Effects of mild hypothermia on cerebral blood flow-independent changes in cortical extracellular levels of amino acids following contusion trauma in the rat

Spreading Depolarizations Contribute to the Acute Behavior Deficits Associated With a Mild Traumatic Brain Injury in Mice

Concussions or mild traumatic brain injuries (mTBIs) are often described and diagnosed by the acute signs and symptoms of neurological dysfunction including weakness, dizziness, disorientation, headaches, and altered mental state. The cellular and physiological mechanisms of neurological dysfunction and acute symptoms are unclear. Spreading depolarizations (SDs) occur after severe TBIs and have recently been identified in closed-skull mouse models of mTBIs. SDs are massive waves of complete depolarization that result in suppression of cortical activity for multiple minutes. Despite the clear disruption of brain physiology after SDs, the role of SDs in the acute neurological dysfunction and acute behavioral deficits following mTBIs remains unclear. We used a closed-skull mouse model of mTBI and a series of behavioral tasks collectively scored as the neurological severity score (NSS) to assess acute behavior. Our results indicate that mTBIs are associated with significant behavioral deficits in the open field and NSS tasks relative to sham-condition animals. The behavioral deficits associated with the mTBI recovered within 3 h. We show here that the presence of mTBI-induced bilateral SDs were significantly associated with the acute behavioral deficits. To identify the role of SDs in the acute behavioral deficits, we used exogenous potassium and optogenetic approaches to induce SDs in the absence of the mTBI. Bilateral SDs alone were associated with similar behavioral deficits in the open field and NSS tasks. Collectively, these studies demonstrate that bilateral SDs are linked to the acute behavioral deficits associated with mTBIs.

Oxidative Stress in Traumatic Brain Injury

Traumatic Brain Injury (TBI) remains a major cause of disability worldwide. It involves a complex neurometabolic cascade, including oxidative stress. The products of this manuscript is examining the underlying pathophysiological mechanism, including reactive oxygen species (ROS) and reactive nitrogen species (RNS). This process in turn leads to secondary injury cascade, which includes lipid peroxidation products. These reactions ultimately play a key role in chronic inflammation and synaptic dysfunction in a synergistic fashion. Although there are no FDA approved antioxidant therapy for TBI, there is a number of antioxidant therapies that have been tested and include free radical scavengers, activators of antioxidant systems, inhibitors of free radical generating enzymes, and antioxidant enzymes. Antioxidant therapies have led to cognitive and functional recovery post TBI, and they offer a promising treatment option for patients recovering from TBI. Current major challenges in treatment of TBI symptoms include heterogenous nature of injury, as well as access to timely treatment post injury. The inherent benefits of antioxidant therapies include minimally reported side effects, and relative ease of use in the clinical setting. The current review also provides a highlight of the more studied anti-oxidant regimen with applicability for TBI treatment with potential use in the real clinical setting.

Proteoglycan 4 Reduces Neuroinflammation and Protects the Blood-Brain Barrier after Traumatic Brain Injury

Neuroinflammation and dysfunction of the blood-brain barrier (BBB) are two prominent mechanisms of secondary injury in neurotrauma. It has been suggested that Toll-like receptors (TLRs) play important roles in initiating and propagating neuroinflammation resulting from traumatic brain injury (TBI), but potential beneficial effects of targeting these receptors in TBI have not been broadly studied. Here, we investigated the effect of targeting TLRs with proteoglycan 4 (PRG4) on post-traumatic neuroinflammation and BBB function. PRG4 is a mucinous glycoprotein with strong anti-inflammatory properties, exerting its biological effects by interfering with TLR2/4 signaling. In addition, PRG4 has the ability to inhibit activation of cluster of differentiation 44 (CD44), a cell-surface glycoprotein playing an important role in inflammation. Using the controlled cortical impact model of TBI in rats, we showed a rapid and prolonged upregulation of message for TLR2/4 and CD44 in the injured cortex. In the in vitro model of the BBB, recombinant human PRG4 (rhPRG4) crossed the endothelial monolayers through a high-capacity, saturable transport system. In rats sustaining TBI, PRG4 delivery to the brain was enhanced by post-traumatic increase in BBB permeability. rhPRG4 injected intravenously at 1 h post-TBI potently inhibited post-traumatic activation of nuclear factor kappa B and extracellular signal-regulated kinases 1/2, the two major signal transduction pathways associated with TLR2/4 and CD44, and curtailed the post-traumatic influx of monocytes. In addition, PRG4 restored normal BBB function after TBI by preventing the post-traumatic loss of tight junction protein claudin 5 and reduced neuronal death. Our observations provide support for therapeutic strategies targeting TLRs in TBI.

MicroRNAs: The New Challenge for Traumatic Brain Injury Diagnosis

The acronym TBI refers to traumatic brain injury, an alteration of brain function, or an evidence of brain pathology, that is caused by an external force. TBI is estimated to become the third leading cause of permanent disability and mortality worldwide. TBI-related injuries can be classified in many ways, according to the degree of severity or the pathophysiology of brain injury (primary and secondary damage). Numerous cellular pathways act in secondary brain damage: excitotoxicity (mediated by excitatory neurotransmitters), free radical generation (due to mitochondrial impairment), neuroinflammatory response (due to central nervous system and immunoactivation) and apoptosis. In this scenario, microRNAs are implicated in the regulation of almost all genes at the post-transcriptional level. Several microRNAs have been demonstrated to be specifically expressed in particular cerebral areas; moreover, physiological changes in microRNA expression during normal cerebral development upon the establishment of neural networks have been characterized. More importantly, microRNAs show profound alteration in expression in response to brain pathological states, both traumatic or not. This review summarizes the most important molecular networks involved in TBI and examines the most recent and important findings on TBI-related microRNAs, both in animal and clinical studies. The importance of microRNA research holds promise to find biomarkers able to unearth primary and secondary molecular patterns altered upon TBI, to ultimately identify key points of regulation, as a valuable support in forensic pathology and potential therapeutic targets for clinical treatment.

Therapeutic hypothermia to reduce intracranial pressure after traumatic brain injury: the Eurotherm3235 RCT

BACKGROUND

Traumatic brain injury (TBI) is a major cause of disability and death in young adults worldwide. It results in around 1 million hospital admissions annually in the European Union (EU), causes a majority of the 50,000 deaths from road traffic accidents and leaves a further ≈10,000 people severely disabled.

OBJECTIVE

The Eurotherm3235 Trial was a pragmatic trial examining the effectiveness of hypothermia (32-35 °C) to reduce raised intracranial pressure (ICP) following severe TBI and reduce morbidity and mortality 6 months after TBI.

DESIGN

An international, multicentre, randomised controlled trial.

SETTING

Specialist neurological critical care units.

PARTICIPANTS

We included adult participants following TBI. Eligible patients had ICP monitoring in place with an ICP of > 20 mmHg despite first-line treatments. Participants were randomised to receive standard care with the addition of hypothermia (32-35 °C) or standard care alone. Online randomisation and the use of an electronic case report form (CRF) ensured concealment of random treatment allocation. It was not possible to blind local investigators to allocation as it was obvious which participants were receiving hypothermia. We collected information on how well the participant had recovered 6 months after injury. This information was provided either by the participant themself (if they were able) and/or a person close to them by completing the Glasgow Outcome Scale - Extended (GOSE) questionnaire. Telephone follow-up was carried out by a blinded independent clinician.

INTERVENTIONS

The primary intervention to reduce ICP in the hypothermia group after randomisation was induction of hypothermia. Core temperature was initially reduced to 35 °C and decreased incrementally to a lower limit of 32 °C if necessary to maintain ICP at < 20 mmHg. Rewarming began after 48 hours if ICP remained controlled. Participants in the standard-care group received usual care at that centre, but without hypothermia.

MAIN OUTCOME MEASURES

The primary outcome measure was the GOSE [range 1 (dead) to 8 (upper good recovery)] at 6 months after the injury as assessed by an independent collaborator, blind to the intervention. A priori subgroup analysis tested the relationship between minimisation factors including being aged < 45 years, having a post-resuscitation Glasgow Coma Scale (GCS) motor score of < 2 on admission, having a time from injury of < 12 hours and patient outcome.

RESULTS

We enrolled 387 patients from 47 centres in 18 countries. The trial was closed to recruitment following concerns raised by the Data and Safety Monitoring Committee in October 2014. On an intention-to-treat basis, 195 participants were randomised to hypothermia treatment and 192 to standard care. Regarding participant outcome, there was a higher mortality rate and poorer functional recovery at 6 months in the hypothermia group. The adjusted common odds ratio (OR) for the primary statistical analysis of the GOSE was 1.54 [95% confidence interval (CI) 1.03 to 2.31]; when the GOSE was dichotomised the OR was 1.74 (95% CI 1.09 to 2.77). Both results favoured standard care alone. In this pragmatic study, we did not collect data on adverse events. Data on serious adverse events (SAEs) were collected but were subject to reporting bias, with most SAEs being reported in the hypothermia group.

CONCLUSIONS

In participants following TBI and with an ICP of > 20 mmHg, titrated therapeutic hypothermia successfully reduced ICP but led to a higher mortality rate and worse functional outcome.

LIMITATIONS

Inability to blind treatment allocation as it was obvious which participants were randomised to the hypothermia group; there was biased recording of SAEs in the hypothermia group. We now believe that more adequately powered clinical trials of common therapies used to reduce ICP, such as hypertonic therapy, barbiturates and hyperventilation, are required to assess their potential benefits and risks to patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN34555414.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 45. See the NIHR Journals Library website for further project information. The European Society of Intensive Care Medicine supported the pilot phase of this trial.

A New Vision for Therapeutic Hypothermia in the Era of Targeted Temperature Management: A Speculative Synthesis

Three decades of animal studies have reproducibly shown that hypothermia is profoundly cerebroprotective during or after a central nervous system (CNS) insult. The success of hypothermia in preclinical acute brain injury has not only fostered continued interest in research on the classic secondary injury mechanisms that are prevented or blunted by hypothermia but has also sparked a surge of new interest in elucidating beneficial signaling molecules that are increased by cooling. Ironically, while research into cold-induced neuroprotection is enjoying newfound interest in chronic neurodegenerative disease, conversely, the scope of the utility of therapeutic hypothermia (TH) across the field of acute brain injury is somewhat controversial and remains to be fully defined. This has led to the era of Targeted Temperature Management, which emphasizes a wider range of temperatures (33–36°C) showing benefit in acute brain injury. In this comprehensive review, we focus on our current understandings of the novel neuroprotective mechanisms activated by TH, and discuss the critical importance of developmental age germane to its clinical efficacy. We review emerging data on four cold stress hormones and three cold shock proteins that have generated new interest in hypothermia in the field of CNS injury, to create a framework for new frontiers in TH research. We make the case that further elucidation of novel cold responsive pathways might lead to major breakthroughs in the treatment of acute brain injury, chronic neurological diseases, and have broad potential implications for medicines of the distant future, including scenarios such as the prevention of adverse effects of long-duration spaceflight, among others. Finally, we introduce several new phrases that readily summarize the essence of the major concepts outlined by this review—namely, Ultramild Hypothermia, the “Responsivity of Cold Stress Pathways,” and “Hypothermia in a Syringe.”

Selective Brain Hypothermia Mitigates Brain Damage and Improves Neurological Outcome after Post-Traumatic Decompressive Craniectomy in Mice

Hypothermia and decompressive craniectomy (DC) have been considered as treatment for traumatic brain injury. The present study investigates whether selective brain hypothermia added to craniectomy could improve neurological outcome after brain trauma. Male CD-1 mice were assigned into the following groups: sham; DC; closed head injury (CHI); CHI followed by craniectomy (CHI+DC); and CHI+DC followed by focal hypothermia (CHI+DC+H). At 24 h post-trauma, animals were subjected to Neurological Severity Score (NSS) test and Beam Balance Score test. At the same time point, magnetic resonance imaging using a 9.4 Tesla scanner and subsequent volumetric evaluation of edema and contusion were performed. Thereafter, the animals were sacrificed and subjected to histopathological analysis. According to NSS, there was a significant impairment among all the groups subjected to trauma. Animals with both trauma and craniectomy performed significantly worse than animals with craniectomy alone. This deleterious effect disappeared when additional hypothermia was applied. BBS was significantly worse in the CHI and CHI+DC groups, but not in the CHI+DC+H group, compared to the sham animals. Edema and contusion volumes were significantly increased in CHI+DC animals, but not in the CHI+DC+H group, compared to the DC group. Histopathological analysis showed that neuronal loss and contusional blossoming could be attenuated by application of selective brain hypothermia. Selective brain cooling applied post-trauma and craniectomy improved neurological function and reduced structural damage and may be therefore an alternative to complication-burdened systemic hypothermia. Clinical studies are recommended in order to explore the potential of this treatment.

Cellular and molecular mechanisms of injury and spontaneous recovery

Until recently, most have assumed that traumatic brain injury (TBI) was singularly associated with the overt destruction of brain tissue resulting in subsequent morbidity or death. More recently, experimental and clinical studies have shown that the pathobiology of TBI is more complex, involving a host of cellular and subcellular changes that impact on neuronal function and viability while also affecting vascular reactivity and the activation of multiple biological response pathways. Here we review the brain's response to injury, examining both focal and diffuse changes and their implications for post-traumatic brain dysfunction and recovery. TBI-induced neuronal dysfunction and death as well as the diffuse involvement of multiple fiber projections are discussed together with considerations of how local axonal membrane changes or channelopathy translate into local ionic dysregulation and axonal disconnection. Concomitant changes in the cerebral microcirculation are also discussed and their relationship with the parallel changes in the brain's metabolism is considered. These cellular and subcellular events occurring within neurons and their blood supply are correlated with multiple biological response modifiers evoked by generalized post-traumatic inflammation and the parallel activation of oxidative stress processes. The chapter closes with considerations of recovery following focal or diffuse injury. Evidence for dynamic brain reorganization/repair is presented, with considerations of traumatically induced circuit disruption and their progression to either adaptive or in some cases, maladaptive reorganization.

Progress in Clinical Neurosciences: Therapeutic Hypothermia in Severe Traumatic Brain Injury

Severe traumatic brain injury (sTBI) is a relatively common problem with few therapies proven effective. Despite its use for over 50 years, therapeutic hypothermia has not gained widespread acceptance in the treatment of sTBI due to conflicting results from clinical trials. This review will summarize the current evidence from animal, mechanistic and clinical studies supporting the use of therapeutic hypothermia. In addition, issues of rewarming and optimal temperature will be discussed. Finally, the future of hypothermia in sTBI will be addressed.

Diffuse traumatic brain injury and the sensory brain

In this review we discuss the consequences to the brain's cortex, specifically to the sensory cortex, of traumatic brain injury. The thesis underlying this approach is that long-term deficits in cognition seen after brain damage in humans are likely underpinned by an impaired cortical processing of the sensory information needed to drive cognition or to be used by cognitive processes to produce a response. We take it here that the impairment to sensory processing does not arise from damage to peripheral sensory systems, but from disordered brain processing of sensory input.

Blood-brain barrier pathophysiology in traumatic brain injury

The blood-brain barrier (BBB) is formed by tightly connected cerebrovascular endothelial cells, but its normal function also depends on paracrine interactions between the brain endothelium and closely located glia. There is a growing consensus that brain injury, whether it is ischemic, hemorrhagic, or traumatic, leads to dysfunction of the BBB. Changes in BBB function observed after injury are thought to contribute to the loss of neural tissue and to affect the response to neuroprotective drugs. New discoveries suggest that considering the entire gliovascular unit, rather than the BBB alone, will expand our understanding of the cellular and molecular responses to traumatic brain injury (TBI). This review will address the BBB breakdown in TBI, the role of blood-borne factors in affecting the function of the gliovascular unit, changes in BBB permeability and post-traumatic edema formation, and the major pathophysiological factors associated with TBI that may contribute to post-traumatic dysfunction of the BBB. The key role of neuroinflammation and the possible effect of injury on transport mechanisms at the BBB will also be described. Finally, the potential role of the BBB as a target for therapeutic intervention through restoration of normal BBB function after injury and/or by harnessing the cerebrovascular endothelium to produce neurotrophic growth factors will be discussed.

Lesion-induced alterations in astrocyte glutamate transporter expression and function in the hippocampus

Astrocytes express the sodium-dependent glutamate transporters GLAST and GLT-1, which are critical to maintain low extracellular glutamate concentrations. Here, we analyzed changes in their expression and function following a mechanical lesion in the CA1 area of organotypic hippocampal slices. 6-7 days after lesion, a glial scar had formed along the injury site, containing strongly activated astrocytes with increased GFAP and S100 β immunoreactivity, enlarged somata, and reduced capability for uptake of SR101. Astrocytes in the scar's periphery were swollen as well, but showed only moderate upregulation of GFAP and S100 β and efficiently took up SR101. In the scar, clusters of GLT-1 and GLAST immunoreactivity colocalized with GFAP-positive fibers. Apart from these, GLT-1 immunoreactivity declined with increasing distance from the scar, whereas GLAST expression appeared largely uniform. Sodium imaging in reactive astrocytes indicated that glutamate uptake was strongly reduced in the scar but maintained in the periphery. Our results thus show that moderately reactive astrocytes in the lesion periphery maintain overall glutamate transporter expression and function. Strongly reactive astrocytes in the scar, however, display clusters of GLAST and GLT-1 immunoreactivity together with reduced glutamate transport activity. This reduction might contribute to increased extracellular glutamate concentrations and promote excitotoxic cell damage at the lesion site.

Glutamate transporter EAAT2: a new target for the treatment of neurodegenerative diseases

Glutamate is the primary excitatory amino acid neurotransmitter in the CNS. The concentration of glutamate in the synaptic cleft is tightly controlled by interplay between glutamate release and glutamate clearance. Abnormal glutamate release and/or dysfunction of glutamate clearance can cause overstimulation of glutamate receptors and result in neuronal injury known as excitotoxicity. The glial glutamate transporter EAAT2 plays a major role in glutamate clearance. Dysfunction or reduced expression of EAAT2 has been documented in many neurodegenerative diseases. In addition, many studies in animal models of disease indicate that increased EAAT2 expression provides neuronal protection. Here, we summarize these studies and suggest that EAAT2 is a potential target for the prevention of excitotoxicity. EAAT2 can be upregulated by transcriptional or translational activation. We discuss current progress in the search for EAAT2 activators, which is a promising direction for the treatment of neurodegenerative diseases.

Disruptions in the regulation of extracellular glutamate by neurons and glia in the rat striatum two days after diffuse brain injury

Disrupted regulation of extracellular glutamate in the central nervous system contributes to and can exacerbate the acute pathophysiology of traumatic brain injury (TBI). Previously, we reported increased extracellular glutamate in the striatum of anesthetized rats 2 days after diffuse brain injury. To determine the mechanism(s) responsible for increased extracellular glutamate, we used enzyme-based microelectrode arrays (MEAs) coupled with specific pharmacological agents targeted at in vivo neuronal and glial regulation of extracellular glutamate. After TBI, extracellular glutamate was significantly increased in the striatum by (∼90%) averaging 4.1±0.6 μM compared with sham 2.2±0.4 μM. Calcium-dependent neuronal glutamate release, investigated by local application of an N-type calcium channel blocker, was no longer a significant source of extracellular glutamate after TBI, compared with sham. In brain-injured animals, inhibition of glutamate uptake with local application of an excitatory amino acid transporter inhibitor produced significantly greater increase in glutamate spillover (∼ 65%) from the synapses compared with sham. Furthermore, glutamate clearance measured by locally applying glutamate into the extracellular space revealed significant reductions in glutamate clearance parameters in brain-injured animals compared with sham. Taken together, these data indicate that disruptions in calcium-mediated glutamate release and glial regulation of extracellular glutamate contribute to increased extracellular glutamate in the striatum 2 days after diffuse brain injury. Overall, these data suggest that therapeutic strategies used to regulate glutamate release and uptake may improve excitatory circuit function and, possibly, outcomes following TBI.

Pre-hospital hypothermia is not associated with increased survival after traumatic brain injury

BACKGROUND

Conclusions from in vivo and in vitro studies suggest hypothermia may be protective in traumatic brain injury (TBI). Few studies evaluated the effect of admission temperature on outcomes. The purpose of this study is to examine the relationship between admission hypothermia and mortality in patients with isolated, blunt, moderate to severe TBI.

METHODS

The Los Angeles Trauma Database was queried for all patients ≥ 14 y of age with isolated, blunt, moderate to severe TBI (head abbreviated injury score (AIS) ≥ 3, all other <3), admitted between 2005 and 2009. The study population was then stratified into two groups by admission temperature: hypothermic (≤ 35°C) and normothermic (>35°C). Demographic characteristics and outcomes were compared between groups. Logistic regression analysis was used to determine the relationship between admission hypothermia and mortality.

RESULTS

A total of 1834 patients were analyzed and then stratified into two groups: hypothermic (n = 44) and normothermic (n = 1790). There was a significant difference noted in overall mortality (25% versus 7%), with the hypothermic group being four times more likely to succumb to their injuries. After adjusting for confounding factors, admission hypothermia was independently associated with increased mortality (AOR 2.5; 95% CI 1.1-6.3; P = 0.04).

CONCLUSIONS

Although in-vivo and in-vitro studies demonstrate induced hypothermia may be protective in TBI, our study demonstrates that admission hypothermia was associated with increased mortality in isolated, blunt, moderate to severe TBI. Further prospective research is needed to elucidate the role of thermoregulation in patients sustaining TBI.

Hypothermia in Traumatic Brain Injury – A Literature Review

Traumatic brain injury is the leading cause of death in young people. Induced hypothermia has been used as a therapeutic intervention to improve outcome, based on results of animal studies. This article reviews the mechanisms of brain injury, the results of animal and human studies and the reasons that human studies do not always reflect the success seen in animal studies and why results may be ‘lost in translation’ to treatment of patients. It concludes by suggesting further areas of work to investigate the clinical use of therapeutic hypothermia.

The effect of hyperthermia on blood glutamate levels

INTRODUCTION

Glutamate neurotoxicity is determined by the balance between glutamate release within the brain and efflux of excess glutamate from the brain. Brain-to-blood efflux of glutamate is increased by decreasing the concentration of glutamate in blood. Little is known about the effect of hyperthermia on blood glutamate concentrations, and the effectiveness of blood glutamate-decreasing mechanisms in these conditions. Although hyperthermia is hypothesized to decrease blood glutamate concentrations by activation of stress mechanisms, blunting the stress response by blocking β-adrenergic receptors should prevent this decrease. Furthermore, during hyperthermia there should be a concurrent process of leakage of glutamate from muscle tissue into blood, resulting in a contradictory increase of blood glutamate concentrations. In this study we investigated the effects of hyperthermia on blood glutamate levels and studied the effects of the β-adrenergic receptor antagonist propranolol on stress-induced changes in glutamate levels. We then studied the effectiveness of the blood glutamate scavenger oxaloacetate on hyperthermia-induced increases of glutamate levels.

MATERIALS AND METHODS

Twenty-four rats were randomly divided into 3 groups. Rats' body temperatures were increased (by 1°C every 40 minutes) from 37°C to 42°C. The first group received 1 mL per 100 g of isotonic saline (control). The second group received 1 mL per 100 g of 1M oxaloacetate when the temperature reached 39°C. The third group received 10 mg/kg of propranolol before initiation of the warming.

RESULTS

Warming the rats from 37°C to 39°C decreased the blood glutamate levels in the control group (P < 0.01) and oxaloacetate treatment group (P < 0.0001), whereas further increases in temperature from 40°C to 42°C increased the blood glutamate levels (P < 0.01 and P < 0.0001, respectively). Pretreatment with propranolol prevented the decrease in blood glutamate concentrations seen in mild hyperthermia and did not affect the increase in blood glutamate levels seen at temperatures of 41°C and 42°C (P < 0.005).

DISCUSSION

The results of this study demonstrated that hyperthermia leads to decreases in glutamate levels in the blood, presumably by activation of the sympathetic nervous system. Oxaloacetate, previously reported to reduce blood glutamate levels at 37°C, was ineffective at temperatures over 40°C. Propranolol pretreatment blunted the initial decrease in blood glutamate, and thereafter had no effect when compared with control and treatment groups. Understanding the mechanisms underlying glutamate regulation in the blood during states of hyperthermia and stress has important clinical implications in treating neurodegenerative conditions.

Bench-to-bedside review: Hypothermia in traumatic brain injury

Traumatic brain injury remains a major cause of death and severe disability throughout the world. Traumatic brain injury leads to 1,000,000 hospital admissions per annum throughout the European Union. It causes the majority of the 50,000 deaths from road traffic accidents and leaves 10,000 patients severely handicapped: three quarters of these victims are young people. Therapeutic hypothermia has been shown to improve outcome after cardiac arrest, and consequently the European Resuscitation Council and American Heart Association guidelines recommend the use of hypothermia in these patients. Hypothermia is also thought to improve neurological outcome after neonatal birth asphyxia. Cardiac arrest and neonatal asphyxia patient populations present to health care services rapidly and without posing a diagnostic dilemma; therefore, therapeutic systemic hypothermia may be implemented relatively quickly. As a result, hypothermia in these two populations is similar to the laboratory models wherein systemic therapeutic hypothermia is commenced very soon after the injury and has shown so much promise. The need for resuscitation and computerised tomography imaging to confirm the diagnosis in patients with traumatic brain injury is a factor that delays intervention with temperature reduction strategies. Treatments in traumatic brain injury have traditionally focussed on restoring and maintaining adequate brain perfusion, surgically evacuating large haematomas where necessary, and preventing or promptly treating oedema. Brain swelling can be monitored by measuring intracranial pressure (ICP), and in most centres ICP is used to guide treatments and to monitor their success. There is an absence of evidence for the five commonly used treatments for raised ICP and all are potential 'double-edged swords' with significant disadvantages. The use of hypothermia in patients with traumatic brain injury may have beneficial effects in both ICP reduction and possible neuro-protection. This review will focus on the bench-to-bedside evidence that has supported the development of the Eurotherm3235Trial protocol.

The evidence for hypothermia as a neuroprotectant in traumatic brain injury

This article reviews published experimental and clinical evidence for the benefits of modest hypothermia in the treatment of traumatic brain injury (TBI). Therapeutic hypothermia has been reported to improve outcome in several animal models of CNS injury and has been successfully translated to specific patient populations. A PubMed search for hypothermia and TBI was conducted, and important papers were selected for review. The research summarized was conducted at major academic institutions throughout the world. Experimental studies have emphasized that hypothermia can affect multiple pathophysiological mechanisms thought to participate in the detrimental consequences of TBI. Published data from several relevant clinical trials on the use of hypothermia in severely injured TBI patients are also reviewed. The consequences of mild to moderate levels of hypothermia introduced by different strategies to the head-injured patient for variable periods of time are discussed. Both experimental and clinical data support the beneficial effects of modest hypothermia following TBI in specific patient populations. Following on such single-institution studies, positive findings from multicenter TBI trials will be required before this experimental treatment can be considered standard of care.

Protection in animal models of brain and spinal cord injury with mild to moderate hypothermia

For the past 20 years, various laboratories throughout the world have shown that mild to moderate levels of hypothermia lead to neuroprotection and improved functional outcome in various models of brain and spinal cord injury (SCI). Although the potential neuroprotective effects of profound hypothermia during and following central nervous system (CNS) injury have long been recognized, more recent studies have described clinically feasible strategies for protecting the brain and spinal cord using hypothermia following a variety of CNS insults. In some cases, only a one or two degree decrease in brain or core temperature can be effective in protecting the CNS from injury. Alternatively, raising brain temperature only a couple of degrees above normothermia levels worsens outcome in a variety of injury models. Based on these data, resurgence has occurred in the potential use of therapeutic hypothermia in experimental and clinical settings. The study of therapeutic hypothermia is now an international area of investigation with scientists and clinicians from every part of the world contributing to this important, promising therapeutic intervention. This paper reviews the experimental data obtained in animal models of brain and SCI demonstrating the benefits of mild to moderate hypothermia. These studies have provided critical data for the translation of this therapy to the clinical arena. The mechanisms underlying the beneficial effects of mild hypothermia are also summarized.

Therapeutic hypothermia preserves antioxidant defenses after severe traumatic brain injury in infants and children

OBJECTIVE

Oxidative stress contributes to secondary damage after traumatic brain injury (TBI). Hypothermia decreases endogenous antioxidant consumption and lipid peroxidation after experimental cerebral injury. Our objective was to determine the effect of therapeutic hypothermia on oxidative damage after severe TBI in infants and children randomized to moderate hypothermia vs. normothermia.

DESIGN

Prospective randomized controlled study.

SETTING

Pediatric intensive care unit of Pittsburgh Children's Hospital.

PATIENTS

The study included 28 patients.

MEASUREMENTS AND MAIN RESULTS

We compared the effects of hypothermia (32 degrees C-33 degrees C) vs. normothermia in patients treated in a single center involved in a multicentered randomized controlled trial of hypothermia in severe pediatric TBI (Glasgow Coma Scale score <or=8). The patients randomized to hypothermia (n = 13) were cooled to target temperature within approximately 6 to 24 hours for 48 hours and then rewarmed. Antioxidant status was assessed by measurements of total antioxidant reserve and glutathione. Protein oxidation and lipid peroxidation were assessed by measurements of protein thiols and F2-isoprostane, respectively, in ventricular cerebrospinal fluid (CSF) samples (n = 76) obtained on day 1-3 after injury. The association between Glasgow Coma Scale score, age, gender, treatment, temperature, time after injury, and CSF antioxidant reserve, glutathione, protein-thiol, F2-isoprostane levels were assessed by bivariate and multiple regression models. Demographic and clinical characteristics were similar between the two treatment groups. Mechanism of injury included both accidental injury and nonaccidental injury. Multiple regression models revealed preservation of CSF antioxidant reserve by hypothermia (p = 0.001). Similarly, a multiple regression model showed that glutathione levels were inversely associated with patient temperature at the time of sampling (p = 0.002). F2-isoprostane levels peaked on day 1 after injury and were progressively decreased thereafter. Although F2-isoprostane levels were approximately three-fold lower in patients randomized to hypothermia vs. normothermia, this difference was not statistically significant.

CONCLUSION

To our knowledge, this is the first study demonstrating that hypothermia attenuates oxidative stress after severe TBI in infants and children. Our data also support the concept that CSF represents a valuable tool for monitoring treatment effects on oxidative stress after TBI.

Neuroprotection (including hypothermia)

There have been over 2000 publications in the last year addressing the topic of neuroprotection. Novel and emerging therapeutic targets that have been explored include cerebral inflammation, hypothermia, neural transplantation and repair and gene therapy. Unfortunately, with few exceptions, the successes of experimental neuroprotection have not been translated into clinical practice. The possible reasons for the discrepancy between experimental success and clinical benefit are explored.

Postinjury administration of pituitary adenylate cyclase activating polypeptide (PACAP) attenuates traumatically induced axonal injury in rats

Pituitary adenylate cyclase activating polypeptide (PACAP) has several different actions in the nervous system. Numerous studies have shown its neuroprotective effects both in vitro and in vivo. Previously, it has been demonstrated that PACAP reduces brain damage in rat models of global and focal cerebral ischemia. Based on the protective effects of PACAP in cerebral ischemia and the presence of common pathogenic mechanisms in cerebral ischemia and traumatic brain injury (TBI), the aim of the present study was to investigate the possible protective effect of PACAP administered 30 min or 1 h postinjury in a rat model of diffuse axonal injury. Adult Wistar male rats were subjected to impact acceleration, and PACAP was administered intracerebroventricularly 30 min (n = 4), and 1 h after the injury (n = 5). Control animals received the same volume of vehicle at both time-points (n = 5). Two hours after the injury, brains were processed for immunohistochemical localization of damaged axonal profiles displaying either beta-amyloid precursor protein (beta-APP) or RMO-14 immunoreactivity, both considered markers of specific features of traumatic axonal injury. Our results show that treatment with PACAP (100 microg) 30 min or 1 h after the induction of TBI resulted in a significant reduction of the density of beta-APP-immunopositive axon profiles in the corticospinal tract (CSpT). There was no significant difference between the density of beta-APP-immunopositive axons in the medial longitudinal fascicle (MLF). PACAP treatment did not result in significantly different number of RMO-14-immunopositive axonal profiles in either brain areas 2 hours post-injury compared to normal animals. While the results of this study highlighted the complexity of the pathogenesis and manifestation of diffuse axonal injury, they also indicate that PACAP should be considered a potential therapeutic agent in TBI.

Excitotoxic mechanisms and the role of astrocytic glutamate transporters in traumatic brain injury

Glutamate excitotoxicity plays an important role in the development of secondary injuries that occur following traumatic brain injury (TBI), and contributes significantly to expansion of the total volume of injury. Acute increases in extracellular glutamate levels have been detected in both experimental brain trauma models and in human patients, and can lead to over-stimulation of glutamate receptors, resulting in a cascade of excitotoxic-related mechanisms culminating in neuronal damage. These elevated levels of glutamate can be effectively controlled by the astrocytic glutamate transporters GLAST (EAAT1) and GLT-1 (EAAT2). However, evidence indicate these transporters and splice variant are downregulated shortly following the insult, which then precipitates glutamate-mediated excitotoxic conditions. Lack of success with glutamate receptor antagonists as a potential source of clinical intervention treatment following TBI has resulted in the necessity for a better understanding of the mechanisms that underlie the process of excitotoxicity, including the function and regulation of glutamate transporters. Such new insight should improve the likelihood of development of novel avenues for therapeutic intervention following TBI.

Neurotoxic zinc translocation into hippocampal neurons is inhibited by hypothermia and is aggravated by hyperthermia after traumatic brain injury in rats

Hypothermia reduces excitotoxic neuronal damage after seizures, cerebral ischemia and traumatic brain injury (TBI), while hyperthermia exacerbates damage from these insults. Presynaptic release of ionic zinc (Zn2+), translocation and accumulation of Zn2+ ions in postsynaptic neurons are important mechanisms of excitotoxic neuronal injury. We hypothesized that temperature-dependent modulation of excitotoxicity is mediated in part by temperature-dependent changes in the synaptic release and translocation of Zn2+. In the present studies, we used autometallographic (AMG) and fluorescent imaging of N-(6-methoxy-8-quinolyl)-para-toluenesulfonamide (TSQ) staining to quantify the influence of temperature on translocation of Zn2+ into hippocampal neurons in adult rats after weight drop-induced TBI. The central finding was that TBI-induced Zn2+ translocation is strongly influenced by brain temperature. Vesicular Zn2+ release was detected by AMG staining 1 h after TBI. At 30 degrees C, hippocampus showed almost no evidence of vesicular Zn2+ release from presynaptic terminals; at 36.5 degrees C, the hippocampus showed around 20% to 30% presynaptic vesicular Zn2+ release; and at 39 degrees C vesicular Zn2+ release was significantly greater (40% to 60%) than at 36.5 degrees C. At 6 h after TBI, intracellular Zn2+ accumulation was detected by the TSQ staining method, which showed that Zn2+ translocation also paralleled the vesicular Zn2+ release. Neuronal injury, assessed by counting eosinophilic neurons, also paralleled the translocation of Zn2+, being minimal at 30 degrees C and maximal at 39 degrees C. We conclude that pathological Zn2+ translocation in brain after TBI is temperature-dependent and that hypothermic neuronal protection might be mediated in part by reduced Zn2+ translocation.

Early, Transient Increase in Complexin I and Complexin II in the Cerebral Cortex following Traumatic Brain Injury Is Attenuated by N-Acetylcysteine

Alteration of excitatory neurotransmission is a key feature of traumatic brain injury (TBI) in which extracellular glutamate levels rise. Although increased synaptic release of glutamate occurs at the injury site, the precise mechanism is unclear. Complexin I and complexin II constitute a family of cytosolic proteins involved in the regulation of neurotransmitter release, competing with the chaperone protein alpha-SNAP (soluble N-ethylmaleimide-sensitive factor-attachment protein) for binding to the synaptic vesicle protein synaptobrevin as well as the synaptic membrane proteins SNAP-25 and syntaxin, which together form the SNAP receptor (SNARE) complex. Complexin I is predominantly a marker of axosomatic (inhibitory) synapses, whereas complexin II mainly labels axodendritic and axospinous synapses, the majority of which are excitatory. In order to examine the role of these proteins in TBI, we have studied levels of both complexins in the injured hemisphere by immunoblotting over a time period ranging from 6 h to 7 days following lateral fluid-percussion brain injury in the rat. Transient increases in the levels of complexin I and complexin II proteins were detected in the injured cerebral cortex 6 h following TBI. This increase was followed by a decrease of complexin I in the injured cortex and hippocampus, and a decrease in both complexins in the injured thalamus region at day 3 and day 7 post-injury. The early, transient increase in the injured cortex was completely blocked by N-acetylcysteine (NAC) administered 5 min following trauma, suggesting an involvement of oxidative stress. Neuronal loss was also reduced in the injured hemisphere with post-TBI NAC treatment. Our findings suggest a dysregulation of both inhibitory and excitatory neurotransmission following traumatic injury that is responsive to antioxidant treatment. These alterations in complexin levels may also play an important role in neuronal cell loss following TBI, and thus contribute to the pathophysiology of cerebral damage following brain injury.

Traumatic injury in the developing brain–effects of hypothermia

Little is known about the underlying mechanisms of head trauma in the developing brains, despite considerable social and economic impact following such injuries. Age has been shown to substantially influence morbidity and mortality. Children younger than 4 years of age had worse cognitive, motor, and brain atrophy outcomes than children 6 years of age and older. Younger children tend to more frequently suffer from diffuse cerebral swelling compared to adults. Typical autoptic findings also include axonal injury and ischemic neurodegeneration. These differences impact not only the primary response of the brain to injury but the secondary response as well. The complexity of damaging mechanisms in traumatic brain injury contributes to the problem of determining effective therapy. As an alternative/ adjunct to pharmacological approaches, hypothermia has been shown to be cerebroprotective in traumatized adult brains. Although a large number of animal studies have shown protective effects of hypothermia in a variety of damaging mechanisms after TBI, little data exist for young, developing brains. The injury mechanisms of TBI in the immature, effects of hypothermia following resuscitation on adult and immature traumatized brains, and some possible mechanisms of action of hypothermia in the immature traumatized brain are discussed in this review.

Secondary injuries in brain trauma: effects of hypothermia

Hypothermia has been shown to be cerebroprotective in traumatized brains. Although a large number of traumatic brain injury (TBI) studies in animals have shown that hypothermia is effective in suppressing a variety of damaging mechanisms, clinical investigations have shown less consistent results. The complexity of damaging mechanisms in human TBI may contribute to these discrepancies. In particular, secondary injuries such as hypotension and hypoxemia may promote poor outcome. However, few experimental TBI studies have employed complex models that included such secondary injuries to clarify the efficacy of hypothermia. This review discusses the effects of hypothermia in various TBI models addressing primary and acute secondary injuries. Included are recently published clinical data using hypothermia as a therapeutic tool for preventing or reducing the detrimental posttraumatic secondary injuries and neurobehavioral deficits. Also discussed are recent successful applications of hypothermia from outside the TBI realm. Based on all available data, some general considerations for the application of hypothermia in TBI patients are given.

Early loss of the glutamate transporter splice-variant GLT-1v in rat cerebral cortex following lateral fluid-percussion injury

Glutamate transporter proteins are essential for the control of interstitial glutamate levels, with an impairment of their function or levels being a major potential contributor to excitotoxicity. We have investigated the effects of lateral fluid percussion on the levels of the glutamate transporter proteins GLT-1alpha, its splice variant GLT-1v, GLAST, and EAAC1 in the rat in order to evaluate their pathogenetic role in this model of traumatic brain injury (TBI). Immunoblot analysis revealed neuronal loss in the cerebral cortex was accompanied by a 54% decrease in GLT-1v 6 h following the insult which progressed to an 83% loss of the transporter after 24 h. No changes in GLT-1alpha, GLAST, or EAAC1 were observed in this brain region at either time point. GLT-1v content was also decreased by 55% and 68% in the hippocampus and thalamus, respectively, at 6 h post-injury, but recovered fully after 24 h in both brain regions. In contrast, levels of GLT-1alpha were increased in the hippocampus at 6 h and 24 h post-TBI. These alterations in transporter protein content were also confirmed using immunohistochemical methods. Our results show for the first time a pattern of early, dynamic changes in the levels of GLT-1 transporter splice variants in different brain regions in this trauma model. In addition, correlation of GLT-1v levels with both neuronal cell loss and alpha-internexin content in the injured cortex suggests that loss of this novel glutamate transporter may be a key factor in determining cerebral vulnerability following this type of brain injury.

Clinical trials for cytoprotection in stroke

To date, many cytoprotective drugs have reached the stage of pivotal phase 3 efficacy trials in acute stroke patients. (Table 1) Unfortunately, throughout the neuroprotective literature, the phrase "failure to demonstrate efficacy" prevails as a common thread among the many neutral or negative trials, despite the largely encouraging results encountered in preclinical studies. The reasons for this discrepancy are multiple, and have been discussed by Dr. Zivin in his review. Many of the recent trials have addressed deficiencies of the previous ones with more rigorous trial design, including more specific patient selection criteria (ensure homogeneity of stroke location and severity), stratified randomization algorithms (time-to-treat), narrowed therapeutic time-window and pharmacokinetic monitoring. Current trials have also incorporated biologic surrogate markers of toxicity and outcome such as drug levels and neuroimaging. Lastly, multi-modal therapies and coupled cytoprotection/reperfusion strategies are being investigated to optimize tissue salvage. This review will focus on individual therapeutic strategies and we will emphasize what we have learned from these trials both in terms of trial design and the biologic effect (or lack thereof) of these agents.

Mild Hypothermia Inhibits Exogenous Glutamate-Induced Increases in Nitric Oxide Synthesis

The purpose of this study was to investigate changes in nitric oxide (NO) synthesis induced by exogenous glutamate perfusion into the cerebral cortex, and the effects of mild hypothermia on this glutamate-induced NO synthesis. Glutamate-induced cortical lesions were produced by perfusion of 0.5 M glutamate solution via a microdialysis probe, and the extracellular concentrations of NO end-products (nitrite and nitrate) were measured by microdialysis in normothermic (37 degrees C) and hypothermic (32 degrees C) rats. The levels of NO end-products in the normothermia group were elevated markedly by glutamate perfusion, and this change was completely attenuated by the induction of hypothermia. The glutamate-induced increases were also attenuated markedly by both Nomega-nitro-L-arginine methyl ester (L-NAME) and 7-nitroindazole (7-NI). These results suggest that the perfusion of exogenous glutamate into the cortex induces NO synthesis, that is derived primarily from the activity of neuronal NO synthase. These results also demonstrate that hypothermia prevents this glutamate-induced increase in NO, suggesting that the protection afforded by the hypothermic condition is most likely linked to its inhibition of the glutamate-induced NO synthesis.

Effects of delayed, prolonged hypothermia on the pial vascular response after traumatic brain injury in rats

Object. In the experimental setting, hypothermia has been demonstrated to attenuate the damaging consequences of stroke and traumatic brain injury (TBI). Laboratory studies of TBI have focused primarily on the use of early hypothermic intervention, with little consideration of the potential efficacy of more delayed but prolonged hypothermia, which would constitute a more clinically relevant approach. In this investigation, the authors evaluated whether delayed, prolonged hypothermia after TBI protected the cerebral microcirculation.

Methods. Male Sprague—Dawley rats were equipped with cranial windows for direct visualization of the pial arterial circulation and then subjected to impact-acceleration brain injury. The rats were randomly divided into four experimental groups: Group 1 consisted of normothermic animals; in Group 2 the rats received a 1-hour period of hypothermia (32°C) 30 minutes posttrauma, followed by slow rewarming (32–37°C/90 minutes); and in Groups 3 and 4 the rats received a more delayed induction (at 1 hour postinjury) of either 1 hour (Group 3) or 2 hours (Group 4) of hypothermia, followed by the slow rewarming. The pial arteriolar responses to acetylcholine (ACh) or hypercapnia were measured until up to 6 hours postinjury. With this approach the authors found that the normothermic group demonstrated severely impaired vasoreactivity in terms of ACh-dependent dilation and CO2 reactivity in comparison to baseline values (p < 0.001). In contrast, hypothermia of short duration that was initiated early (30 minutes postinjury) conferred significant cerebrovascular protection (p < 0.001), yet this protection was reduced when the onset of this 1-hour hypothermic period was postponed to 1 hour postinjury. Nevertheless, reduced protection could be significantly improved (p < 0.001) with prolongation of the hypothermic period to 2 hours.

Conclusions. The results of this study show that early as well as delayed but prolonged hypothermia attenuate the impaired vascular responsiveness seen after TBI, indicating the potential clinical usefulness of this treatment.

Relationship between apoE4 allele and excitatory amino acid levels after traumatic brain injury

OBJECTIVE

Apolipoprotein E isoform (E4) has been posited to affect outcomes after central nervous system injury. This project sought to determine the relationship between the apoE4 allele and the recovery of amino acid neurotransmitters (aspartate, glutamate, and lactate/pyruvate ratio [L/P]) following a traumatic brain injury (TBI) after controlling for patient characteristics.

DESIGN

This prospective clinical study examined neurotransmitters and L/P within the cerebrospinal fluid and compared the trends by apoE genotypes.

SETTING

Adults with TBI were recruited from a neurotrauma intensive care unit within a trauma I university medical center.

PATIENTS

Ninety-one patients were enrolled into the study after a severe TBI (Glasgow Coma Scale [GCS] score, </=8). Cerebrospinal fluid was serially sampled from a ventriculostomy every 4 hrs for the first 24 hrs and every 6 hrs for 25-120 hrs after injury.

MEASUREMENTS AND MAIN RESULTS

Hierarchical linear modeling analyses were used to compare the change of glutamate, aspartate, and L/P over time by the presence or absence of the apoE4 allele, with GCS score, sex, race, and therapeutic hypothermias included as covariates. There was a significant apoE4 allele group effect on both the linear and quadratic slopes in aspartate. In glutamate, the rate of change in glutamate was statistically related to GCS score. There was no significant difference in the glutamate response over time by the presence of the apoE4 allele. There was a significant difference in the change in L/P across time, with faster recovery when the apoE4 allele was absent.

CONCLUSIONS

Recovery of aspartate and L/P differed depending on the presence of the apoE4 allele. Patients with the allele had significant increased and sustained levels of aspartate and L/P after TBI. Changes in glutamate were related to severity of illness and were independent of the presence of the apoE4 allele.

Influence of norepinephrine and dopamine on cortical perfusion, EEG activity, extracellular glutamate, and brain edema in rats after controlled cortical impact injury

Following traumatic brain injury, catecholamines given to ameliorate cerebral perfusion may induce brain damage via cerebral arteriolar constriction and increased neuronal excitation. In the present study the acute effects of norepinephrine and dopamine on pericontusional cortical perfusion (rCBF), electroencephalographic (EEG) activity, extracellular glutamate, and brain edema were investigated in rats following controlled cortical impact injury (CCI). rCBF, cerebral perfusion pressure (CPP), EEG activity, and glutamate were determined before, during, and after infusing norepinephrine or dopamine, increasing MABP to 120 mm Hg for 90 min at 4 h after CCI. Control rats received physiological saline. At 8 h after CCI, hemispheric swelling and water content were determined gravimetrically. Following CCI, rCBF was significantly decreased. In parallel to elevating MABP and CPP, rCBF was significantly increased by norepinephrine and dopamine, being mostly pronounced with norepinephrine (+44% vs. +29%). In controls, rCBF remained diminished (-45%). EEG activity was significantly increased by norepinephrine and dopamine, while pericontusional glutamate was only elevated by norepinephrine (28 +/- 6 vs. 8 +/- 4 microM). Brain edema was not increased compared to control rats. Despite significantly increasing MABP and CPP to the same extent, norepinephrine and dopamine seem to differentially influence pericontusional cortical perfusion and glutamatergic transmission. In addition to the pressure-passive increase in CPP local cerebral effects seem to account for the sustained norepinephrine-induced increase in pericontusional cortical perfusion. The significantly elevated pericontusional glutamate concentrations in conjunction with the increased EEG activity suggest a sustained metabolically driven increase in cortical perfusion during norepinephrine infusion.

Severe cerebral blood flow reduction inhibits nitric oxide synthesis

The purpose of this study was to investigate the relationship between cerebral blood flow (CBF) and nitric oxide (NO) synthesis using a rat model of transient forebrain ischemia of varying severity. Forebrain ischemia was induced for 30 min by occlusion of the bilateral common carotid arteries without hemorrhagic hypotension. The production of NO end-products (nitrite and nitrate) was measured by in vivo microdialysis, and CBF by the hydrogen clearance technique. Ischemia induced NO synthesis, although the increase in the quantity of NO end-products was not remarkable during the ischemic period but became prominent after reperfusion. Such increases were abolished by Nomega-nitro-L-arginine methyl ester (L-NAME), although 7-nitroindazole (7-NI) appeared to have only slight effects. The production of NO end-products during ischemia increased when the CBF during ischemia was less than 60 mL/100 g/min. In animals in which the CBF during ischemia was higher than 22.7 mL/100 g/min, the production of NO end-products increased gradually after the induction of ischemia and reached a peak during the reperfusion period, whereas in other animals in which the CBF during ischemia fell below 22.7 mL/100 g/min, the NO end-products decreased during ischemia and increased transiently after reperfusion. These results suggest that the increase in NO end-products is NO synthase (NOS)-dependent and that most of the increase is derived from endothelial NOS. It is also suggested that NO synthesis during ischemia is closely related to CBF, and that severe CBF reduction may inhibit NO synthesis.

Influence of early posttraumatic hypothermia therapy on local cerebral blood flow and glucose metabolism after fluid-percussion brain injury

Object

Using autoradiographic image averaging, the authors recently described prominent foci of marked glucose metabolism-greater-than-blood-flow uncoupling in the acutely traumatized rat brain. Because hypothermia is known to ameliorate injury in this and other injury models, the authors designed the present study to assess the effects of post-traumatic therapeutic hypothermia on the local cerebral metabolic rate of glucose (LCMRglu) and local cerebral blood flow (LCBF) following moderate parasagittal fluid-percussion head injury (FPI) in rats.

Methods

Either cranial hypothermia (30°C) or normothermia (37°C) was induced for 3 hours in matched groups of rats immediately after FPI; LCMRglu and LCBF were assessed 3 hours after concluding these temperature manipulations.

In rats subjected to FPI, regardless of whether normothermia or hypothermia ensued, LCBF was reduced relative to the sham-injury groups. In addition, when FPI was followed by hypothermia (FPI–30°C group), the subsequent LCBF was significantly lower (35–38% on average) than in FPI–37°C rats. Statistical mapping of LCBF difference imaging data revealed confluent cortical and subcortical zones of significantly reduced LCBF (largely ipsilateral to the prior injury) in FPI–30°C rats relative to the FPI–37°C group. Local glucose utilization was reduced in both hemispheres of FPI–37°C rats relative to the sham-injury group and was lower in the right (traumatized) hemisphere than in the left. However, LCMRglu values were largely unaffected by temperature manipulation in either the FPI or sham-injury groups. The LCMRglu/LCBF ratio was nearly doubled in FPI–30°C rats relative to the FPI–37°C group, in a diffuse and bihemispheric fashion. Linear regression analysis comparing LCMRglu and LCBF revealed that the FPI–37°C and FPI–30°C data sets were completely nonoverlapping, whereas the two sham-injury data sets were intermixed.

Conclusions

Despite its proven neuroprotective efficacy, early posttraumatic hypothermia (30°C for 3 hours) nonetheless induces a moderate decline in cerebral perfusion without the (anticipated) improvement in cerebral glucose utilization, so that a state of mild metabolism-greater-than-blood-flow dissociation is perpetuated.

Isoflurane doubles plasma glutamate and increases posttraumatic brain edema

Increased plasma and cerebral glutamate levels may contribute to posttraumatic edema formation. Since volatile anesthetics elevate plasma amino acid concentrations, the influence of isoflurane on arterial plasma glutamate levels and brain edema formation was investigated in brain-injured rats. Rats were anesthetized with chloral hydrate (380 mg/kg i.p.) or isoflurane (1.2-2.0 vol%) for four hours following controlled cortical impact injury. Isoflurane significantly increased arterial glutamate levels compared to chloral hydrate (124 +/- 12 vs. 60 +/- 5 microM; p < 0.005). At eight hours after trauma, water content was significantly increased in the traumatized hemisphere compared to the non-traumatized side (p < 0.005). In addition, four hours of isoflurane anesthesia caused a significant increase in brain water content of both hemispheres compared to chloral hydrate (80.1 +/- 0.1 vs. 79.6 +/- 0.1%; p < 0.005). Prolonged isoflurane anesthesia is associated with a significant increase in arterial plasma glutamate levels and brain water content. This increase in brain water content must be considered when performing prolonged isoflurane anesthesia.

Evidence for lactate uptake after rat fluid percussion brain injury

Traumatic brain injury (TBI) places enormous early energy demand on brain tissue to reinstate normal ionic balance. Glucose declines and lactate increases after TBI as demonstrated in clinical and lab studies, suggesting increased glycolysis. This led us to hypothesize that high extracellular fluid (ECF) lactate may be beneficial after TBI. We measured cerebral dialysate lactate and glucose, and arterial lactate and glucose, before & after rat Fluid Percussion Injury (FPI) (2.06 +/- 0.13 atm) with and without i.v. lactate infusion (100 mM x 4.5 hours) to test the hypotheses that arterial lactate determines ECF lactate. 14C-lactate autoradiography was also performed, to demonstrate whether lactate is taken up by traumatized brain.

RESULTS

Dialysate lactate was always significantly higher than arterial. After lactate infusion, both the dialysate and the arterial lactate were significantly increased (P < 0.0001). Dialysate lactate increased within 10 min. following FPI, with significantly higher values in the lactate infusion group (82% higher with lactate infusion after FPI). Dialysate glucose fell following FPI, with a more severe decline in the saline group (129% lower), suggesting lactate infusion preserves or "spares" glucose in ECF. In our autoradiographic study, i.v. 14C-lactate accumulated at the injury site, with levels 2-4 times higher than in contralateral cortex. In conclusion, arterial lactate augmentation thus increases brain dialysate lactate and results in less reduction in ECF glucose, after FPI. Infused lactate accumulates at the injury site, where metabolism is probably the greatest.

Group I metabotropic glutamate antagonist reduces acute neuronal degeneration and behavioral deficits after traumatic brain injury in rats

Recent studies indicate that acute activation of Group I mGluRs following traumatic brain injury (TBI) contributes to the ensuing pathophysiology. The present study examined the effects of post-TBI administration of the selective mGluR1 antagonist (RS)-1-aminoindan-1,5-dicarboxylic acid (AIDA) on acute neuronal degeneration in the hippocampus and long-term sensorimotor and learning/memory outcome. In Experiment 1, 26 rats received 0.4, 2.0, or 10.0 nmol AIDA or artificial CSF vehicle infusion into the hippocampus starting 5 min postinjury. At 24 h after TBI characteristic pyramidal cell degeneration was observed in Fluoro-Jade-stained coronal sections of the CA2/3 sectors of the dorsal hippocampus. The mean (+/-SEM) number of Fluoro-Jade-positive neurons in the 10 nmol AIDA group (184 +/- 32) was significantly less (P < 0.05) than the vehicle group (310 +/- 47). In Experiment 2, 20 rats were trained on sensorimotor and memory tasks prior to parasagittal fluid percussion TBI. Rats were administered 10 nmol AIDA or vehicle as in Experiment 1. Rats were assessed on beam walking and radial arm maze (RAM) performance weekly for 6 weeks after TBI. Acquisition of a Morris water maze (MWM) task was assessed on days 11-15 after TBI. The AIDA-treated group had significantly reduced deficits in beam walk, MWM, and RAM performance compared to the vehicle-treated group. These data indicate that injury-induced acute activation of mGluR1 receptors contributes to both the cellular pathology and the behavioral morbidity associated with TBI.

Traumatic brain injury outcome: concepts for emergency care

Injury to the brain is the leading factor in mortality and morbidity from traumatic injury. The devastating personal, social, and financial consequences of traumatic brain injury (TBI) are compounded by the fact that most people with TBI are young and previously healthy. From the emergency physician's standpoint, patients with severe TBI are those with a presenting Glasgow Coma Scale score of less than 9. Over the past 30 years, mortality from severe traumatic brain injury for those patients who survive to the hospital has been reduced by half from nearly 50% to approximately 25%. Because most of the pathologic processes that determine outcome are fully active during the first hours after TBI, the decisions of emergency care providers may be crucial. This review addresses new concepts and information in the pathophysiology of TBI and secondary brain injury and demonstrates how emergency management may be linked to neurologic outcome.