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de Veij Mestdagh CF, Smit AB, Henning RH, van Kesteren RE. Mitochondrial Targeting against Alzheimer's Disease: Lessons from Hibernation. Cells 2023; 13:12. [PMID: 38201215 PMCID: PMC10778235 DOI: 10.3390/cells13010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Alzheimer's disease (AD) is the most common cause of dementia worldwide and yet remains without effective therapy. Amongst the many proposed causes of AD, the mitochondrial cascade hypothesis is gaining attention. Accumulating evidence shows that mitochondrial dysfunction is a driving force behind synaptic dysfunction and cognitive decline in AD patients. However, therapies targeting the mitochondria in AD have proven unsuccessful so far, and out-of-the-box options, such as hibernation-derived mitochondrial mechanisms, may provide valuable new insights. Hibernators uniquely and rapidly alternate between suppression and re-activation of the mitochondria while maintaining a sufficient energy supply and without acquiring ROS damage. Here, we briefly give an overview of mitochondrial dysfunction in AD, how it affects synaptic function, and why mitochondrial targeting in AD has remained unsuccessful so far. We then discuss mitochondria in hibernation and daily torpor in mice, covering current advancements in hibernation-derived mitochondrial targeting strategies. We conclude with new ideas on how hibernation-derived dual mitochondrial targeting of both the ATP and ROS pathways may boost mitochondrial health and induce local synaptic protein translation to increase synaptic function and plasticity. Further exploration of these mechanisms may provide more effective treatment options for AD in the future.
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Affiliation(s)
- Christina F. de Veij Mestdagh
- Department of Molecular and Cellular Neurobiology, Center for Neurogenomics and Cognitive Research, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (A.B.S.); (R.E.v.K.)
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands;
- Alzheimer Center Amsterdam, Amsterdam UMC Location VUmc, 1081 HV Amsterdam, The Netherlands
| | - August B. Smit
- Department of Molecular and Cellular Neurobiology, Center for Neurogenomics and Cognitive Research, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (A.B.S.); (R.E.v.K.)
| | - Robert H. Henning
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands;
| | - Ronald E. van Kesteren
- Department of Molecular and Cellular Neurobiology, Center for Neurogenomics and Cognitive Research, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands; (A.B.S.); (R.E.v.K.)
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Seo Y, Bang S, Son J, Kim D, Jeong Y, Kim P, Yang J, Eom JH, Choi N, Kim HN. Brain physiome: A concept bridging in vitro 3D brain models and in silico models for predicting drug toxicity in the brain. Bioact Mater 2022; 13:135-148. [PMID: 35224297 PMCID: PMC8843968 DOI: 10.1016/j.bioactmat.2021.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/01/2021] [Accepted: 11/06/2021] [Indexed: 12/12/2022] Open
Abstract
In the last few decades, adverse reactions to pharmaceuticals have been evaluated using 2D in vitro models and animal models. However, with increasing computational power, and as the key drivers of cellular behavior have been identified, in silico models have emerged. These models are time-efficient and cost-effective, but the prediction of adverse reactions to unknown drugs using these models requires relevant experimental input. Accordingly, the physiome concept has emerged to bridge experimental datasets with in silico models. The brain physiome describes the systemic interactions of its components, which are organized into a multilevel hierarchy. Because of the limitations in obtaining experimental data corresponding to each physiome component from 2D in vitro models and animal models, 3D in vitro brain models, including brain organoids and brain-on-a-chip, have been developed. In this review, we present the concept of the brain physiome and its hierarchical organization, including cell- and tissue-level organizations. We also summarize recently developed 3D in vitro brain models and link them with the elements of the brain physiome as a guideline for dataset collection. The connection between in vitro 3D brain models and in silico modeling will lead to the establishment of cost-effective and time-efficient in silico models for the prediction of the safety of unknown drugs.
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Affiliation(s)
- Yoojin Seo
- Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Seokyoung Bang
- Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
| | - Jeongtae Son
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, 34141, Republic of Korea
| | - Dongsup Kim
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, 34141, Republic of Korea
| | - Yong Jeong
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, 34141, Republic of Korea
| | - Pilnam Kim
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, 34141, Republic of Korea
| | - Jihun Yang
- Next&Bio Inc., Seoul, 02841, Republic of Korea
| | - Joon-Ho Eom
- Medical Device Research Division, National Institute of Food and Drug Safety Evaluation, Cheongju, 28159, Republic of Korea
| | - Nakwon Choi
- Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
- Division of Bio-Medical Science & Technology, KIST School, Korea University of Science and Technology (UST), Seoul, 02792, Republic of Korea
- KU-KIST Graduate School of Converging Science and Technology, Korea University, Seoul, 02841, Republic of Korea
| | - Hong Nam Kim
- Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, 02792, Republic of Korea
- Division of Bio-Medical Science & Technology, KIST School, Korea University of Science and Technology (UST), Seoul, 02792, Republic of Korea
- School of Mechanical Engineering, Yonsei University, Seoul, 03722, Republic of Korea
- Yonsei-KIST Convergence Research Institute, Yonsei University, Seoul, 03722, Republic of Korea
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Hypothermia-rewarming: A Double-edged sword? Med Hypotheses 2019; 133:109387. [PMID: 31541781 DOI: 10.1016/j.mehy.2019.109387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 01/05/2023]
Abstract
Hypothermia is a condition in which the body's core temperature drops below 35.0 °C. Hypothermia is the opposite of hyperthermia, which the metabolism and body functions are abnormal. Severe hypothermia is a life-threatening problem that may cause atrial and ventricular dysrhythmias, coagulopathy, cardiac, and central nervous system depression. What is worse, it is fatal when untreated or treated improperly. Accidental deaths due to hypothermia resulting from immersion in cold water, especially involving naval fighters and maritime victims have occurred continually in the past years. Currently, the treatment of hypothermia has become a research focus. Rewarming is the only approach that should be considered for hypothermia treatment. However, the treatment is of low efficiency, and few active rewarming cases have been reported. It is well known that timely reperfusion is the best way to save the lives of patients with ischemia. Similarly, reoxygenation is effective for hypoxia. However, several studies have identified that improper reperfusion of ischemic tissues and reoxygenation of hypoxic tissues give rise to further injury. Analogically, this study attempts to propose the hypothesis that hypothermia-rewarming injury may also exist. When suffered from hypothermia, both the blood circulation and the oxygen supply in the body will be affected in a deficient state, an injury may also appear in the improper rewarming process. In a word, hypothermia-rewarming may be a double-edged sword.
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Martony M, Hernandez JA, de Wit M, St Leger J, Erlacher-Reid C, Vandenberg J, Stacy NI. Clinicopathological prognostic indicators of survival and pathological findings in cold-stressed Florida manatees Trichechus manatus latirostris. DISEASES OF AQUATIC ORGANISMS 2019; 132:85-97. [PMID: 30628575 DOI: 10.3354/dao03306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Cold-stress syndrome (CSS) is a leading natural cause of mortality in free-ranging Florida manatees Trichechus manatus latirostris, but comprehensive investigations into blood analyte derangements and prognostic indicators in CSS are lacking. The objectives of this study were to (1) compare admission blood analyte data of manatees pre and post rehabilitation for CSS to identify clinicopathological derangements, (2) identify blood analyte prognostic indicators for survival, and (3) correlate post-mortem anatomic pathological changes with clinicopathological findings to improve the understanding of CS pathophysiology. CSS manatees admitted to a rehabilitation facility between 2007 and 2017 were included: 59 manatees with data for clinicopathological analysis (7 non-survivors and 49 survivors) and 14 manatees with necropsy data (7 with and 7 without blood analyte data). Main interpretive clinicopathological findings indicated systemic inflammation, bone marrow damage, diuresis, malnutrition, tissue necrosis, fat mobilization, hepatic impairment, acid-base imbalances, and gastrointestinal ulceration. The best diagnostically performing prognostic indicators for survival included platelet concentration, aspartate aminotransferase, calcium, and blood urea nitrogen. The main anatomic pathological findings were cutaneous lesions (n = 14), lipid depletion (n = 12), upper gastrointestinal ulceration and/or hemorrhage (n = 9), and pneumonia (n = 5). Based on the identified blood prognostic indicators interpreted in the context of anatomic pathological findings, multi-organ tissue injury, gastrointestinal ulceration and/or hemorrhage, and hemodynamic and platelet derangements are the presumptive major factors of CSS manatee mortality. These results contribute to the understanding of the complex CSS pathophysiology and offer the use of blood analyte prognostic indicators as a clinically applicable tool for the medical care of manatees during rehabilitation, thereby contributing to increased rehabilitation success and conservation of the Florida manatee.
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Affiliation(s)
- Molly Martony
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida 32608, USA
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Wu TW, Tamrazi B, Soleymani S, Seri I, Noori S. Hemodynamic Changes During Rewarming Phase of Whole-Body Hypothermia Therapy in Neonates with Hypoxic-Ischemic Encephalopathy. J Pediatr 2018; 197:68-74.e2. [PMID: 29571928 DOI: 10.1016/j.jpeds.2018.01.067] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/10/2018] [Accepted: 01/24/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To delineate the systemic and cerebral hemodynamic response to incremental increases in core temperature during the rewarming phase of therapeutic hypothermia in neonatal hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN Continuous hemodynamic data, including heart rate (HR), mean arterial blood pressure (MBP), cardiac output by electrical velocimetry (COEV), arterial oxygen saturation, and renal (RrSO2) and cerebral (CrSO2) regional tissue oxygen saturation, were collected from 4 hours before the start of rewarming to 1 hour after the completion of rewarming. Serial echocardiography and transcranial Doppler were performed at 3 hours and 1 hour before the start of rewarming (T-3 and T-1; "baseline") and at 2, 4, and 7 hours after the start of rewarming (T+2, T+4, and T+7; "rewarming") to determine Cardiac output by echocardiography (COecho), stroke volume, fractional shortening, and middle cerebral artery (MCA) flow velocity indices. Repeated-measures analysis of variance was used for statistical analysis. RESULTS Twenty infants with HIE were enrolled (mean gestational age, 38.8 ± 2 weeks; mean birth weight, 3346 ± 695 g). During rewarming, HR, COecho, and COEV increased from baseline to T+7, and MBP decreased. Despite an increase in fractional shortening, stroke volume remained unchanged. RrSO2 increased, and renal fractional oxygen extraction (FOE) decreased. MCA peak systolic flow velocity increased. There were no changes in CrSO2 or cerebral FOE. CONCLUSIONS In neonates with HIE, CO significantly increases throughout rewarming. This is due to an increase in HR rather than stroke volume and is associated with an increase in renal blood flow. The lack of change in cerebral tissue oxygen saturation and extraction, in conjunction with an increase in MCA peak systolic velocity, suggests that cerebral flow metabolism coupling remained intact during rewarming.
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Affiliation(s)
- Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA.
| | - Benita Tamrazi
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Sadaf Soleymani
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Istvan Seri
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA; First Department of Pediatrics, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Tong Y, Liu J, Zou L, Feng Z, Zhou C, Lv R, Jin Y. Perioperative Outcomes of Using Different Temperature Management Strategies on Pediatric Patients Undergoing Aortic Arch Surgery: A Single-Center, 8-Year Study. Front Pediatr 2018; 6:356. [PMID: 30542643 PMCID: PMC6277883 DOI: 10.3389/fped.2018.00356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/01/2018] [Indexed: 01/12/2023] Open
Abstract
Background: With the widespread application of regional low-flow perfusion (RLFP), development of surgical techniques, and shortened circulatory arrest time, deep hypothermia is indispensable for organ protection. Clinicians have begun to increase the temperature to reduce hypothermia-related adverse outcomes. The aim of this study was to evaluate the safety and efficacy of elevated temperatures during aortic arch surgery with lower body circulatory arrest (LBCA) combined with RLFP. Methods: We retrospectively analyzed data from 207 consecutive pediatric patients who underwent aortic arch repair with LBCA & RLFP between January 2010 and July 2017 and evaluated different hypothermia management strategies. The overall cohort was divided into three groups: deep hypothermia (DH, 20.0-25.0°C), moderate hypothermia (MoH, 25.1-30.0°C) and mild hypothermia (MH, 30.1-34.0°C). Results: The percentage of AKI-1 occurrences was significantly increased in the MH group (51.52%) compared to those in the DH (25.40%) and MoH (37.84%) groups (P = 0.036); prolonged hospital stay occurrences were decreased with elevated temperature (DH 47.62%, MoH 28.83%, MH 18.18%, P = 0.006). Neurological complications, peritoneal dialysis, hepatic dysfunction, 30-day hospital mortality, delay extubation occurrences were no significant among the groups. Logistic analysis showed that the MH group was negatively associated with post-op AKI-1 compared with the DH group [OR = 0.329 (0.137-0.788), P = 0.013], no differences were found between the MoH and the MH group. Compared to other groups, the intubation time (P = 0.006) and postoperative hospital stay (P = 0.009) were significantly decreased in the MH group. Multivariate logistic analysis showed hypothermia levels were not significant with prolonged hospital stay. Conclusions: This retrospective analysis demonstrated that for pediatric patients undergoing surgeries with RLFP & LBCA, three different gradient temperature management strategies are available: deep, moderate, and mild hypothermia. Utilizing mild or moderate hypothermia is safe and feasible. Although the number of AKI-1 occurrences in the MH group was significantly increased compared to those in the other groups, further analysis showed no significance in the MoH and MH group, mild hypothermia management is as safe as others when used appropriately.
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Affiliation(s)
- Yuanyuan Tong
- Department of Cardiopulmonary Bypass, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Lihua Zou
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhengyi Feng
- Department of Cardiopulmonary Bypass, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Chun Zhou
- Department of Cardiopulmonary Bypass, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Ruoning Lv
- Department of Cardiopulmonary Bypass, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, Chinese Academy of Medical Sciences and Peking Union Medical College Fuwai Hospital, Beijing, China
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Zhang C, Wang C, Ren J, Guo X, Yun K. Morphine Protects Spinal Cord Astrocytes from Glutamate-Induced Apoptosis via Reducing Endoplasmic Reticulum Stress. Int J Mol Sci 2016; 17:ijms17101523. [PMID: 27783050 PMCID: PMC5085616 DOI: 10.3390/ijms17101523] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 08/30/2016] [Accepted: 09/04/2016] [Indexed: 12/24/2022] Open
Abstract
Glutamate is not only a neurotransmitter but also an important neurotoxin in central nervous system (CNS). Chronic elevation of glutamate induces both neuronal and glial cell apoptosis. However, its effect on astrocytes is complex and still remains unclear. In this study, we investigated whether morphine, a common opioid ligand, could affect glutamate-induced apoptosis in astrocytes. Primary cultured astrocytes were incubated with glutamate in the presence/absence of morphine. It was found that morphine could reduce glutamate-induced apoptosis of astrocytes. Furthermore, glutamate activated Ca2+ release, thereby inducing endoplasmic reticulum (ER) stress in astrocytes, while morphine attenuated this deleterious effect. Using siRNA to reduce the expression of κ-opioid receptor, morphine could not effectively inhibit glutamate-stimulated Ca2+ release in astrocytes, the protective effect of morphine on glutamate-injured astrocytes was also suppressed. These results suggested that morphine could protect astrocytes from glutamate-induced apoptosis via reducing Ca2+ overload and ER stress pathways. In conclusion, this study indicated that excitotoxicity participated in the glutamate mediated apoptosis in astrocytes, while morphine attenuated this deleterious effect via regulating Ca2+ release and ER stress.
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Affiliation(s)
- Chao Zhang
- Department of Forensic Medicine, Shanxi Medical University, 56 South Xinjian Road, Taiyuan 030001, China.
| | - Chendan Wang
- Department of Nephrology, People's Hospital of Shanxi Province, 29 Shuang-ta Street, Taiyuan 030012, China.
| | - Jianbo Ren
- Department of Forensic Medicine, Shanxi Medical University, 56 South Xinjian Road, Taiyuan 030001, China.
| | - Xiangjie Guo
- Department of Forensic Medicine, Shanxi Medical University, 56 South Xinjian Road, Taiyuan 030001, China.
| | - Keming Yun
- Department of Forensic Medicine, Shanxi Medical University, 56 South Xinjian Road, Taiyuan 030001, China.
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Calcium signaling mechanisms disrupt the cytoskeleton of primary astrocytes and neurons exposed to diphenylditelluride. Biochim Biophys Acta Gen Subj 2016; 1860:2510-2520. [PMID: 27475002 DOI: 10.1016/j.bbagen.2016.07.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/20/2016] [Accepted: 07/25/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Diphenylditelluride (PhTe)2 is a potent neurotoxin disrupting the homeostasis of the cytoskeleton. METHODS Cultured astrocytes and neurons were incubated with (PhTe)2, receptor antagonists and enzyme inhibitors followed by measurement of the incorporation of [32P]orthophosphate into intermediate filaments (IFs). RESULTS (PhTe)2 caused hyperphosphorylation of glial fibrillary acidic protein (GFAP), vimentin and neurofilament subunits (NFL, NFM and NFH) from primary astrocytes and neurons, respectively. These mechanisms were mediated by N-methyl-d-aspartate (NMDA) receptors, L-type voltage-dependent calcium channels (L-VDCCs) as well as metabotropic glutamate receptors upstream of phospholipase C (PLC). Upregulated Ca(2+) influx activated protein kinase A (PKA) and protein kinase C (PKC) in astrocytes causing hyperphosphorylation of GFAP and vimentin. Hyperphosphorylated (IF) together with RhoA-activated stress fiber formation, disrupted the cytoskeleton leading to altered cell morphology. In neurons, the high intracellular Ca(2+) levels activated the MAPKs, Erk and p38MAPK, beyond PKA and PKC, provoking hyperphosphorylation of NFM, NFH and NFL. CONCLUSIONS Our findings support that intracellular Ca(2+) is one of the crucial signals that modulate the action of (PhTe)2 in isolated cortical astrocytes and neurons modulating the response of the cytoskeleton against the insult. GENERAL SIGNIFICANCE Cytoskeletal misregulation is associated with neurodegeneration. This compound could be a valuable tool to induce molecular changes similar to those found in different pathologies of the brain.
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Gupta B, Dodge-Khatami A, Tucker J, Taylor MB, Maposa D, Urencio M, Salazar JD. Antegrade cerebral perfusion at 25 °C for arch reconstruction in newborns and children preserves perioperative cerebral oxygenation and serum creatinine. Transl Pediatr 2016; 5:114-124. [PMID: 27709092 PMCID: PMC5035759 DOI: 10.21037/tp.2016.06.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Antegrade cerebral perfusion (ACP) typically is used with deep hypothermia for cerebral protection during aortic arch reconstructions. The impact of ACP on cerebral oxygenation and serum creatinine at a more tepid 25 °C was studied in newborns and children. METHODS Between 2010 and 2014, 61 newborns and children (<5 years old) underwent aortic arch reconstruction using moderate hypothermia (25.0±0.9 °C) with ACP and a pH-stat blood gas management strategy. These included 44% Norwood-type operations, 30% isolated arch reconstructions, and 26% arch reconstructions with other major procedures. Median patient age at surgery was 9 days (range, 3 days-4.7 years). Cerebral oxygenation (NIRS) was monitored continuously perioperatively for 120 hours. Serum creatinine was monitored daily. RESULTS Median cardiopulmonary bypass (CPB) and cross clamp times were 181 minutes (range, 82-652 minutes) and 72 minutes (range, 10-364 minutes), respectively. ACP was performed at a mean flow rate of 46±6 mL/min/kg for a median of 48 minutes (range, 10-123 minutes). Cerebral and somatic NIRS were preserved intraoperatively and remained at baseline postoperatively during the first 120 hours. Peak postoperative serum creatinine levels averaged 0.7±0.3 mg/dL for all patients. There were 4 (6.6%) discharge mortalities. Six patients (9.8%) required ECMO support. Median postoperative length of hospital and intensive care unit (ICU) stay were 16 days(range, 4-104 days) and 9 days (range, 1-104 days), respectively. Two patients (3.3%) received short-term peritoneal dialysis for fluid removal, and none required hemodialysis. Three patients (4.9%) had an isolated seizure which resolved with medical therapy, and none had a neurologic deficit or stroke. CONCLUSIONS ACP at 25 °C preserved perioperative cerebral oxygenation and serum creatinine for newborns and children undergoing arch reconstruction. Early outcomes are encouraging, and additional study is warranted to assess the impact on late outcomes.
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Affiliation(s)
- Bhawna Gupta
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ali Dodge-Khatami
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Juan Tucker
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Mary B Taylor
- Divisions of Pediatric Critical Care and Pediatric Cardiology, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Douglas Maposa
- Division of Pediatric Anesthesiology, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Miguel Urencio
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jorge D Salazar
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
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Jo YH, Kim K, Lee JH, Rim KP, Cho IS. Rapid rewarming after therapeutic hypothermia worsens outcome in sepsis. Clin Exp Emerg Med 2014; 1:120-125. [PMID: 27752563 PMCID: PMC5052836 DOI: 10.15441/ceem.14.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 07/05/2014] [Accepted: 07/17/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study was performed to investigate the effect of the rewarming rate on survival and acute lung injury in sepsis. METHODS Male Sprague-Dawley rats underwent cecal ligation and incision. After 1 hour of sepsis induction, normothermia (37°C±0.5°C, NT group) or hypothermia (32°C±0.5°C) was induced. Hypothermia was maintained for 4 hours and rats were divided into two groups according to the rewarming rate: RW1 group, 1 hour of rewarming; and RW2 group, 2 hours of rewarming. In the survival study, rats were observed for 12 hours after sepsis induction (n=6 per group). In the second experiment, rats were sacrificed 7 hours after sepsis induction, and lung tissues and plasma were harvested (n=10 per group). RESULTS In the survival study, the RW2 group survived longer than the RW1 group (P<0.05), but the RW1 and NT groups showed no significant difference in survival duration (P>0.05). The histological lung injury score and malondialdehyde concentrations in the lung tissues were significantly higher in the RW1 group than in the RW2 group (P<0.05). Plasma interleukin (IL)-6 concentration and the ratio of IL-6 to IL-10 were higher in the RW1 group than in the RW2 group (P<0.05). CONCLUSION Rapid rewarming after therapeutic hypothermia results in a shorter survival period and acute lung injury in sepsis, which could be associated with the inflammatory responses.
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Affiliation(s)
- You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kwang Pil Rim
- Department of Emergency Medicine, St. Carollo General Hospital, Suncheon, Korea
| | - In Soo Cho
- Department of Emergency Medicine, Kepco Medical Center, Seoul, Korea
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Mokrushin AA, Pavlinova LI, Borovikov SE. Influence of cooling rate on activity of ionotropic glutamate receptors in brain slices at hypothermia. J Therm Biol 2014; 44:5-13. [PMID: 25086967 DOI: 10.1016/j.jtherbio.2014.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 05/23/2014] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
Hypothermia is a known approach in the treatment of neurological pathologies. Mild hypothermia enhances the therapeutic window for application of medicines, while deep hypothermia is often accompanied by complications, including problems in the recovery of brain functions. The purpose of present study was to investigate the functioning of glutamate ionotropic receptors in brain slices cooled with different rates during mild, moderate and deep hypothermia. Using a system of gradual cooling combined with electrophysiological recordings in slices, we have shown that synaptic activity mediated by the alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid and N-methyl-D-aspartate receptors in rat olfactory cortex was strongly dependent on the rate of lowering the temperature. High cooling rate caused a progressive decrease in glutamate receptor activity in brain slices during gradual cooling from mild to deep hypothermia. On the contrary, low cooling rate slightly changed the synaptic responses in deep hypothermia. The short-term potentiation may be induced in slices by electric tetanization at 16 °C in this case. Hence, low cooling rate promoted preservation of neuronal activity and plasticity in the brain tissue.
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Affiliation(s)
- Anatoly A Mokrushin
- I.P. Pavlov Institute of Physiology, Russian Academy of Science, 199034, Nab. Makarova, 6, Saint-Petersburg, Russia
| | - Larisa I Pavlinova
- I.P. Pavlov Institute of Physiology, Russian Academy of Science, 199034, Nab. Makarova, 6, Saint-Petersburg, Russia; Institute of Experimental Medicine, Russian Academy of Science, 197376, Ul.Akad. Pavlova, 12, Saint-Petersburg, Russia.
| | - Sergey E Borovikov
- Science Center "Bio", 197376 Street L. Tolstoy, Building 7, 5-H (9), Saint-Petersburg, Russia
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Signaling mechanisms and disrupted cytoskeleton in the diphenyl ditelluride neurotoxicity. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2014; 2014:458601. [PMID: 25050142 PMCID: PMC4090446 DOI: 10.1155/2014/458601] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/26/2014] [Indexed: 01/14/2023]
Abstract
Evidence from our group supports that diphenyl ditelluride (PhTe)2 neurotoxicity depends on modulation of signaling pathways initiated at the plasma membrane. The (PhTe)2-evoked signal is transduced downstream of voltage-dependent Ca2+ channels (VDCC), N-methyl-D-aspartate receptors (NMDA), or metabotropic glutamate receptors activation via different kinase pathways (protein kinase A, phospholipase C/protein kinase C, mitogen-activated protein kinases (MAPKs), and Akt signaling pathway). Among the most relevant cues of misregulated signaling mechanisms evoked by (PhTe)2 is the cytoskeleton of neural cells. The in vivo and in vitro exposure to (PhTe)2 induce hyperphosphorylation/hypophosphorylation of neuronal and glial intermediate filament (IF) proteins (neurofilaments and glial fibrillary acidic protein, resp.) in different brain structures of young rats. Phosphorylation of IFs at specific sites modulates their association/disassociation and interferes with important physiological roles, such as axonal transport. Disrupted cytoskeleton is a crucial marker of neurodegeneration and is associated with reactive astrogliosis and apoptotic cell death. This review focuses the current knowledge and important results on the mechanisms of (PhTe)2 neurotoxicity with special emphasis on the cytoskeletal proteins and their differential regulation by kinases/phosphatases and Ca2+-mediated mechanisms in developmental rat brain. We propose that the disrupted cytoskeletal homeostasis could support brain damage provoked by this neurotoxicant.
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Scantling D, Klonoski E, Valentino DJ. Use of therapeutic hypothermia in cocaine-induced cardiac arrest: further evidence. Am J Crit Care 2014; 23:89-92. [PMID: 24382622 DOI: 10.4037/ajcc2014299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Therapeutic hypothermia is an important and successful treatment that has been endorsed only in specific clinical settings of cardiac arrest. Inclusion criteria thus far have not embraced drug-induced cardiac arrest, but clinical evidence has been mounting that therapeutic hypothermia may be beneficial in such cases. A 59-year-old man who experienced a cocaine-induced cardiac arrest had a full neurological recovery after use of therapeutic hypothermia. The relevant pathophysiology of cocaine-induced cardiac arrest is reviewed, the mechanism and history of therapeutic hypothermia are discussed, and the clinical evidence recommending the use of therapeutic hypothermia in cocaine-induced cardiac arrest is reinforced.
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Affiliation(s)
- Dane Scantling
- Dane Scantling is a fourth year medical student at The Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania. Emily Klonoski is an internal medicine resident a St Luke’s University Health Network in Bethlehem, Pennsylvania. Dominic J. Valentino III is the medical director of critical care at Mercy Fitzgerald Hospital in Darby, Pennsylvania
| | - Emily Klonoski
- Dane Scantling is a fourth year medical student at The Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania. Emily Klonoski is an internal medicine resident a St Luke’s University Health Network in Bethlehem, Pennsylvania. Dominic J. Valentino III is the medical director of critical care at Mercy Fitzgerald Hospital in Darby, Pennsylvania
| | - Dominic J. Valentino
- Dane Scantling is a fourth year medical student at The Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania. Emily Klonoski is an internal medicine resident a St Luke’s University Health Network in Bethlehem, Pennsylvania. Dominic J. Valentino III is the medical director of critical care at Mercy Fitzgerald Hospital in Darby, Pennsylvania
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Gregersen M, Lee DH, Gabatto P, Bickler PE. Limitations of Mild, Moderate, and Profound Hypothermia in Protecting Developing Hippocampal Neurons After Simulated Ischemia. Ther Hypothermia Temp Manag 2013; 3:178-188. [PMID: 24380031 PMCID: PMC3868300 DOI: 10.1089/ther.2013.0017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Mild hypothermia (33°C-34°C) after cerebral ischemia in intact animals or ischemia-like conditions in vitro reduces neuron death. However, it is now clear that more profound hypothermia or delayed hypothermia may not provide significant protection. To further define the limitations of hypothermia after cerebral ischemia, we used hippocampal slice cultures to examine the effects of various degrees, durations, and delays of hypothermia on neuron death after an ischemia-like insult. Organotypic cultures of the hippocampus from 7- to 8 day-old rat pups were cooled to 32°C, 23°C, 17°C, or 4°C immediately or after a 2-4 hour delay from an injurious insult of oxygen and glucose deprivation (OGD). Cell death in CA1, CA3 and dentate regions of the cultures was assessed 24 hours later with SYTOX® or propidium iodide, both of which are fluorescent markers labeling damaged cells. OGD caused extensive cell death in CA1, CA3, and dentate regions of the hippocampal cultures. Hypothermia (32°C, 23°C and 17°C) for 4-6 hours immediately after OGD was protective at 24 hours, but when hypothermia was applied for longer periods or delayed after OGD, no protection or increased death was seen. Ultra-profound hypothermia (4°C) increased cell death in all cell areas of the hippocampus even when after a milder insult of only hypoxia. In an in vitro model of recovery after an ischemia-like insult, mild to profound hypothermia is protective only when applied without delay and for limited periods of time (6-8 hours). Longer durations of hypothermia, or delayed application of the hypothermia can increase neuron death. These findings may have implications for clinical uses of therapeutic hypothermia after hypoxic or ischemic insults, and suggest that further work is needed to elucidate the limitations of hypothermia as a protective treatment after ischemic stress.
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Affiliation(s)
- Maren Gregersen
- Severinghaus-Radiometer Research Laboratories, Department of Anesthesia and Perioperative Care, University of California at San Francisco , San Francisco, California
| | - Deok Hee Lee
- Severinghaus-Radiometer Research Laboratories, Department of Anesthesia and Perioperative Care, University of California at San Francisco , San Francisco, California
| | - Pablo Gabatto
- Severinghaus-Radiometer Research Laboratories, Department of Anesthesia and Perioperative Care, University of California at San Francisco , San Francisco, California
| | - Philip E Bickler
- Severinghaus-Radiometer Research Laboratories, Department of Anesthesia and Perioperative Care, University of California at San Francisco , San Francisco, California
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Seo KA, Kim S, Lee NM, Chae SA. Susceptibility of rat hippocampal neurons to hypothermia during development. KOREAN JOURNAL OF PEDIATRICS 2013; 56:446-50. [PMID: 24244213 PMCID: PMC3827493 DOI: 10.3345/kjp.2013.56.10.446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 07/10/2013] [Accepted: 08/19/2013] [Indexed: 12/04/2022]
Abstract
Purpose This study evaluated the extent of damage due to hypothermia in the mature and immature brain. Methods Hippocampal tissue cultures at 7 and 14 days in vitro (DIV) were used to represent the immature and mature brain, respectively. The cultures were exposed at 25℃ for 0, 10, 30, and 60 minutes (n=30 in each subgroup). Propidium iodide fluorescent images were captured 24 and 48 hours after hypothermic injury. Damaged areas of the cornu ammonis 1 (CA1), CA3, and dentate gyrus (DG) were measured using image analysis. Results At 7 DIV, the tissues exposed to cold injury for 60 minutes showed increased damage in CA1 (P<0.001) and CA3 (P=0.005) compared to the control group at 48 hours. Increased damage to DG was observed at 24 (P=0.008) and 48 hours (P=0.011). The 14 DIV tissues did not demonstrate any significant differences compared with the control group, except for the tissues exposed for 30 minutes in which DG showed less damage at 48 hours than the control group (P=0.048). In tissues at 7 DIV, CA1 (P=0.040) and DG (P=0.013) showed differences in the duration of cold exposure. Conclusion The immature brain is more vulnerable to hypothermic injury than the mature brain.
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Affiliation(s)
- Kyung Ah Seo
- Department of Pediatrics, Chung-Ang University College of Medicine, Seoul, Korea
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Kazmierska P, Konopacki J. Development of NMDA-induced theta rhythm in hippocampal formation slices. Brain Res Bull 2013; 98:93-101. [DOI: 10.1016/j.brainresbull.2013.07.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 07/11/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
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Tsai JY, Pan W, LeMaire SA, Pisklak P, Lee VV, Bracey AW, Elayda MA, Preventza O, Price MD, Collard CD, Coselli JS. Moderate hypothermia during aortic arch surgery is associated with reduced risk of early mortality. J Thorac Cardiovasc Surg 2013; 146:662-7. [DOI: 10.1016/j.jtcvs.2013.03.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 02/18/2013] [Accepted: 03/05/2013] [Indexed: 12/20/2022]
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Freitas K, Negus SS, Carroll FI, Damaj MI. In vivo pharmacological interactions between a type II positive allosteric modulator of α7 nicotinic ACh receptors and nicotinic agonists in a murine tonic pain model. Br J Pharmacol 2013; 169:567-79. [PMID: 23004024 PMCID: PMC3682705 DOI: 10.1111/j.1476-5381.2012.02226.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 08/09/2012] [Accepted: 08/29/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE The α7 nicotinic ACh receptor subtype is abundantly expressed in the CNS and in the periphery. Recent evidence suggests that α7 nicotinic ACh receptor (nAChR) subtypes, which can be activated by an endogenous cholinergic tone comprising ACh and the α7 agonist choline, play an important role in chronic pain and inflammation. In this study, we evaluated whether type II α7 positive allosteric modulator PNU-120596 induces antinociception on its own and in combination with choline in the formalin pain model. EXPERIMENTAL APPROACH We assessed the effects of PNU-120596 and choline and the nature of their interactions in the formalin test using an isobolographic analysis. In addition, we evaluated the interaction of PNU-120596 with PHA-54613, an exogenous selective α7 nAChR agonist, in the formalin test. Finally, we assessed the interaction between PNU-120596 and nicotine using acute thermal pain, locomotor activity, body temperature and convulsing activity tests in mice. KEY RESULTS We found that PNU-120596 dose-dependently attenuated nociceptive behaviour in the formalin test after systemic administration in mice. In addition, mixtures of PNU-120596 and choline synergistically reduced formalin-induced pain. PNU-120596 enhanced the effects of nicotine and α7 agonist PHA-543613 in the same test. In contrast, PNU-120596 failed to enhance nicotine-induced convulsions, hypomotility and antinociception in acute pain models. Surprisingly, it enhanced nicotine-induced hypothermia via activation of α7 nAChRs. CONCLUSIONS AND IMPLICATIONS Our results demonstrate that type II α7 positive allosteric modulators produce antinociceptive effects in the formalin test through a synergistic interaction with the endogenous α7 agonist choline.
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Affiliation(s)
- K Freitas
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA 23298-0613, USA
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Pu J, Niu X, Zhao J. Excitatory amino acid changes in the brains of rhesus monkeys following selective cerebral deep hypothermia and blood flow occlusion. Neural Regen Res 2013; 8:143-8. [PMID: 25206484 PMCID: PMC4107508 DOI: 10.3969/j.issn.1673-5374.2013.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 11/22/2012] [Indexed: 11/18/2022] Open
Abstract
Selective cerebral deep hypothermia and blood flow occlusion can enhance brain tolerance to ischemia and hypoxia and reduce cardiopulmonary complications in monkeys. Excitotoxicity induced by the release of a large amount of excitatory amino acids after cerebral ischemia is the major mechanism underlying ischemic brain injury and nerve cell death. In the present study, we used selective cerebral deep hypothermia and blood flow occlusion to block the bilateral common carotid arteries and/or bilateral vertebral arteries in rhesus monkey, followed by reperfusion using Ringer's solution at 4°C. Microdialysis and transmission electron microscope results showed that selective cerebral deep hypothermia and blood flow occlusion inhibited the release of glutamic acid into the extracellular fluid in the brain frontal lobe and relieved pathological injury in terms of the ultrastructure of brain tissues after severe cerebral ischemia. These findings indicate that cerebral deep hypothermia and blood flow occlusion can inhibit cytotoxic effects and attenuate ischemic/hypoxic brain injury through decreasing the release of excitatory amino acids, such as glutamic acid.
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Affiliation(s)
- Jun Pu
- Department of Neurosurgery, Beijing Tiantan Hospital of Capital Medical University, Beijing 100065, China
| | - Xiaoqun Niu
- Department of Respiratory Medicine, Second Hospital of Kunming Medical University, Kunming 650101, Yunnan Province, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital of Capital Medical University, Beijing 100065, China
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Anesthetic protection of neurons injured by hypothermia and rewarming: roles of intracellular Ca2+ and excitotoxicity. Anesthesiology 2012; 117:280-92. [PMID: 22728782 DOI: 10.1097/aln.0b013e318260a7b9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Mild hypothermia is neuroprotective after cerebral ischemia but surgery involving profound hypothermia (PH, temperature less than 18°C) is associated with neurologic complications. Rewarming (RW) from PH injures hippocampal neurons by glutamate excitotoxicity, N-methyl-D-aspartate receptors, and intracellular calcium. Because neurons are protected from hypoxia-ischemia by anesthetic agents that inhibit N-methyl-D-aspartic acid receptors, we tested whether anesthetics protect neurons from damage caused by PH/RW. METHODS Organotypic cultures of rat hippocampus were used to model PH/RW injury, with hypothermia at 4°C followed by RW to 37°C and assessment of cell death 1 or 24 h later. Cell death and intracellular Ca were assessed with fluorescent dye imaging and histology. Anesthetic agents were present in the culture media during PH and RW or only RW. RESULTS Injury to hippocampal CA1, CA3, and dentate neurons after PH and RW involved cell swelling, cell rupture, and adenosine triphosphate (ATP) loss; this injury was similar for 4 through 10 h of PH. Isoflurane (1% and 2%), sevoflurane (3%) and xenon (60%) reduced cell loss but propofol (3 μM) and pentobarbital (100 μM) did not. Isoflurane protection involved reduction in N-methyl-D-aspartate receptor-mediated Ca influx during RW but did not involve γ-amino butyric acid receptors or KATP channels. However, cell death increased over the next day. CONCLUSION Anesthetic protection of neurons rewarmed from 4°C involves suppression of N-methyl-D-aspartate receptor-mediated Ca overload in neurons undergoing ATP loss and excitotoxicity. Unlike during hypoxia/ischemia, anesthetic agents acting predominantly on γ-aminobutyric acid receptors do not protect against PH/RW. The durability of anesthetic protection against cold injury may be limited.
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Helbok R, Schiefecker A, Fischer M, Dietmann A, Schmutzhard E. Hypothermia and advanced neuromonitoring. Crit Care 2012. [PMCID: PMC3389487 DOI: 10.1186/cc11285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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