Altered white matter metabolism in delayed neurologic sequelae after carbon monoxide poisoning: A proton magnetic resonance spectroscopic study

Examination of central nervous system by functional observation battery after massive intravenous infusion of carbon monoxide-bound and oxygen-bound hemoglobin vesicles in rats

Carbon monoxide (CO) is known as a toxic gas inducing "CO poisoning", which acutely affects the central nervous system (CNS) and which persistently affects brain functions depending on the exposure time and CO concentration. By contrast, in pathological rodent models, intravenous infusion of CO-bound hemoglobin vesicles (CO-HbV) has shown various beneficial effects such as anti-oxidative and anti-inflammatory reactions. This study assessed effects of CO-HbV infusion on CNS using a functional observation battery, sensory reflexes, grip strength, and landing foot splay measurements. The test fluids were CO-HbV and O₂-bound HbV (O₂-HbV) suspended in saline ([Hb] ​= ​10 ​g/dL), and saline alone for comparison. The rats received either 16 or 32 ​mL/kg of fluid intravenously at 1.5 ​mL/min/kg. Observations were made before infusion, and at 5 ​min, 4, 8, 24, 48 and 72 ​h after infusion. Massive doses of 16 and 32 ​mL/kg respectively corresponded to about 29 and 57% of the whole circulating blood volume (56 ​mL/kg). No toxicological effect was observed in any measurement item for any group in comparison to the control saline infusion group. Histopathological examination of hippocampal tissue at 14 days after infusion showed the number of necrotic cells to be minimal. Results obtained from rats in this experiment suggest that the massive intravenous infusion of CO-HbV yields beneficial anti-oxidative and anti-inflammatory effects without showing CO-poisoning-related symptoms of CNS damage.

Astrocyte-derived microparticles initiate a neuroinflammatory cycle due to carbon monoxide poisoning

We hypothesized that carbon monoxide (CO) establishes an inflammatory cycle mediated by microparticles (MPs). Mice exposed to a CO protocol (1000 ​ppm for 40 ​min and then 3000 ​ppm for 20 ​min) that causes neuroinflammation exhibit NF-κB activation in astrocytes leading to generation of MPs expressing thrombospondin-1(TSP-1) that collect in deep cervical lymph nodes draining the brain glymphatic system. TSP-1 bearing MPs gain access to the blood stream where they activate neutrophils to generate a new family of MPs, and also stimulate endothelial cells as documented by leakage of intravenous 2000 ​kDa dextran. At the brain microvasculature, neutrophil and MPs sequestration, and myeloperoxidase activity result in elevations of the p65 subunit of NF-κB, serine 536 phosphorylated p65, CD36, and loss of astrocyte aquaporin-4 that persist for at least 7 days. Knock-out mice lacking the CD36 membrane receptor are resistant to all CO inflammatory changes. Events triggered by CO are recapitulated in naïve wild type mice injected with cervical node MPs from CO-exposed mice, but not control mice. All MPs-mediated events are inhibited with a NF-κB inhibitor, a myeloperoxidase inhibitor, or anti-TSP-1 antibodies. We conclude that astrocyte-derived MPs expressing TSP-1 establish a feed-forward neuroinflammatory cycle involving endothelial CD36-to-astrocyte NF-κB crosstalk. As there is currently no treatment for CO-induced neurological sequelae, these findings pose several possible sites for therapeutic interventions.

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Carbon monoxide (CO) causes neurological injuries poorly correlated to hypoxic stress.

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Astrocyte NF-κB triggers thrombospondin-1(TSP-1) microparticle (MP) production.

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TSP-1 MPs enter the blood stream, stimulating neutrophils and endothelium.

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Circulating MPs linkage to endothelial cell CD36 causes vascular damage.

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Endothelial CD36-to-astrocyte NF-κB crosstalk establishes a neuroinflammatory cycle.

Neurocognitive sequelae after carbon monoxide poisoning and hyperbaric oxygen therapy

Carbon monoxide (CO) has been the leading cause of poisoning mortality in many countries and hyperbaric oxygen (HBO) is a widely accepted treatment for CO poisoning. However, some patients with CO poisoning will still develop neurocognitive sequelae regardless of HBO therapy, which can persist since CO poisoning or be present days to weeks after a recovery from CO poisoning. HBO has been used in the prevention and treatment of neurocognitive sequelae after CO poisoning, and some mechanisms are also proposed for the potential neuroprotective effects of HBO on the neurocognitive impairment after CO poisoning, but there is still controversy on the effectiveness of HBO on neurocognitive sequelae after CO poisoning. In this paper, we briefly introduce the neurocognitive sequelae after CO poisoning, summarize the potential predictive factors of neurocognitive sequelae, and discuss the use of HBO in the treatment and prevention of neurocognitive sequelae after CO poisoning.

Interaction of dopamine transporter and metabolite ratios underpinning the cognitive dysfunction in patients with carbon monoxide poisoning: A combined SPECT and MRS study

Cognitive dysfunction has been reported in patients with carbon monoxide (CO) poisoning. However, the underpinning mechanism remained unclear. This study examined dopamine transporter (DAT) and metabolite ratios concurrently and their relationships with cognitive dysfunction in CO poisoning. Eighteen suicide attempters with charcoal burning which results in CO poisoning and 18 age- and gender- matched normal controls were recruited. A battery of cognitive assessments including attention, memory, and executive function was administered. Each participant received one single photon emission computed tomography with ^99mTc-TRODAT for measuring striatal DAT availability and proton magnetic resonance spectroscopy to determine N-acetyl aspartate/creatine (NAA/Cr), choline-containing compounds/creatine (Cho/Cr) and myo-inositol/creatine (mI/Cr) in the left parietal white matter and mid-occipital gray matter (OGM). CO poisoning patients had significant impairments in memory and executive function. Compared to normal, CO poisoning patients had lower striatal DAT availability, lower NAA/Cr levels in both regions and higher Cho/Cr levels in both regions. In CO poisoning patients, the altered left striatal DAT availability and Cho/Cr level in OGM were significantly associated with executive dysfunction in the expected directions. Moreover, there was a significant interaction between these two imaging indices on their relationships with executive dysfunction and combination of them could adequately predict executive dysfunction in more CO poisoning cases than either alone. The current results suggested that both alterations in DAT availability and metabolite ratios might play crucial roles in executive dysfunction in CO poisoning. This research also highlights the importance of multimodal imaging approaches for studying neurotoxicity effects.

Oligodendrocyte dysfunction and regeneration failure: A novel hypothesis of delayed encephalopathy after carbon monoxide poisoning

Carbon monoxide (CO) poisoning usually causes brain lesions and delayed encephalopathy, also known as delayed neurological sequelae (DNS). Demyelination of white matter (WM) is one of the most common sites of abnormalities in patients with DNS, but its mechanisms remain unclear. Oligodendrocytes (OLs) are myelinated cells that ensure the rapid conduction of neuronal axon signals and provide the nutritional factors necessary for maintaining nerve integrity in the central nervous system (CNS). OLs readily regenerate and replace damaged myelin membranes around axons in the adult mammalian CNS following demyelination. The ability to regenerate OLs depends on the availability of precursor cells (OPCs) in the CNS of adults. Multiple injury-related signals can induce OPC expansion followed by OL differentiation, axonal contact and myelin regeneration (remyelination). Therefore, OL dysfunction and regeneration failure in the deep WM of the brain are the key pathophysiological mechanisms leading to delayed brain injury after CO poisoning. CO-induced toxicity may interfere with OL function and render OPCs unable to regenerate OLs through some unclear mechanisms, leading to progressive demyelinating damage and resulting in DNS. In the future, combination therapies to reduce OL damage and promote OPC differentiation and remyelination may be important for the prevention and treatmentof DNS after CO poisoning.

Delayed neurologic sequelae of carbon monoxide intoxication

Altered consciousness and accompanying neurological symptoms are both complex and challenging cases for emergency physicians. These are not specific and may be a sign of a variety of medical conditions including stroke and delayed neurological sequelae (DNS) is a recurrent transient neuropsychiatric consequence of CO intoxication. DNS produces a spectrum of varying symptoms and the diagnosis is primarily made on the basis of clinical features and radiological findings from CT and conventional MRI. In clinical practice, serious CO intoxication is treated only with oxygen therapy although no effective treatment exists. Emergency physicians play a major role in managing patients presenting with CO intoxication and preventing DNS.