Cerebral metabolism during sustained hypoxemia in preterm fetal sheep

Hemodynamic and metabolic correlates of perinatal white matter injury severity

Background and Purpose

Although the spectrum of perinatal white matter injury (WMI) in preterm infants is shifting from cystic encephalomalacia to milder forms of WMI, the factors that contribute to this changing spectrum are unclear. We hypothesized that the variability in WMI quantified by immunohistochemical markers of inflammation could be correlated with the severity of impaired blood oxygen, glucose and lactate.

Methods

We employed a preterm fetal sheep model of in utero moderate hypoxemia and global severe but not complete cerebral ischemia that reproduces the spectrum of human WMI.

Since there is small but measurable residual brain blood flow during occlusion, we sought to determine if the metabolic state of the residual arterial blood was associated with severity of WMI. Near the conclusion of hypoxia-ischemia, we recorded cephalic arterial blood pressure, blood oxygen, glucose and lactate levels. To define the spectrum of WMI, an ordinal WMI rating scale was compared against an unbiased quantitative image analysis protocol that provided continuous histo-pathological outcome measures for astrogliosis and microgliosis derived from the entire white matter.

Results

A spectrum of WMI was observed that ranged from diffuse non-necrotic lesions to more severe injury that comprised discrete foci of microscopic or macroscopic necrosis. Residual arterial pressure, oxygen content and blood glucose displayed a significant inverse association with WMI and lactate concentrations were directly related. Elevated glucose levels were the most significantly associated with less severe WMI.

Conclusions

Our results suggest that under conditions of hypoxemia and severe cephalic hypotension, WMI severity measured using unbiased immunohistochemical measurements correlated with several physiologic parameters, including glucose, which may be a useful marker of fetal response to hypoxia or provide protection against energy failure and more severe WMI.

Restrained cerebral hyperperfusion in response to superimposed acute hypoxemia in growth-restricted human fetuses with established brain-sparing blood flow

OBJECTIVE

To investigate the cerebral circulatory response to superimposed acute hypoxemia in growth-restricted fetuses with established brain-sparing flow (BSF) during basal conditions.

MATERIAL AND METHODS

76 term fetuses suspected of growth restriction were exposed to Doppler velocimetry in the umbilical artery (UA) and middle cerebral artery (MCA), and in 38-39 cases also in Galen's vein (GV), straight sinus (SS), and transverse sinus (TS), before and during an oxytocin challenge test (OCT), and simultaneous to electronic fetal heart rate monitoring. Nonparametric statistical analyses compared presence/absence of established BSF (MCA-to-UA pulsatility index [PI] ratio <1.08) with a two-tailed P<0.05 considered significant.

RESULTS

The OCT (positive/negative) was not different in the BSF group (BSFG, N=16) and the normal flow group (NFG, N=60) (P=0.2). During uterine contractions, the MCA PI decreased in the NFG, but not in the BSFG. De novo GV pulsations and increase of GV maximum flow velocity occurred during contractions in the NFG, but not in the BSFG. Significant SS flow velocity waveform changes were found in neither group and TS flow changes in the BSFG only.

CONCLUSIONS

Fetuses without established brain-sparing flow during basal conditions responded with both arterial and venous brain-sparing flow during acute hypoxemia, whereas in fetuses with established brain-sparing flow the cerebral circulatory responses were absent or equivocal. Fetuses with established brain-sparing flow may have a limited capacity of further cerebral hyperperfusion during superimposed acute hypoxic stress.

Determining the contribution of asphyxia to brain damage in the neonate

Studies in the research laboratory have demonstrated the complex relationship between fetal and newborn asphyxia and brain damage, a balance between the degree, duration and nature of the asphyxia and the quality of the cardiovascular compensatory response. Clinical studies would support the contention that the human fetus and newborn behave in a similar manner. An accurate diagnosis of asphyxia requires a blood gas and acid base assessment. The clinical classification of fetal asphyxia is based on a measure of metabolic acidosis to confirm that fetal asphyxia has occurred and the expression of neonatal encephalopathy and other organ system complications to express the severity of the asphyxia. The prevalence of fetal asphyxia at delivery is at term, 25 per 1000 live births of whom 15% are moderate or severe; and in the preterm, 73 per 1000 live births of whom 50% are moderate or severe. It remains to be determined how often the asphyxia recognized at delivery may have been present before the onset of labor. There is a growing body of indirect and direct evidence to support the contention that antepartum fetal asphyxia is important in the occurrence of brain damage. Although much of the brain damage observed in the newborn reflects events that occurred before delivery, newborn asphyxia and hypotension, particularly in the preterm newborn, may contribute to the brain damage accounting for deficits in surviving children.

Fetal brain regional responses to cerebral hypoperfusion: modulation by estrogen

We have previously demonstrated that cerebral hypoperfusion stimulates several physiological and molecular responses which are components of homeostatic reflexes. Physiological increases in fetal plasma estradiol concentration modulate fetal brain responsiveness to hypotension. In the present study, we tested the effect of cerebral hypoperfusion and/or estradiol on the expression of Fos, the protein product of the gene c-fos in late-gestation fetal sheep. We hypothesized that estrogen and cerebral hypoperfusion alone would augment Fos abundance in various brain regions, including the hypothalamus and brainstem, and that estrogen would augment or otherwise modify the Fos response to cerebral hypoperfusion. Singleton or twin fetuses of time-dated pregnant ewes were chronically catheterized and fitted with an extravascular balloon occluder around the brachiocephalic artery using aseptic techniques. In one-half of the fetuses, we implanted a pellet subcutaneously which released estradiol at a rate of 5 mg in 21 days. Fetuses were studied at least 5 days after surgery (124-128 days' gestation, term is approximately 147 days). One-half of the fetuses were subjected to a 10-min period of brachiocephalic occlusion (BCO). One hour after the start of the experiment, the ewe and fetus were euthanized and the fetal brain was rapidly recovered, dissected, and frozen in a polypropylene tube in an acetone/dry ice bath. Brain tissue was homogenized in a boiling lysis buffer, and protein concentrations measured using the Bradford method. Extracted proteins were electrophoresed on 7.5% polyacrylamide gels, transferred to nitrocellulose membranes, and probed for Fos. In most brain regions, estradiol or BCO altered the expression of Fos. Analyzed by two-way analysis of variance, there was a statistically significant (p<0.05) interaction between estradiol and BCO in brainstem, cerebellum, and hippocampus, nearly significant in hypothalamus (p=0.07) and not statistically significant in cerebral cortex. In these regions with statistically significant interactions, the expression of Fos in response to the combined treatment of estradiol and BCO was less than the sum of responses to either treatment alone. We conclude that estradiol has a potent action on the fetal brain which is identifiable in the brainstem, cerebellum, and hippocampus and that it modulates the Fos response to cerebral hypoperfusion. The measurement of regional Fos responses using Western blot reveals a negative interaction between estrogen and BCO which might result from alterations in cerebral blood flow or metabolism.

Adenosine mediates decreased cerebral metabolic rate and increased cerebral blood flow during acute moderate hypoxia in the near-term fetal sheep

Exposure of the fetal sheep to moderate to severe hypoxic stress results in both increased cortical blood flow and decreased metabolic rate. Using intravenous infusion of 8-cyclopentyl-1,3-dipropylxanthine (DPCPX), a selective adenosine A1 receptor antagonist that is permeable to the blood brain barrier, we examine the role of adenosine A1 receptors in mediating cortical blood flow and metabolic responses to moderate hypoxia. The effects of DPCPX blockade are compared to controls as well as animals receiving intravenous 8-(p-sulfophenyl)-theophylline) (8-SPT), a non-selective adenosine receptor antagonist which has been found to be blood brain barrier impermeable. Laser Doppler flow probes, tissue PO2, and thermocouples were implanted in the cerebral cortices of near-term fetal sheep. Catheters were placed in the brachial artery and sagittal sinus vein for collection of samples for blood gas analysis. Three to seven days later responses to a 30-min period of fetal hypoxemia (arterial PO2 10-12 mmHg) were studied with administration of 8-SPT, DPCPX, or vehicle. Cerebral metabolic rate was determined by calculation of both brain heat production and oxygen consumption. In response to hypoxia, control experiments demonstrated a 42 +/- 7 % decrease in cortical heat production and a 35 +/- 10 % reduction in oxygen consumption. In contrast, DPCPX infusion during hypoxia resulted in no significant change in brain heat production or oxygen consumption, suggesting the adenosine A1 receptor is involved in lowering metabolic rate during hypoxia. The decrease in cerebral metabolic rate was not altered by 8-SPT infusion, suggesting that the response is not mediated by adenosine receptors located outside the blood brain barrier. In response to hypoxia, control experiments demonstrated a 35 +/- 7 % increase in cortical blood flow. DPCPX infusion did not change this increase in cortical blood flow, however 8-SPT infusion attenuated increases in flow, indicating that hypoxic increases in cerebral blood flow are mediated by adenosine but not via the A1 receptor. In summary, adenosine appears to play a key role in fetal hypoxic defences, acting to increase O2 delivery via adenosine A2 receptors and to decrease metabolic rate via A1 receptors inside the blood brain barrier. These data show for the first time in the mammalian fetus that the adenosine A1 receptor is an important mediator of brain metabolic rate during moderate hypoxia.

Delayed neuronal migration of protein kinase Cgamma immunoreactive cells in hippocampal CA1 area after 48 h of moderate hypoxemia in the near term ovine fetus

The brain is uniquely sensitive to disturbances in energy and oxygen supply, particularly during the early stage of life. Since hypoxemia can indirectly activate the intracellular messenger protein kinase C (PKC), we studied the PKCgamma-immunoreaction in the fetal hippocampal CA1 region of naive (n=4), instrumented control (n=7), and instrumented hypoxemic fetuses (n=14), at a mean gestational age of 127 days. Forty-eight hours of mild to moderate hypoxemia, were followed by a 48-h recovery period. Hypoxemia resulted in an increase in carotid blood flow (137% of control), and a shift towards a higher percentage of high-voltage electrocortical activity. After recovery, the fetal brain was fixated by perfusion of both carotid arteries, sectioned and immunostained for PKCgamma. The distribution of PKCgamma-immunoreactive cells was significantly changed after 48 h of hypoxemia in that the migration of cells (from the ventricular region towards the stratum pyramidale) was delayed (p<0.01) compared to naive and instrumented control animals. In contrast to the distribution, the relative total optical density of PKCgamma-ir cells and fibres in the CA1 hippocampal area was not significant different between the animal groups. We conclude that hypoxemia delayed migration of PKCgamma-ir cells, without neuronal degeneration.

Regional cerebral glucose utilization in immature fetal guinea pigs during maternal isocapnic hypoxemia

Recent studies in immature fetal animals demonstrated only a slight or variable increase in the cerebral glycolytic rate during moderate isocapnic hypoxemia. However, the methods used in those studies did not allow for detection of small differences or of regional redistributions of the cerebral glycolytic rate. Hence, a global increase or a regional redistribution of the cerebral glycolytic rate during hypoxemia accompanied by a severe increase in tissue lactate concentration in a few brain areas may have been overlooked in these studies. Because these pathophysiologic mechanisms seem to considerably exacerbate neuronal cell damage due to hypoxic/ischemic insults, we were keen to clarify this point. We, therefore, applied the 2-deoxyglucose method to fetal guinea pigs in utero and measured total and regional cerebral glucose utilization in fetuses of this species at 0.75 of gestation during maternal isocapnic hypoxemia. At 0.75 of gestation guinea pig dams were chronically catheterized. Control groups were exposed to room air, whereas study groups were exposed to a hypoxic atmosphere (10% oxygen, 2% carbon dioxide, and 88% nitrogen). To measure total and regional cerebral glucose utilization during normoxemia and isocapnic hypoxemia, we injected i.v. 100 microCi of 2-[3H]deoxyglucose into the dams. Total and regional cerebral glucose utilization were determined from the steady-state clearance of 2-deoxyglucose between the maternal arterial plasma and the fetal brain, the glucose concentration in the maternal arterial plasma, and the "lumped constant." During isocapnic hypoxemia, total fetal cerebral glucose utilization was not significantly higher than that previously measured during normoxemia (8 +/- 0.8 versus 8 +/- 1.0 micromol/100 g/min). Furthermore, no redistribution of cerebral glucose utilization could be detected. We conclude that moderate isocapnic hypoxemia in the immature fetal brain does not lead to any significant increase or redistribution of glucose utilization or to any major lactate accumulation. This may be related to the low cerebral metabolic demands of brain tissue at this stage of development. Whether this is the main reason for the known resistance of the immature fetal brain toward ischemic neuronal cell damage remains to be established.

Regional blood flow and the endocrine response to sustained hypoxemia in the preterm ovine fetus

To determine the circulatory response of the preterm fetus to a sustained hypoxic insult, regional blood flow was measured (microsphere technique) in 12 unanesthetized fetal sheep (0.75 gestation) during a normoxic control period, after 1 h and 8 h of sustained hypoxemia, and after a 1-h recovery period. Associated endocrine changes which might relate to organ-specific changes in blood flow were also assessed. Myocardial and cerebral blood flow were increased by 240 and 90%, respectively, such that oxygen delivery to the heart was well maintained throughout the study, whereas that to the brain was significantly decreased by 8 h of hypoxic study. Regional blood flows for all structures within the brain showed similar percent increases, except that for the pituitary gland, where the increase was much smaller, and that for the choroid plexus, where blood flow actually fell. Whereas blood flow to upper body muscle showed no significant change throughout the study, that to the thyroid was increased by 70% by 1 h of hypoxic study but fell thereafter. Adrenal cortical blood flow relative to that of the medulla was increased 3-fold by 8 h of hypoxic study, indicating a differential effect of sustained hypoxia on these vascular beds. Although pituitary and thyroid blood flows showed no relationship to respective trophic and/or secretory hormones measured, values for adrenal cortical flow relative to medullary flow were well correlated with plasma concentrations of ACTH. It is concluded that the "centralization" of blood flow to vital organs in response to a sustained hypoxic insult is qualitatively similar for both the preterm and near term ovine fetus and that hypoxic regulatory mechanisms may be better protective of the heart. Additionally, a role for the functional activation of the adrenal gland in its blood flow response to sustained hypoxemia is suggested.

Local cerebral glucose utilization in fetal guinea pigs at 0.75 gestation

OBJECTIVE

Using the 2-deoxyglucose method, measurements of local cerebral glucose utilization in large fetal animals are very difficult and expensive. To circumvent these problems we recently modified the 2-deoxyglucose method for use in the fetal guinea pig in utero (Berger et al., J Neurochem 1994; 63: 271-279). The present study was designed to measure the rates of local cerebral glucose utilization in fetal guinea pigs at 0.75 of gestation.

STUDY DESIGN

After intravenous injection of 14C 2-deoxyglucose into the dams, local cerebral glucose utilization of the fetuses was measured from the time integral of the tracer in the maternal plasma and the autoradiographically determined concentration of the tracer in various parts of the fetal brain.

RESULTS

Fetal cerebral glucose utilization was low as compared to adult animals and varied in different brain structures from 19 +/- 4 to 29 +/- 7 mumol/100 g/min.

CONCLUSION

This study demonstrates the feasibility to measure local cerebral glucose utilization in undisturbed fetal guinea pigs in utero. We conclude that the low rate of cerebral glucose utilization and its small overall variability may reflect the neurological immaturity of the fetal brain.

Cerebral metabolism within 18 hours of birth asphyxia: a proton magnetic resonance spectroscopy study

Proton magnetic resonance spectroscopy (1H MRS) was performed within 18 h of birth (median 13, range 4-18 h) on 16 term infants with clinical features of birth asphyxia. Ten infants with no evidence of birth asphyxia were studied as controls at 5-18 (median 8) h after birth. To detect delayed impairments in cerebral energy metabolism, 15 infants suspected of asphyxia underwent 31P MRS at 33-106 (median 62) h of age. Choline, creatine, and N-acetylaspartate (NAA) were detected in spectra located to the basal ganglia in all infants. Lactate was detected in 15 of the 16 infants suspected of asphyxia, but in only 4 of the 10 controls (p < 0.05, chi 2). Glutamine and glutamate (Glx) was detected in 11 infants suspected of asphyxia and in three controls, but this difference was not significant at the 5% level. The spectra revealed no other significant differences between asphyxiated infants and controls. In the asphyxiated infants, there was a negative correlation between the ratio of lactate to creatine in the first 18 h of life and phosphocreatine/inorganic phosphate (PCr/ P(i)) at 33-106 h (p < 0.001). Five severely asphyxiated infants had PCr/P(i) < 0.75 (median 0.53, range 0.14-0.65), indicating a poor neurodevelopmental prognosis, and a further infant died before PCr/Pi could be measured. Ten infants had PCr/P(i) > 0.75 (1.03, 0.76-1.49). Median lactate/creatine was 1.47 (range 0.67-3.81) in the six severely affected subjects, 0.38 (0-1.51) in the latter group, and 0 (0-0.6) in controls (p < 0.0005, Kruskall-Wallis). These results suggest that, after birth asphyxia, cerebral energy metabolism is abnormal during the period when 31P MRS characteristically gives normal results. 1H MRS might be of value in predicting which infants are likely to suffer a decline in cerebral high energy phosphate concentrations and subsequent neurodevelopmental impairment.