CGS-19755 is neuroprotective during repetitive ischemia: this effect is significantly enhanced when combined with hypothermia

Therapeutic Hypothermia and Neuroprotection in Acute Neurological Disease

Therapeutic hypothermia has consistently been shown to be a robust neuroprotectant in many labs studying different models of neurological disease. Although this therapy has shown great promise, there are still challenges at the clinical level that limit the ability to apply this routinely to each pathological condition. In order to overcome issues involved in hypothermia therapy, understanding of this attractive therapy is needed. We review methodological concerns surrounding therapeutic hypothermia, introduce the current status of therapeutic cooling in various acute brain insults, and review the literature surrounding the many underlying molecular mechanisms of hypothermic neuroprotection. Because recent work has shown that body temperature can be safely lowered using pharmacological approaches, this method may be an especially attractive option for many clinical applications. Since hypothermia can affect multiple aspects of brain pathophysiology, therapeutic hypothermia could also be considered a neuroprotection model in basic research, which would be used to identify potential therapeutic targets. We discuss how research in this area carries the potential to improve outcome from various acute neurological disorders.

Effects of Therapeutic Hypothermia Combined with Other Neuroprotective Strategies on Ischemic Stroke: Review of Evidence

Ischemic stroke is a major cause of death and disability globally, and its incidence is increasing. The only treatment approved by the US Food and Drug Administration for acute ischemic stroke is thrombolytic treatment with recombinant tissue plasminogen activator. As an alternative, therapeutic hypothermia has shown excellent potential in preclinical and small clinical studies, but it has largely failed in large clinical studies. This has led clinicians to explore the combination of therapeutic hypothermia with other neuroprotective strategies. This review examines preclinical and clinical progress towards developing highly effective combination therapy involving hypothermia for stroke patients.

Oxygen or cooling, to make a decision after acute ischemia stroke

The presence of a salvageable penumbra, a region of ischemic brain tissue with sufficient energy for short-term survival, has been widely agreed as the premise for thrombolytic therapy with tissue plasminogen activator (tPA), which remains the only United States Food and Drug Administration (FDA) approved treatment for acute ischemia stroke. However, the use of tPA has been profoundly constrained due to its narrow therapeutic time window and the increased risk of potentially deadly hemorrhagic transformation (HT). Blood brain barrier (BBB) damage within the thrombolytic time window is an indicator for tPA-induced HT and both normobaric hyperoxia (NBO) and hypothermia have been shown to protect the BBB from ischemia/reperfusion injury. Therefore, providing the O₂ as soon as possible (NBO treatment), freezing the brain (hypothermia treatment) to slow down ischemia-induced BBB damage or their combined use may extend the time window for the treatment of tPA. In this review, we summarize the protective effects of NBO, hypothermia or their use combined with tPA on ischemia stroke, based on which, the combination of NBO and hypothermia may be an ideal early stroke treatment to preserve the ischemic penumbra. Given this, there is an urge for large randomized controlled trials to address the effect.

Therapeutic applications of hypothermia in cerebral ischaemia

There is considerable experimental evidence that hypothermia is neuroprotective and can reduce the severity of brain damage after global or focal cerebral ischaemia. However, despite successful clinical trials for cardiac arrest and perinatal hypoxia-ischaemia and a number of trials demonstrating the safety of moderate and mild hypothermia in stroke, there are still no established guidelines for its use clinically. Based upon a review of the experimental studies we discuss the clinical implications for the use of hypothermia as an adjunctive therapy in global cerebral ischaemia and stroke and make some suggestions for its use in these situations.

Plasminogen activator inhibitor type 1 derived peptide, EEIIMD, diminishes cortical infarct but fails to improve neurological function in aged rats following middle cerebral artery occlusion

Age is a primary risk factor in stroke that is often overlooked in animal studies. We contend that using aged animals yields insight into aspects of stroke injury and recovery that are masked, or not elicited, in younger animals. In this study, we examined effects of co-administration of a plasminogen activator inhibitor type 1 derived peptide, Glu-Glu-Iso-Iso-Met-Asp (EEIIMD), with tissue plasminogen activator (tPA) on infarct volume and functional outcome in aged rats following a transient middle cerebral artery occlusion. Results of our study showed aged (18-20 months) rats treated with EEIIMD along with tPA had reduced cortical infarction volume. However, aged rats showed no improvement in total infarction volume, edema formation, or functional outcome as compared to aged rats administered only tPA. Young adult rats (3-4 months) treated with EEIIMD showed significant improvement in cortical and total infarction volumes, edema formation, and functional outcome. Striatal infarction volume was unaffected by EEIIMD treatment in both young adult and aged rats. These findings emphasize that physiological differences exist between young adult and aged rats and suggest that taking aging processes into account when assessing stroke may improve our ability to discern which therapeutics can be translated from bench to bedside.

Antiischemic effects of topiramate in a transient global forebrain ischemia model: a neurochemical, histological, and behavioral evaluation

The mechanisms of action of the anticonvulsant topiramate (TPM) are indicative of a potential benefit during cerebral ischemia. TPM was studied in a transient global forebrain ischemia (TGFI) model in gerbils in which 40 mg/kg was administered before or after TGFI. Control groups were administered 0.9% normal saline similarly. The evaluation consisted of neurochemical, histological, and functional analyses. The data obtained indicates that unlike the focal cerebral ischemia model, TPM is not neuroprotective in TGFI. The difference in effect, which may be due to the difference in species or the type of ischemia, points to the need for caution when extrapolating animal data from this drug to humans.

Effects of minocycline alone and in combination with mild hypothermia in embolic stroke

Inflammatory reactions occurring in the brain after ischemia may contribute to secondary damage. In the present study effects of minocycline, an anti-inflammatory agent, alone or in combination with mild hypothermia, on focal embolic brain ischemia have been examined. Focal ischemic injury was induced by embolizing a preformed clot into the middle cerebral artery (MCA). Infarct volume was measured at 48 h after the injury. Administration of minocycline alone or minocycline plus mild hypothermia reduced infarct volume significantly. However, mild hypothermia in combination with minocycline did not show any additive effect. These results suggest that minocycline is beneficial in focal ischemic brain injury, and the lack of the enhanced neuroprotection may be due to the brief exposure to hypothermia.

Delayed minocycline but not delayed mild hypothermia protects against embolic stroke

BACKGROUND

Inflammatory reactions occurring in the brain after ischemia may contribute to secondary damage. In the present study, effects of minocycline, an anti-inflammatory agent, alone or in combination with mild hypothermia on focal embolic cerebral ischemia have been examined.

METHODS

Focal ischemic injury was induced by embolizing a preformed clot into the middle cerebral artery (MCA). Infarction volume was measured at 48 h after the injury. Mortality was also recorded.

RESULTS

Delayed administration of minocycline alone or delayed minocycline plus delayed mild hypothermia reduced the infarction volume significantly. However, delayed mild hypothermia alone was not protective and delayed mild hypothermia in combination with minocycline did not show any additive effect.

CONCLUSIONS

These results suggest that minocycline is beneficial in focal ischemic brain injury, and the lack of the enhanced neuroprotection may be due to the brief exposure to hypothermia.

Usefulness of postischemic thrombolysis with or without neuroprotection in a focal embolic model of cerebral ischemia

OBJECT

Recent studies have shown that the use of thrombolysis in the setting of acute stroke is associated with an increased risk of cerebral hemorrhage. The time of onset of symptoms to initiation of medication and the dose levels of the thrombolytic agents are important determinants for the risk of cerebral hemorrhage. The authors evaluated the time course of thrombolysis-related hemorrhages in experimental settings and tested whether the addition of neuroprotective medication augments the efficacy of thrombolysis and reduces the incidence of hemorrhages.

METHODS

Male Wistar rats were subjected to right middle cerebral artery embolization with an autologous thrombus and were then randomly assigned to one of the following groups: Group 1, saline-treated (2 hours after ischemic insult) animals as controls; Groups 2 to 4, high-dose urokinase (5,000 U/kg) at 2, 3, and 6 hours after the insult; Group 5, low-dose urokinase (2,500 U/kg) at 2 hours after the insult; Group 6, 20 mg/kg topiramate (TPM) at 2 hours after the insult; Group 7, a combination of 20 mg/kg TPM at 2 hours and low-dose urokinase (2,500 U/kg) at 6 hours after the insult; and Group 8, 20 mg/kg TPM (20 mg/kg) at 2 hours and high-dose urokinase (5,000 U/kg) at 2 hours after the insult. Neurological behavior and the infarct volume in the brain were assessed following cerebral embolism and the various treatments. All animals in the single therapy and low-dose combination groups survived surgery. Three of eight animals treated with high-dose urokinase alone at 6 hours and three of six animals in the combined high-dose urokinase and TPM group developed fatal intracerebral hemorrhages. There was a significantly better neurological outcome at 24 hours in the animals treated with either medication compared with controls. The volume of the infarct in the saline-treated group was 54.2 +/- 9%. The use of TPM at 2 hours led to a decrease in the infarct to 20.1 +/- 11.2% (p < 0.01). Treatment with urokinase at 6 hours after the occlusion showed a trend toward protection; the infarct volume was 31.9 +/- 14.1% (p < 0.05). The addition of TPM to low- or high-dose urokinase achieved better neuroprotection (8.2 +/- 6% and 11.9 +/- 10.7%, respectively; both p < 0.01).

CONCLUSIONS

In this study the authors show that the volume of the infarct can be significantly decreased with 2 to 6-hour delayed intraarterial thrombolysis with urokinase and that the efficacy of thrombolysis may be enhanced by combining neuroprotective agents like TPM. It is also shown that low-dose combination therapy may decrease the likelihood of cerebral hemorrhage.

Glial glutamate transporter GLT-1 down-regulation precedes delayed neuronal death in gerbil hippocampus following transient global cerebral ischemia

Glial (GLT-1 and GLAST) and neuronal (EAAC1) high-affinity transporters mediate the sodium dependent glutamate reuptake in mammalian brain. Their dysfunction leads to neuronal damage by allowing glutamate to remain in the synaptic cleft for a longer duration. The purpose of the present study is to understand their contribution to the ischemic delayed neuronal death seen in gerbil hippocampus following transient global cerebral ischemia. The protein levels of these three transporters were studied by immunoblotting as a function of reperfusion time (6 h to 7 days) following a 10 min occlusion of bilateral common carotid arteries in gerbils. In the vulnerable hippocampus, there was a significant decrease in the protein levels of GLT-1 (by 36-46%, P < 0.05; between 1 and 3 days of reperfusion) and EAAC1 (by 42-68%, P < 0.05; between 1 and 7 days of reperfusion). Histopathological evaluation showed no neuronal loss up to 2 days of reperfusion but an extensive neuronal loss (by approximately 84%, P < 0.01) at 7 days of reperfusion in the hippocampal CA1 region. The time frame of GLT-1 dysfunction (1-3 days of reperfusion) precedes the initiation of delayed neuronal death (2-3 days of reperfusion). This suggests GLT-1 dysfunction as a contributing factor for the hippocampal neuronal death following transient global cerebral ischemia. Furthermore, decreased EAAC1 levels may contribute to GABAergic dysfunction and excitatory/inhibitory imbalance following transient global ischemia.

AR-R15896AR reduces cerebral infarction volumes after focal ischemia in cats

OBJECTIVE

The use of competitive and noncompetitive N-methyl-D-aspartate receptor antagonists to prevent neuronal death during ischemia has been comprehensively studied. This study was performed to examine the neuroprotective effects and pharmacokinetics of the noncompetitive N-methyl-D-aspartate receptor channel blocker (S)-alpha-phenylpyridine-ethanamine dihydrochloride, AR-R15896AR (formerly designated ARL 15896AR), using a gyrencephalic cat middle cerebral artery occlusion model.

METHODS

In a separate experiment, three cats were used for pharmacokinetic analysis, thus establishing the optimal dose of AR-R15896AR. Focal cerebral ischemia was induced in 21 cats. After 30 minutes of a 90-min ischemic insult, the cats received an intravenous infusion (total volume, 3 ml), in a 15-minute period, of either AR-R15896AR or normal saline solution (control). Physiological data were obtained after 40 and 80 minutes of ischemia and at 2, 4, and 6 hours after ischemia. At 6 hours after ischemia, each cat was positioned for both T2- and diffusion-weighted scans (eight slices, 5-mm thick). At 8 hours after ischemia, the animals were perfusion-fixed for histopathological analysis.

RESULTS

Pharmacokinetic studies indicated that AR-R15896AR remained in the blood at elevated levels for the 6 hours studied, with a calculated half-life of approximately 6 hours. AR-R15896AR rapidly entered the brain and exhibited a brain/plasma ratio of approximately 8:1. The infarction volumes for the AR-R15896AR-treated group were 1138.5+/-363.1, 651.3+/-428.9, and 118.6+/-50.1 mm3, as calculated using diffusion- and T2-weighted MRI and histopathological data, respectively. The infarction volumes for the control group were 3866.3+/-921, 3536+/-995.7, and 359.9+/-80.2 mm3, as calculated using diffusion- and T2-weighted MRI and histopathological data, respectively. No significant changes were observed in the physiological parameters measured (mean arterial blood pressure, pH, arterial carbon dioxide pressure, arterial oxygen pressure, sodium, potassium, chloride, and glucose levels, hematocrit, and temperature) for either the control or AR-R15896AR-treated group. Postischemic calcium levels returned to normal in the AR-R15896AR-treated cats, whereas they decreased in the control cats.

CONCLUSION

When administered after ischemia, AR-R15896AR was effective in significantly reducing infarction volumes, as measured using diffusion- or T2-weighted magnetic resonance imaging data or quantitative histopathological data. This study also demonstrated that infarction volumes were greater in the diffusion- and T2-weighted magnetic resonance imaging scans than in the qualitative histopathological analyses, with the diffusion-weighted scans exibiting the largest infarction volumes.

The role of taurine in neuronal protection following transient global forebrain ischemia

Osmoregulation and post ischemic glutamate surge suppression (PIGSS) are important mechanisms in the neuroprotective properties of taurine. We studied the role of taurine in PIGSS following transient global forebrain ischemia (TGFI). A group of gerbils received a high dose of continuous intracerebral taurine during the peri-ischemic period. Beta-alanine was given similarly to a negative control group. The control group consisted of animals undergoing only TGFI. On the fourth day following commencement of drug administration, TGFI was induced. Concurrently, half the animals from each group receiving an agent had intracerebral microdialysis. All animals underwent histological assessment at day 7. The microdialysis and histological data was analyzed. Our results showed that taurine treatment did not cause PIGSS. The histological difference between the three groups was statistically insignificant. We conclude that intracerebral taurine in the dosage administered during peri-ischemic period, does not result in PIGSS or histologically evident neuroprotection.

Combination treatment for acute ischemic stroke: A ray of Hope?

BACKGROUND

With the implementation of thrombolysis, a large number of distinct pharmacological agents are now under consideration for the treatment of acute ischemic stroke, with disappoiting early results. Because the processes that ultimately lead to ischemic cell death involve a variety of pathophysiologic pathways, it is likely that combinations of agents may be necessary to positively affect neurological outcome. We review the general strategies under consideration for reduction of ischemic injury in the central nervous system, the types of possible interactions between compounds, and the experimental evidence showing effective combination therapies.

SUMMARY OF REVIEW

Reduction of ischemic injury has been attempted by the following pharmacologic mechanisms: thrombolysis, neuroprotection, and perfusion/reperfusion enhancers. There is experimental evidence that the combination of thrombolytic therapy with a neuroprotective agent is additive in some ischemic models, as is the combination of a thrombolytic with an agent that facilitates reperfusion (thromboxane A(2) receptor antagonist and neutrophil adhesion/activation inhibition). Combinations of neuroprotective agents such as glutamate antagonists and calcium channel antagonists may be additive, and other combinations of neuroprotective agents, such as a glutamate antagonist with a gamma-aminobutyric acid (GABA) agonist, have even shown synergism in a rat stroke model. It has also been suggested that lower doses of toxic drugs may be used together to yield a positive neurologic outcome. Successful demonstration of additive or synergistic effects of pharmacologic agents in ischemia will depend on (1) the model used (well below a maximal "ceiling effect"); (2) the timing of drug administration; (3) the doses of the drugs used; and (4) the primary neurologic endpoint used. (Infarction size requires prolonged survival.)

CONCLUSIONS

It appears from preclinical studies that some combinations of pharmacotherapeutic agents may be beneficial in cerebral ischemia, but rigorous evaluation is needed before initiating clinical trials.

Combination drug therapy and mild hypothermia: a promising treatment strategy for reversible, focal cerebral ischemia

BACKGROUND AND PURPOSE

Hypothermia has been suggested to be the most potent therapeutic approach to reduce experimental ischemic brain injury identified to date, and mild hypothermia is increasingly used for neuroprotection during neurovascular surgery. We have recently demonstrated that combined administration of tirilazad mesylate and magnesium provides for an overall enhanced neuroprotective effect. The present study was designed to determine whether the efficacy of mild hypothermia (33 degrees C) can be increased by combination pharmacotherapy with tirilazad and magnesium (MgCl(2)).

METHODS

Forty Sprague-Dawley rats were subjected to transient, middle cerebral artery occlusion and were randomly assigned to 1 of 4 treatment arms (n=10 each): (1) normothermia+vehicle, (2) normothermia+tirilazad+MgCl(2), (3) hypothermia+vehicle, or (4) hypothermia+tirilazad+MgCl(2). Cortical blood flow was monitored by a bilateral laser-Doppler flowmeter, and the electroencephalogram was continuously recorded. Functional deficits were quantified by daily neurological examinations. Infarct volume was assessed after 7 days.

RESULTS

Tirilazad+MgCl(2), hypothermia, and hypothermia+tirilazad+MgCl(2) reduced total infarct volume by 56%, 63%, and 77%, respectively, relative to controls. In animals treated with both hypothermia and combination pharmacotherapy, cortical infarction was almost completely abolished (-99%), and infarct volume in the basal ganglia was significantly reduced by 55%. In addition, this treatment provided for the best electrophysiological recovery and functional outcome.

CONCLUSIONS

The neuroprotective efficacy of hypothermia can be increased by pharmacological antagonism of excitatory amino acids and free radicals by using clinically available drugs. This treatment strategy could be of great benefit when applied during temporary artery occlusion in cerebrovascular surgery.

Combined therapy affects outcomes differentially after mild traumatic brain injury and secondary forebrain ischemia in rats

Muscarinic and NMDA receptors contribute to post-traumatic hypersensitivity to secondary ischemia. However, the effect of these receptor antagonists on behavior and CA1 neuronal death after traumatic brain injury (TBI) with acute (1 h after TBI) forebrain ischemia has not been systematically assessed. We examined cognitive and motor dysfunction and the relationship of behavior deficits to neuronal death in this model using muscarinic and NMDA antagonists. Three behavioral groups (n=10/group) of Wistar rats were subjected to mild TBI and 6 min of forebrain ischemia imposed 1 h after TBI with 45 days survival. Motor and spatial memory performance were assessed using the rotarod task and Morris water maze. Seven additional groups (n=6/group) were evaluated only for CA1 death after 7 days survival following sham, individual or combined injury with and without drug treatments. Rats were given 0.3 mg/kg MK-801 (M) and 1.0 mg/kg scopolamine (S) alone or combined (M-S) before or 45 min after TBI. Rotarod performance was tested at days 1-5 and maze performance on days 11-15 and 40-44 after M-S treatment. The 7-day studies showed M-S treatment (p<0.01) reduced CA1 neuronal death better than either S or M alone. Behavioral groups had inadvertent post-ischemic hypothermia that decreased CA1 death and likely influenced behavioral morbidity. M-S given before TBI (p<0.01) decreased memory deficits on day 15, while M-S treatment given after TBI was ineffective. Unexpectedly, M-S treatment before or after TBI produced transient motor deficits (p<0. 01). Memory improvement occurred independent of CA1 death.

Intraarterial urokinase produces significant attenuation of infarction volume in an embolic focal ischemia model

A number of models of focal ischemia have been created to mimic acute middle cerebral artery (MCA) occlusion. In the present series of experiments, we report our observations on the thrombin model of MCA occlusion and the neuroprotective effects of intraarterial thrombolysis with two doses of urokinase (2500 and 5000 units/kg). In all experiments male Wistar rats were used and the animals were allowed to recover for 48 h before assessment of neurobehavioral performance on a four-point scale. The extent of cerebral hemispheric damage was calculated as the percentage of brain infarction using TTC staining. Occlusion of the MCA was effected by the introduction of an autologous blood clot into the internal carotid artery (ICA) approximately 2 mm from the origin of the MCA. This clot was formed by the drawing of 10 microl of blood into a bovine thrombin (20 microg per animal) containing intraarterial catheter, which was inserted into the right ECA. After standing for 15 min to allow clot formation, the catheter was advanced gently through the ICA to the site of injection. MCA occlusion produced a consistent large infarction in all animals. Urokinase infusion (i.a. ) was started 2 h after arterial occlusion in the initial series. In animals treated with low dose urokinase infusion there was mild protection. Animals treated with high dose urokinase infusion showed a highly significant improvement in the motor recovery and a decrease in the extent of infarction compared to control animals. In the final group, the infusion of urokinase was delayed for 3 h. While producing protection in some animals, it also produced intracerebral hemorrhage in two of eight animals. Thus delay of infusion to 180 min increased the risk of hemorrhage. This model may in the future be used to test the protective effects of combination therapy with thrombolysis and neuroprotective medications.

GABA and glutamate levels in the substantia nigra reticulata following repetitive cerebral ischemia in gerbils

Repetitive cerebral ischemia produces more severe damage than a similar single duration insult. We have previously shown that, in gerbils, damage in the substantia nigra reticulata (SNr) is seen with repetitive insults rather than a single insult. We have also shown that there is a progressive decrease in the extracellular GABA in the striatum in the days preceding such damage, speculating that a loss of GABA may be in part responsible for this damage. This study evaluates the GABA levels in the SNr in animals exposed to repetitive ischemic insults. Each animal received a total of three ischemic insults of 3-min duration at hourly intervals. In vivo microdialysis was carried out to analyze the GABA and glutamate dialysate levels on Days 1, 3, 5, 7, and 14 following the ischemic insult. In the control and treated (ischemic) animals, there was a significant increase in the GABA levels with the introduction of nipecotic acid on Days 1, 3, 5, and 14. However, on Day 7 there was a significant attenuation in the GABA response to nipecotic acid in the treated animals in comparison to the controls. The glutamate levels in the treated animals were similar to the control animals on Days 1, 3, 5, and 7. However, on Day 14 the glutamate levels were significantly lower than on previous days. Our experiments for the first time measure extracellular glutamate and GABA responses in the SNr in animals exposed to repetitive ischemic insults. Our experiments show that there is a significant decrease in the GABA concentrations at a time when ischemic damage is developing in this region. This confirms our hypothesis that a decrease in GABA may be one factor contributing to neuronal damage during the period following repetitive ischemic insults. Further, the rebound increase in GABA levels on Day 14 with a concomitant fall in glutamate levels would indicate that reparative processes are still active in the 2 weeks following the insult.

Morphological investigation of the neuroprotective effects of graded hypothermia after diverse periods of global cerebral ischemia in gerbils

Hypothermia is known to be the most effective method to protect the neuronal damage induced by ischemia. In the present study, we investigated the histopathological consequences of hippocampal CA1 pyramidal neurons as well as the glial reactions in the hippocampus, after diverse periods of ischemic insult at graded intra-ischemic hypothermia ranging from 32 to 20 degrees C. Gerbils were exposed to forebrain ischemia by clamping the bilateral common carotid arteries for 5-120 min depending upon the temperatures. The morphological study was performed 7 days after ischemia or sham-operation. Histopathological evaluation of delayed neuronal death (DND) was performed by Cresyl violet (CV) staining and MAP2 immunoreactivity. Glial reactions were examined by GFAP immunostaining and isolectin B4 histochemistry, corresponding to astrocytes and microglia, respectively. The forebrain ischemia at 32 degrees C for 10 min and at 28 degrees C for 20 min did not induce DND in the CA1 region. However, the ischemia at 32 degrees C for 20 min and at 28 degrees C for 30 min caused extensive degeneration of CA1 pyramidal neurons as observed in normothermic ischemic animals. Under the condition of deep hypothermia, the ischemia for 60 min at 24 degrees C and for 120 min at 20 degrees C which were the longest durations of each temperature within the limitation of the animal survival following 7 days, induced no DND in CA1 pyramidal neurons. The reactive changes of astrocytes were observed not only in ischemic animals with DND, but also in ischemic animals without DND. Computer image analysis showed that the area fraction of GFAP-positive structures in the CA1 region was significantly increased in both ischemic cases with and without DND compared with each sham group. In contrast, the distribution of activated microglia was much more restricted to the CA1 region and they were always accompanied by DND at 7 days postischemia. The present results demonstrate the remarkable neuroprotective effect of deep hypothermia that has been widely used in cardiovascular surgeries as the cerebroprotective strategy during total circulatory cessation. The findings also suggest that even under the condition of hypothermia, glial reactions may play an important role in neuronal survival and death after ischemia.

Effects of clomethiazole on radial-arm maze performance following global forebrain ischemia in gerbils

The functional and neuroanatomical protective effects of clomethiazole (CMZ) were examined in an animal model of global forebrain ischemia. Gerbils underwent sham-surgery or were rendered ischemic by the application of aneurysm clips to both carotid arteries for 6 min. Three treatment groups received CMZ (50 mg/kg, 100 mg/kg, or 150 mg/kg) 30 min before ischemia, and one group was given 150 mg/kg of CMZ 30 min after ischemia. Following recovery, the gerbils were tested in a radial-arm maze to assess memory functions. Histological evaluation was assessed blindly using a percentile scoring system. The results indicate that pre-ischemic treatment with 100 mg/kg and 150 mg/kg of CMZ reduced brain damage and working memory errors significantly. Treatment dosage of 150 mg/kg of CMZ was the most effective in preventing neuronal damage in the hippocampus and eliminating the working memory deficit typically induced by ischemia.

Neuroprotection with felbamate: a 7- and 28-day study in transient forebrain ischemia in gerbils

The use of glutamate antagonists and GABA agonists may protect neurons from the effects of transient ischemia. Felbamate is a new antiepileptic drug with glutamate antagonist and GABA agonist properties. We tested the efficacy of felbamate in a gerbil model of transient forebrain ischemia. Damage assessment was done with silver staining at 7 and 28 days after 5 min of bilateral carotid occlusion. Cerebral cortex, hippocampus (CA1 and CA4), thalamus and striatum were evaluated on a 4-point scoring system. The animals sacrificed at 28 days were also tested in a water-maze task to assess recovery of function. The initial dose of felbamate (300 mg/kg) was given 30 min before the ischemic insult in one set of animals and 30 min after the insult in another set of animals. There were 8 animals tested per group (total: 48 animals). There was significant neuronal protection with the use of felbamate, both before and after ischemia in all regions of the brain. Protection was seen in animals sacrificed at 7 and 28 days. Protection was moderate when felbamate was used before ischemia. It was highly significant when felbamate was given 30 min after the insult. Behavioral studies however did not show any difference in the felbamate treated animals versus the saline treated controls. The structural protection with felbamate was very significant when used in the post-ischemic period. This window for protection merits further evaluation in relation to the clinical setting of stroke.

The competitive NMDA antagonist, CGS-19755, improves postischemic hypoperfusion in selectively vulnerable regions in gerbils

We attempted to clarify the effects of an NMDA antagonist on postischemic hypoperfusion in gerbils with 10 min forebrain ischemia and to relate it to postischemic metabolic recovery. We administered 10 mg/kg of CGS-19755, a competitive NMDA antagonist, or the same volume of saline intraperitoneally 30 min before the vascular occlusion. In 26 gerbils, we measured local cerebral blood flow (LCBF) 60 min after the reperfusion using [14C]iodoantipyrine autoradiography. In 20 gerbils, the effects on metabolic recovery were determined by serial measurements of intracellular pH, adenosine triphosphate (ATP) and the ratio between phosphocreatine and inorganic phosphate (PCr/Pi) until 60 min after reperfusion using 31P-magnetic resonance spectroscopy. In another group of 24 gerbils, we determined histopathological damage 24 h after the ischemia. The LCBF autoradiograms in the control group consistently demonstrated a typical postischemic hypoperfusion, i.e. homogeneous 50-75% reduction of blood flow in all forebrain structures. In contrast, CGS-19755 pretreatment animals showed highly heterogeneous LCBF declines, and significantly higher LCBF values were observed in the frontoparietal cortex and thalamus both of which were the most vulnerable area in this model. No significant LCBF change was observed in sham operated animals with or without CGS-19755 pretreatment. The postischemic recovery of PCr/Pi in gerbils pretreated with CGS-19755 was significantly better than that in the control animals. No significant differences in the recovery of ATP and intracellular pH were observed. The histological damage in the CGS-19755-treated group was less extensive than those in the saline-treated group. CGS-19755 pretreatment improved postischemic hypoperfusion and PCr/Pi recovery in the 10-min forebrain ischemia model in gerbils. The improvement of postischemic hypoperfusion in selectively vulnerable regions suggests that the activation of NMDA receptors may be related to the mechanism of developing postischemic hypoperfusion.

Clomethiazole protects the brain in transient forebrain ischemia when used up to 4 h after the insult

Brief periods of forebrain ischemia result in consistent damage in the hippocampus in gerbils. This damage can be attenuated by free radical scavengers, glutamate antagonists and GABA agonists. Most of the work with cerebral protection has been done with agents infused prior to the insult. In this experiment we tested clomethiazole, a GABA agonist, as a neuroprotective agent 1 and 4 h after a 5 min ischemic insult (bilateral carotid occlusion) in gerbils. Damage was assessed using silver staining techniques at 7 days after the insult. There were 10 animals in each group. Clomethiazole was given subcutaneously at a dose of 100 mg/kg. Compared to controls, there was significant protection in the CA1 (P < 0.01) and CA4 (P < 0.01) regions of the hippocampus at 1 and 4 h after the ischemic insult. GABAergic agents may play an important role in neuronal protection when used after ischemic insults.

Insulin elevates hippocampal GABA levels during ischemia. This is independent of its hypoglycemic effect

There are reports that insulin may protect neurons from the effects of ischemia. The mechanisms for this protection are not fully understood. We studied the extracellular levels of glutamate and GABA in insulin-treated animals exposed to transient forebrain ischemia under normoglycemic and hypoglycemic conditions. In vivo microdialysis technique was used to collect extracellular fluid from the CA1 region of the hippocampus. There was a significant increase in GABA levels in the two insulin-treated sub-groups compared with the controls. GABA levels were < 1 pmol/10 microliters in three 10 min collections prior to ischemia in all the groups. It increased from 11.1 +/- 3.5 pmol/10 microliters in the conrol group to 47 +/- 5 (P < 0.001) in the insulin-treated hypoglycemic group and up to 47.2 +/- 9.3+ (P < 0.005) in the insulin-treated normoglycemic group (two-way ANOVA with repeated measures). Ischemia resulted in an increase in the glutamate levels. The glutamate levels returned to baseline within 30 min of the insult. There were no significant differences in the glutamate levels in three groups. The increase in GABA concentrations in the extracellular space may result in the inhibition of CA1 pyramidal neurons. This may be a possible mechanism of neuronal protection in animals treated with insulin (with or without being hypoglycemic) during ischemia.

NMDA antagonists: antiepileptic-neuroprotective drugs with diversified neuropharmacological profiles

In conclusion, NMDA antagonists as anticonvulsants are especially active in preventing the generalization of the behavioural and electrical seizures and display a typical spectrum of in vitro antiepileptiform activities. In addition, based on in vitro and in vivo limbic kindled studies, the drugs should be regarded more as an antiepileptiform than as an anticonvulsant drugs. As neuroprotective drugs, NMDA antagonists are effective against many types of neuronal injury and show a window of activity which does not exceed 1-2 h, thus suggesting an influence of NMDA receptors in the 'early' or 'acute' mechanisms of brain damage. Among NMDA antagonists, glycine antagonists or the morphinans dextromethorphan and dextrorphan showed a spectrum of antiepileptiform and neuroprotective activities broader than other NMDA antagonists. The primary pharmacological activities of NMDA antagonists are accompanied by some effects including perturbation of many sensory, psychological or motor processes. Typical behavioural and EEG changes were also induced by the drugs. In spite of the side-effects elicited by the drugs, differential effects detected among the various classes of NMDA antagonists (i.e. lack of induction of typical EEG-behavioural effects and of typical cortical neurotoxicity) might render some of these suitable for full clinical application as anticonvulsant-neuroprotective drugs.

Post-ischemic therapy with CGS-19755 (alone or in combination with hypothermia) in gerbils

Hypothermia or a glutamate receptor antagonist may offer protection when used before or within seconds of an ischemic insult. In this experiment, we tested the efficacy of hypothermia (34 degrees C) versus CGS-19755 (a potent competitive N-methyl-D-aspartate (NMDA) receptor blocker) and their combination which was administered 0.5 h after a 5-min forebrain ischemic insult in gerbils. Morphological assessments were done in Group A at the end of 7 days while Group B was evaluated at 29 days. Each group had four sets of animals: saline treated controls; hypothermia treated; CGS-19755 treated; and a combination of CGS-19755 + hypothermia treated animals. Group A showed significant 'protection', i.e. minimal neuronal damage in the animals treated with hypothermia alone. Protection was evident in the cerebral cortex (P < 0.001), hippocampus CA1 (P < 0.01), and in the striatum (P < 0.05). There was no evidence of neuronal protection in the animals that had received either CGS-19755 alone or a combination of hypothermia and CGS-19755. In Group B (29 day assessment) the neuroprotective effects were not evident in any of the animals when compared to the controls. Behavioral testing with Morris water-maze testing showed no significant differences between the control and any of the treated animals. Our data suggests that 'post-ischemic' therapy with hypothermia may delay the effects of ischemia but does not offer significant long-term neuronal protection. Protection seen at 7 days is not evident at 29 days.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of post-ischemic hypothermia following repetitive cerebral ischemia in gerbils

Repetitive ischemia may result in more severe damage than a single similar duration insult. Inter-ischemic hypothermia significantly decreases this damage. It is unclear if protection would be evident if cooling was delayed until after the repeated insults. In this study, we evaluated the effects of 3 h of mild cooling (34-35 degrees C) beginning immediately after the third insult of ischemia, 0.5 h after the third insult and 1 h after the third insult in a gerbil model of repetitive ischemia. Neuronal damage was assessed in the cerebral cortex (CTX), hippocampus (CA1, CA4), striatum (STR), thalamus (THL), medial geniculate nucleus (MGN), and the substantia nigra reticulata (SNr). A '4-point' damage scale was used and evaluation was done in a blinded way. Group comparisons were done using the Mann-Whitney U-test for significance between the control and hypothermic groups. Immediate hypothermia after the third ischemic insult produced a significant protection in the CTX (P < 0.05), hippocampus (CA1 and CA4, P < 0.01), STR (P < 0.001), SNr (P < 0.01), MGN (P < 0.01) and THL (P < 0.01). Cooling at 0.5 and 1 h after the third insult produced no protection when compared to ischemic controls. The window of opportunity with hypothermia is narrow in repetitive ischemia. To be effective, therapy must be initiated as soon as possible after ischemic insults.

Neuronal protection with superoxide dismutase in repetitive forebrain ischemia in gerbils

The underlying mechanism for severe damage with repetitive ischemia is not fully understood. Because of prolonged periods of reperfusions between the brief insults, we speculated that the severe damage may be secondary to excessive generation of oxygen free radicals. In this study we tested the efficacy of peg-superoxide dismutase (SOD) in a model of repeated ischemia in gerbils. Superoxide dismutase (SOD) or vehicle (saline) was delivered through osmotic pumps into the lateral ventricles continuously from the onset of the insult until the gerbils were sacrificed 6 days later. Three doses of SOD were used in the experiments (110, 150, and 190 units per microliter). Damage was assessed using a 0-4 point scoring system and statistical comparisons were done using the Mann-Whitney U-test. There was significant protection in the hippocampus (p < 0.05), striatum (p < 0.001), and substantia nigra reticulata (p < 0.05) in the lowest dose SOD-treated group (110 units per microliter). Animals treated with 150 units showed lesser (but significant) protection in the thalamus, medial geniculate nucleus, and striatum. In the animals treated with the higher dose of SOD (190 units per microliter), the extent of damage was no different than vehicle-treated controls in the cortex, striatum, and hippocampus. Compared to controls, neuronal damage was, however, significantly more severe in the medial geniculate nucleus and the thalamus in the high-dose SOD-treated animals (p < 0.05). Our experiments suggest that the SOD may have a small therapeutic window. Higher doses may either have no neuroprotective effects or may be harmful.

Superoxide dismutase, catalase, and U78517F attenuate neuronal damage in gerbils with repeated brief ischemic insults

Repeated ischemic insults at one hour intervals result in more severe neuronal damage than a single similar duration insult. The mechanism for the more severe damage with repetitive ischemia is not fully understood. We hypothesized that the prolonged reperfusion periods between the relatively short ischemic insults may result in a pronounced generation of oxygen free radicals (OFRs). In this study, we tested the protective effects of superoxide dismutase (SOD) and catalase (alone or in combination), and U78517F in a gerbil model of repetitive ischemia. Three episodes (two min each) of bilateral carotid occlusion were used at one hour intervals to produce repetitive ischemia. Superoxide dismutase and catalase were infused via osmotic pumps into the lateral ventricles. Two doses of U78517F were given three times per animal, one half hour prior to each occlusion. Neuronal damage was assessed 7 days later in several brain regions using the silver staining technique. The Mann-Whitney U test was used for statistical comparison. Superoxide dismutase showed significant protection in the hippocampus (CA4), striatum, thalamus and the medial geniculate nucleus (MGN). Catalase showed significant protection in the striatum, hippocampus, thalamus, and MGN and the substantia nigra reticulata. Combination of the two resulted in additional protection in the cerebral cortex. Compared to the controls, there was little protection in a dose of 3 mg/kg of U78517F. There was significant protection with a dose of 10 mg/kg in the hippocampus (CA4), striatum, thalamus, medial geniculate nucleus and the substantia nigra reticulata.(ABSTRACT TRUNCATED AT 250 WORDS)

Mortality in gerbils with repetitive ischemia: CGSGS-19755/hypothermia therapy

Repetitive ischemia causes more severe damage than a single insult of comparable duration. Gerbils were followed for 1 month postrepetitive ischemia and 100% mortality was demonstrated in the unprotected ischemia group by 12 days postischemia. Significant protection against mortality due to repetitive ischemia was offered by both CGS-19755 and combination CGS-19755-hypothermia treatments. Current practices of sacrificing repetitive ischemia subjects shortly postischemia may lead to an underestimation of the effects of ischemia and/or an overestimation of the protective effects of experimental treatments.