resistance arterioles. This constriction decrease cerebral blood flow, which reduces cerebral blood volume and, ultimately, decreases the patient’s ICP. The effects of therapeutic hyperventilation (HV) are transient, but the risks accompanying these changes in cerebral and systemic physiology must be carefully considered before the treatment can be deemed advisable. The most prominent criticism of this approach is the cited possibility of developing cerebral ischemia and tissue hypoxia. While it is true that certain measures, such as cerebral oxygenation monitoring, are needed to mitigate these dangerous conditions, using available evidence of potential poor outcomes associated with HV as justification to dismiss the implementation of therapeutic HV is debatable and remains a controversial subject among physicians. This review highlights various issues surrounding the use of HV as a means of controlling posttraumatic ICH, including indications for treatment, potential risks, and benefits, and a discussion of what techniques can be implemented to avoid adverse complications.

Pro/con debate: should PaCO2 be tightly controlled in all patients with acute brain injuries?

You are the attending intensivist in a neurointensive care unit caring for a woman five days post-rupture of a cerebral aneurysm (World Federation of Neurological Surgeons Grade 4 and Fisher Grade 3). She is intubated for airway protection and mild hypoxemia related to an aspiration event at the time of aneurysm rupture, but is breathing spontaneously on the ventilator. Your patient is spontaneously hyperventilating with high tidal volumes despite minimal support and has developed significant hypocapnia. She has not yet developed the acute respiratory distress syndrome. You debate whether to tightly control her partial pressure of arterial carbon dioxide, weighing the known risks of acute hypocapnia in other forms of brain injury against the potential loss of clinical neuromonitoring associated with deep sedation and neuromuscular blockade in this patient who is at high risk of delayed ischemia from vasospasm. You are also aware of the potential implications of tidal volume control if this patient were to develop the acute respiratory distress syndrome and the effect of permissive hypercapnia on her intracranial pressure. In this paper we provide a detailed and balanced examination of the issues pertaining to this clinical scenario, including suggestions for clinical management of ventilation, sedation and neuromonitoring. Until more definitive clinical trial evidence is available to guide practice, clinicians are forced to carefully weigh the potential benefits of tight carbon dioxide control against the potential risks in each individual patient based on the clinical issues at hand.

Cellular mechanisms of hypoxic injury in the developing brain

The susceptibility of the developing brain to hypoxia should depend on the lipid composition of the brain cell membrane; the rate of lipid peroxidation; the presence of antioxidant defenses; and the development and modulation of the excitatory neurotransmitter receptors such as the N-methyl-D-aspartate (NMDA) receptor, the intracellular Ca++ and intranuclear Ca++-dependent mechanisms. In addition to the developmental status of these cellular components, the response of these potential mechanisms to hypoxia determines the fate of the hypoxic brain cell in the developing brain. In the fetal guinea pig and newborn piglet models, studies have demonstrated that brain tissue hypoxia results in brain cell membrane damage as evidenced by increased membrane lipid peroxidation and decreased Na+,K+-ATPase activity. Using electron spin resonance spectroscopy of alpha-phenyl-N-tert-butyl-nitrone spin-adducts, studies from our laboratory have demonstrated that tissue hypoxia results in increased free radical generation in the cortex of fetal guinea pigs and newborn piglets. We have also shown that brain tissue hypoxia modifies the N-methyl-D-aspartate receptor-ion channel, recognition and modulatory sites. Furthermore, a higher increase in NMDA receptor agonist-dependent Ca++ in synaptosomes of hypoxic as compared to normoxic fetuses was demonstrated. The increase in intracellular Ca++ may activate several enzymatic pathways such as phospholipase A2 and metabolism of arachidonic acid by cyclooxygenase and lipoxygenase, conversion of xanthine dehydrogenase to xanthine oxidase by proteases and activation of nitric oxide synthase. Using specific inhibitors of each of these enzymes such as cyclooxygenase (indomethacin), lipoxygenase (nordihydroguaiaretic acid), xanthine oxidase (allopurinol) and nitric oxide synthase (N-nitro-L-arginine), studies have shown that these enzyme reactions result in oxygen free radical generation, membrane lipid peroxidation and cell membrane dysfunction in the hypoxic brain. We suggest that, during hypoxia, the increased intracellular Ca++ may lead to an increased intranuclear Ca++ concentration and alter nuclear events including transcription of specific genes responsible for programmed cell death. In view of the developmental studies presented, the susceptibility of the fetal brain to hypoxia appears to increase with brain development as gestation approaches term.

Mechanisms of cerebral injury in perinatal asphyxia and strategies for prevention

We have investigated the mechanisms of hypoxic brain cell injury in the immature animal by examining (1) the role of excitatory amino acid neurotransmitter receptors, (2) the receptor-mediated increase in intracellular Ca2+, and (3) the generation of oxygen free radicals. We examined the effect of brain tissue hypoxia on the NMDA receptor-ion channel complex including the glutamate, Mg2+, spermine, CPP, and the non-NMDA receptor kainate sites. Brain tissue hypoxia resulted in modification of the NMDA receptor ion channel and its modulatory sites. Hypoxia increased the affinity of both the ion channel and the glutamate recognition site. Pretreatment of animals with the glutamate antagonist CPP prevented hypoxia-induced modification of the channel. Similarly, pretreatment of animals with Mg2+, a blocker of the NMDA receptor ion channel, prevented the hypoxia-induced modification of the receptor. In addition, an increased agonist-dependent entry of Ca2+ into synaptosomes was observed in hypoxic animals compared with normoxic animals. Increased free radical generation in the cerebral cortex during hypoxia was demonstrated using spin labeling technique and electron spin resonance spectroscopy. We conclude that hypoxia-induced modification of the NMDA receptor-ion channel complex leads to increased intracellular Ca2+ potentiating free radical generation and resulting in hypoxic cell injury.