Pathogenesis of an experimental heatstroke model

Thromboinflammation and microcirculation damage in heatstroke

Rising temperatures associated with climate change have significantly increased the risk of heatstroke. Unfortunately, the trend is anticipated to persist and increasingly threaten vulnerable populations, particularly older adults. According to Japan's environment ministry, over 1000 people died from heatstroke in 2021, and 86% of deaths occurred in those above 65. Since the precise mechanism of heatstroke is not fully understood, we examined the pathophysiology by focusing on the microcirculatory derangement. Online search of published medical literature through MEDLINE and Web of Science using the term "heatstroke," "heat-related illness," "inflammation," "thrombosis," "coagulation," "fibrinolysis," "endothelial cell," and "circulation." Articles were chosen for inclusion based on their relevance to heatstroke, inflammation, and thrombosis. Reference lists were reviewed to identify additional relevant articles. Other than preexisting conditions (genetic background, age, etc.), factors such as hydration status, acclimatization, dysregulated coagulation, and inflammation are the additional major factors that promote tissue malcirculation in heatstroke. The fundamental pathophysiologic mechanisms significantly overlap with those seen in the systemic inflammatory response to sepsis, and as a result, coagulation-predominant coagulopathy develops during heat stress. Although a bleeding tendency is not common, bleeding frequently occurs in the microcirculation, causing additional injury. Sterile inflammation is mediated by proinflammatory cytokines, chemokines, and other humoral mediators in concert with cellular factors, including monocytes, neutrophils, platelets, and endothelial cells. Excess inflammation results in inflammatory cell death, including pyroptosis and necroptosis, and the release of danger signals that further propagate systemic inflammation and coagulopathy. Consequently, thromboinflammation is the critical factor that induces microcirculatory disturbance in heatstroke.

Lessons From Heat Stroke for Understanding Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

We here provide an overview of the pathophysiological mechanisms during heat stroke and describe similar mechanisms found in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Both conditions are characterized by disturbed homeostasis in which inflammatory pathways play a central role. Splanchnic vasoconstriction, increased gut permeability, gut-related endotoxemia, systemic inflammatory response, central nervous system dysfunction, blood coagulation disorder, endothelial-cell injury, and mitochondrial dysfunction underlie heat stroke. These mechanisms have also been documented in ME/CFS. Moreover, initial transcriptomic studies suggest that similar gene expressions are altered in both heat stroke and ME/CFS. Finally, some predisposing factors for heat stroke, such as pre-existing inflammation or infection, overlap with those for ME/CFS. Notwithstanding important differences - and despite heat stroke being an acute condition - the overlaps between heat stroke and ME/CFS suggest common pathways in the physiological responses to very different forms of stressors, which are manifested in different clinical outcomes. The human studies and animal models of heat stroke provide an explanation for the self-perpetuation of homeostatic imbalance centered around intestinal wall injury, which could also inform the understanding of ME/CFS. Moreover, the studies of novel therapeutics for heat stroke might provide new avenues for the treatment of ME/CFS. Future research should be conducted to investigate the similarities between heat stroke and ME/CFS to help identify the potential treatments for ME/CFS.

Ischemic and oxidative damage to the hypothalamus may be responsible for heat stroke

The hypothalamus may be involved in regulating homeostasis, motivation, and emotional behavior by controlling autonomic and endocrine activity. The hypothalamus communicates input from the thalamus to the pituitary gland, reticular activating substance, limbic system, and neocortex. This allows the output of pituitary hormones to respond to changes in autonomic nervous system activity. Environmental heat stress increases cutaneous blood flow and metabolism, and progressively decreases splanchnic blood flow. Severe heat exposure also decreases mean arterial pressure (MAP), increases intracranial pressure (ICP), and decreases cerebral perfusion pressure (CPP = MAP - ICP), all of which lead to cerebral ischemia and hypoxia. Compared with normothermic controls, rodents with heatstroke have higher hypothalamic values of cellular ischemia (e.g., glutamate and lactate-to-pyruvate ratio) and damage (e.g., glycerol) markers, pro-oxidant enzymes (e.g., lipid peroxidation and glutathione oxidation), proinflammatory cytokines (e.g., interleukin-1β and tumor necrosis factor-α), inducible nitric oxide synthase-dependent nitric oxide, and an indicator for the accumulation of polymorphonuclear leukocytes (e.g., myeloperoxidase activity), as well as neuronal damage (e.g., apoptosis, necrosis, and autophagy) after heatstroke. Hypothalamic values of antioxidant defenses (e.g., glutathione peroxidase and glutathione reductase), however, are lower. The ischemic, hypoxic, and oxidative damage to the hypothalamus during heatstroke may cause multiple organ dysfunction or failure through hypothalamic-pituitary-adrenal axis mechanisms. Finding the link between the signaling and heatstroke-induced hypothalamic oxidative and ischemic damage might allow us to clinically attenuate heatstroke. In particular, free radical scavengers, heat shock protein-70 inducers, hypervolemic hemodilution, inducible nitric oxide synthase inhibitors, progenitor stem cells, flutamide, estrogen, interleukin-1 receptor antagonists, glucocorticoid, activated protein C, and baicalin mitigate preclinical heatstroke levels.

Heme oxygenase-1 aggravates heat stress-induced neuronal injury and decreases autophagy in cerebellar Purkinje cells of rats

We previously reported that heat stroke induces autophagy as a protection mechanism against neurodegeneration in the brain. Heme oxygenase (HO)-1 is a stress protein and can be induced by heat stress (HS). Cerebellar Purkinje cells are selectively vulnerable to heat-induced injury. In this study, we first validated an animal model of HS (38°C for 4 h) in which sustained increase of Purkinje cell injury, HO-1 expression up to 24 h post HS (HS₂₄), and hyperthermia reaching a rectal temperature 41.52 ± 0.32 were observed. In subsequent experiments, we investigated the effects of HO-1 on HS-induced Purkinje cell injury. Rats were divided into four groups: one normothermic control group receiving saline vehicle (1 mL/kg, intraperitoneal [i.p.]) and exposed to 25 for 4 h; and three HS groups receiving saline, or HO-1 inducer haemin (30 mg/kg, i.p.) or HO-1 inhibitor tin protoporphyrin (SnPP, 30 mg/kg, i.p.), respectively, at 12 h prior to HS. HS-induced Purkinje cell injury was further enhanced by HO-1 inducer but attenuated by HO-1 inhibitor as evaluated by immunoreactivity of apoptosis marker (active caspase-3) as well as Fluoro-Jade B histochemistry (staining for degenerating neurons), suggesting a detrimental role of HO-1. Interestingly, the protective autophagy was reduced by HO-1 inducer but enhanced by HO-1 inhibitor as demonstrated by autophagy markers including Beclin-1 and microtubule-associated protein light chain 3 in Purkinje cells. Double immunofluorescent labelling of Beclin-1 or 8-hydroxydeoxyguanosine (an oxidative DNA damage marker) with HO-1 immunoreactivity not only demonstrated their co-localization, but also confirmed that HO-1 negatively regulated Beclin-1 but increased oxidative stress in the same Purkinje cell. Taken together, our results indicate that HO-1 aggravates HS injury in cerebellar Purkinje cells. Our findings shed new light on cell damage mechanisms by HS in central nervous system and may help to provide potential therapeutic foci.

The pathopysiology of heat stroke: an integrative view of the final common pathway

Heat stroke is defined as a condition in which body temperature is elevated to such a level that it becomes a noxious agent causing body tissue dysfunction and damage with a characteristic multi-organ clinical and pathological syndrome. Marked hyperthermia, usually above 40.5°C and associated encephalopathy, occurs after thermoregulation is subordinated to circulatory and metabolic demands and to the associated systemic inflammatory reaction. Exertional heat stroke is a function of both intrinsic and extrinsic modulators. Intrinsic modulators like genetics, fitness, acclimatization, illness, medications, and sleep quality can alter individual risk and outcomes, while extrinsic modulators like exercise intensity and duration, clothing and equipment, ambient temperature, relative humidity, and solar radiation can affect the group risk and outcomes. This review integrates the current theoretical and accepted knowledge of physiological alterations into one model that depicts a common pathway from heat stress to heat stroke.

Hyperpyrexia resulting in encephalopathy in a 14-month-old patient with cblC disease

Cobalamin C (cblC) defect, the most common inborn error of cobalamin metabolism, is a multisystem disorder usually presenting with progressive neurological, haematological and ophthalmological signs. We report on a cblC patient diagnosed in the newborn age who developed nearly normal during the first year of life. During an upper respiratory tract infection with severe hyperpyrexia at the age of 14months he developed an acute encephalopathic crisis resulting in severe mental retardation and marked internal and external cerebral atrophy. Hyperacute encephalopathic crises have not been observed so far in patients with cblC defect. It remains unclear, if this association is incidental or if the underlying metabolic defect may have predisposed the brain tissue to hyperpyrexia-induced damage.

Multiple Organ Failure Following Near Fatal Exertional Heat Stroke

We describe the clinical features of a patient with near-fatal heat stroke who was admitted to our intensive care unit. A 14-year-old girl became convulsive and hyperthermic when participating in a strenuous hike under direct sunlight in a hilly area in Venezuela on a very hot and humid day. During the following days, she developed multiple organ failure, including neurological impairment, acute renal failure, disseminated intravascular coagulation, and extensive hepatic and muscle damage. Treatment consisted of ventilatory support, hemodialysis, corticosteroids, and enteral nutrition. This case of multiple organ failure following near-fatal heat stroke illustrates that although there are no specific techniques and measures for the treatment of this condition, intensive care management and conservative strategies can result in patient survival and complete recovery.

Hyperthermia-induced vasoconstriction of the carotid artery and the role of potassium channels

Clinical experience and experimental studies have shown that hyperthermia can cause cerebral ischaemia and brain damage. By in vitro experiments with heating, we previously were able to induce carotid artery constriction. The objective of the present study was to clarify the mechanism of this thermal response. Isometric tension was recorded in rabbit carotid artery specimens using organ baths during stepwise temperature elevation. The heating responses were investigated at basal tone, in precontracted vessels, after blocking of adrenergic responses and administration of potassium (K)-channel activators and inhibitors. Stepwise heating of carotid artery strips from 37 degrees C to 47 degrees C induced reproducible graded contraction. The hyperthermic responses were not due to adrenergic stimulation, which were reduced and resistant to neurogenic blockade by tetrodotoxin. Heating-induced contractions were potentiated by the K-channel inhibitors tetraethylammonium, BaCl2, charybdotoxin, and the Na+/K+ ATPase inhibitor ouabain. Levcromakalim (BRL), a K+-channel activator, reduced heating induced contractions. Heating of carotid artery preparations induced reversible graded vasoconstriction proportional to temperature. The heating-induced contractions were not mediated by an adrenergenic process, but rather were due to inhibition of K+ channels, which increases Ca2+ entry. In vivo, this reaction may lead to a disturbance of autoregulation of cerebral blood flow and ischemia with brain damage.

Inhibition of neuronal nitric oxide synthase causes attenuation of cerebrovascular dysfunction in experimental heatstroke

The present study was performed to assess the prophylactic effect of 7-nitroindazole (7-NI), an inhibitor of neuronal nitric oxide synthase (nNOS), in an animal model of heatstroke. Anesthetized rats, immediately before the start of heat stress, were divided into two major groups and given the following: vehicle solution (1 mL per kg body weight) or 7-NI (5-20mg/mL per kg body weight) intraperitoneally. They were exposed to ambient temperature of 43 degrees C to induce heatstroke. Another group of rats were exposed to room temperature (24 degrees C) and used as normothermic controls. Their physiologic and biochemical parameters were continuously monitored. When the vehicle-pretreated rats underwent heat stress, their survival time values were found to be 21-25 min. Pretreatment with intraperitoneal doses of 7-NI significantly improved survival during heatstroke (55-164 min). As compared to those of normothermic controls, all vehicle-pretreated heatstroke animals displayed higher levels of core temperature, intracranial pressure, nitric oxide metabolite (NO(2)(-)), glutamate, glycerol, lactate/pyruvate ratio, neuronal damage score and nNOS expression in the hypothalamus, and tumor necrosis factor-alpha (TNF-alpha) in the serum. In contrast, all vehicle-pretreated heatstroke animals had lower levels of mean arterial pressure, cerebral perfusion pressure, cerebral blood flow, and brain PO(2). Administration of 7-NI before the start of heat exposure significantly reduced the hyperthermia, intracranial hypertension, nNOS-dependent NO(2)(-), glutamate, glycerol, lactate/pyruvate ratio, and neuronal damage score in the hypothalamus, as well as overproduction of TNF-alpha in the serum that occurred during heatstroke. The data show that reduction of nNOS-dependent NO(2)(-) with 7-NI causes attenuation of cerebrovascular dysfunction, hyperthermia, and TNF-alpha overproduction during heatstroke in the rat.

Methods to produce hyperthermia-induced brain dysfunction

The recent increase in the frequency and intensity of killer heat waves across the globe has aroused worldwide medical attention to exploring therapeutic strategies to attenuate heat-related morbidity and/or mortality. Death due to heat-related illnesses often exceeds >50% of heat victims. Those who survive are crippled with lifetime disabilities and exhibit profound cognitive, sensory, and motor dysfunction akin to premature neurodegeneration. Although more than 50% of the world populations are exposed to summer heat waves; our understanding of detailed underlying mechanisms and the suitable therapeutic strategies have still not been worked out. One of the basic reasons behind this is the lack of a reliable experimental model to simulate clinical hyperthermia. This chapter describes a suitable animal model to induce hyperthermia in rats (or mice) comparable to the clinical situation. The model appears to be useful for studying the effects of heat-related illnesses on changes in various organs and systems, including the central nervous system (CNS). Since hyperthermia is often associated with profound brain dysfunction, additional methods to examine some crucial parameters of brain injury, e.g., blood-brain barrier (BBB) breakdown and brain edema formation, are also described.

Oxidative stress and ischemic injuries in heat stroke

When rats were exposed to high environmental temperature (e.g., 42 or 43 degrees C), hyperthermia, hypotension, and cerebral ischemia and damage occurred during heat stroke were associated with increased production of free radicals (specifically hydroxyl radicals and superoxide anions), higher lipid peroxidation, lower enzymatic antioxidant defenses, and higher enzymatic pro-oxidants in the brain of heat stroke-affected rats. Pretreatment with conventional hydroxyl radical scavengers (e.g., mannitol or alpha-tocopherol) prevented increased production of hydroxyl radicals, increased levels of lipid peroxidation, and ischemic neuronal damage in different brain structures attenuated with heat stroke and increased subsequent survival time. Heat shock preconditioning (a mild sublethal heat exposure for 15min) or regular, daily exercise for at least 3 weeks, in addition to inducing overproduction of heat shock protein 72 in multiple organs including brain, significantly attenuated the heat stroke-induced hyperthermia, hypotension, cerebral ischemia and damage, and overproduction of hydroxyl radicals and lipid peroxidation. The precise function of heat shock protein 72 are unknown, but there is considerable evidence that these proteins are essential for survival at both normal and elevated temperatures. They also play a critical role in the development of thermotolerance and protection from oxidative damage associated with cerebral ischemia and energy depletion during heat stroke. In addition, Shengmai San or magnolol (Chinese herbal medicines) or hypervolemic hemodilution (produced by intravenous infusion of 10% human albumin) is effective for prevention and repair of ischemic and oxidative damage in the brain during heat stroke. Thus, it appears that heat shock protein 72 preconditioning induced by prior heat shock or regular exercise training, as well as pretreatment with Shengmai San or magnolol is able to prevent the oxidative damage during heat stroke. On the other hand, hypervolemic hemodilution, Shengmai San, or magnolol is able to treat the oxidative damage after heat stroke onset.

Heat shock proteins and the heat shock response during hyperthermia and its modulation by altered physiological conditions

The fundamental functions of heat shock proteins (HSPs) are molecular chaperoning and cellular repair. There is little literature on the association between the numerous functions of HSPs and systemic integrative responses, particularly those controlled by the central nervous system. This chapter focuses on the role played by members of the HSP70 superfamily, universally recognized as cytoprotectants during heat stress, within the physiological context of hyperthermia and with its superimposition on situations of chronic stress. In the nucleus tractus solitarius, HSP70 levels enhance the sensitivity of sympathetic and parasympathetic arms of the autonomic nervous system to attenuate heat stroke-induced cerebral ischemia and hypotension. Chronic stressors that alter the heat shock response may affect the physiological profile during hyperthermic conditions. Upon aging, significantly lower HSP70 production is noted in the ventral paraventricular and lateral magnocellular nuclei. Likewise, results from cultured cells suggest that the age-related decline in HSP70 expression is constitutive and is due to decreased binding of the heat shock factor 1 (HSF-1) to the heat shock element (HSE) and diminished HSP70 transcription. These changes may be associated with decreased thermotolerance upon aging, although HSP70 production in response to other stressors is not affected. Heat acclimation (AC), in contrast, increases tissue reserves of HSP70 and accelerates the heat shock response. AC protects epithelial integrity, vascular reactivity and interactions with cellular signaling networks, enhancing protection and delaying thermal injury. The link between HSP70 and the immune system is discussed with respect to exercise. Exercise enhances the immune response via production of HSP72 in central and peripheral structures. At least in part, the effects of HSP72 in the brain are mediated via eHSP72-circulating HSPs providing a "danger signal" to activate the immune response. In summary, HSPs are primarily cytoprotective components, the physiological situations described in this chapter infer their pivotal role in central control of integrative systems.

BRAIN COOLING CAUSES ATTENUATION OF CEREBRAL OXIDATIVE STRESS, SYSTEMIC INFLAMMATION, ACTIVATED COAGULATION, AND TISSUE ISCHEMIA/INJURY DURING HEATSTROKE

The purpose of the present study was to assess the therapeutic effect of hypothermic retrograde jugular vein flush (HRJVF) on heatstroke. HRJVF was accomplished by infusion of 4 degrees C isotonic sodium chloride solution via the external jugular vein (1.7 mL/100 g of body weight over 5 min). Immediately after the onset of heatstroke, anesthetized rats were divided into 2 major groups and given the following: 36 degrees C or 4 degrees C isotonic sodium chloride solution, i.v. They were exposed to ambient temperature of 43 degrees C to induce heatstroke. Another group of rats was exposed to room temperature (24 degrees C) and used as normothermic controls. When the 36 degrees C saline-treated rats underwent heat exposure, their survival time values were found to be 23 to 28 min. Immediately after the onset of heatstroke, resuscitation with an i.v. dose of 4 degrees C saline significantly improved survival during heatstroke (208-252 min). All heat-stressed animals displayed systemic inflammation and activated coagulation, evidenced by increased tumor necrosis factor alpha, prothrombin time, activated partial thromboplastin time, and d-dimer, and decreased platelet count and protein C. Biochemical markers evidenced cellular ischemia and injury/dysfunction: plasma levels of blood urea nitrogen, creatinine, glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, and alkaline phosphatase; and striatal levels of glycerol, glutamate, and lactate/pyruvate; dihydroxy benzoic acid, lipid peroxidation, oxidized-form glutathione reduced-form glutathione, dopamine, and serotonin were all elevated during heatstroke. Core and brain temperatures and intracranial pressure were also increased during heatstroke. In contrast, the values of mean arterial pressure, cerebral perfusion pressure, and striatal levels of local blood flow, partial pressure of oxygen, superoxide dismutase, catalase, glutathione peroxidase, and glutathions reductase activities were all significantly lower during heatstroke. The circulatory dysfunction, systemic inflammation, hypercoagulable state, and cerebral oxidative stress, ischemia, and damage during heatstroke were all significantly suppressed by HRJVF. These findings demonstrate that brain cooling caused by HRJVF therapy may resuscitate persons who had a stroke by attenuating cerebral oxidative stress, systemic inflammation, activated coagulation, and tissue ischemia/injury during heatstroke.

Infusion of human umbilical cord blood cells protect against cerebral ischemia and damage during heatstroke in the rat

Intravenously delivered human umbilical cord blood cells (HUCBC) have been previously shown to improve both morphologic and functional recovery of heat-stroked rats. To extend these findings, we examined both the morphologic and functional alterations in the presence of HUCBC or human peripheral mononuclear cells (PBMC) 24 h before initiation of heatstroke. Anesthetized rats, 1 day before the initiation of heatstroke, were divided into three major groups and given the following: (a) serum-free lymphocyte medium (0.3 ml) intravenously; (b) PBMC (5 x 10(6) in 0.3 ml serum-free lymphocyte medium); or (c) HUCBC (5 x 10(6) in 0.3 ml serum-free lymphocyte medium). Another group of rats were exposed to room temperature (26 degrees C) and used as normothermic controls. In vehicle-treated heatstroke rats, their mean arterial pressure, cerebral blood flow, and brain PO(2) were all lower than in normothermic controls after the onset of heatstroke. However, their body temperatures and striatal levels of inducible nitric oxide synthase (iNOS)-dependent NO, ischemia and damage markers (e.g., glycerol, glutamate, and lactate/pyruvate ratio), and neuronal damage in the striatum were all greater. The heatstroke-induced arterial hypotension, cerebral ischemia and hypoxia, and increased levels of iNOS-dependent NO in the striatum were all significantly reduced by pretreatment with HUCBC, but not with PBMC. Moreover, HUCBC were localized by immunohistochemistry and PCR analysis in the injured brain structures and spleen. These findings indicate that HUCBC transplantation, in addition to having therapeutic values, can be a good choice for preventing heatstroke occurrence.

Hyperthermia influences excitatory and inhibitory amino acid neurotransmitters in the central nervous system. An experimental study in the rat using behavioural, biochemical, pharmacological, and morphological approaches

Role of excitatory amino acids, glutamate, aspartate, and inhibitory amino acids, gamma aminobutyric acid (GABA) and glycine in brain damage caused by heat stress was examined in a rat model. Subjection of rats to 4 h heat stress at 38 degrees C in a biological oxygen demand (BOD) incubator resulted in a marked increase in glutamate and aspartate in some brain regions, whereas a significant decline in GABA and glycine was observed in several brain areas. Profound behavioural alterations and impairment of motor and cognitive functions were seen at this time. Breakdown of the blood-brain barrier (BBB), reduction in regional cerebral blood flow (CBF), edema formation and cell injuries are prominent in several parts of the brain. Pretreatment with multiple opioid receptor antagonist, naloxone (10 mg/kg, i.p.) significantly restored the heat stress induced decline in GABA and glycine and thwarted the elevation of glutamate and aspartate in various brain areas. The motor or cognitive deficits were also attenuated. A significant reduction in BBB permeability, cerebral blood flow abnormalities, edema formation and cell injuries was evident. These novel observations suggest that (i) glutamate, aspartate, GABA and glycine are involved in the pathophysiology of heat stress, and (ii) a balance between excitatory and inhibitory amino acids in brain is crucial in hyperthermia induced brain injuries or repair.

Vulnerability of experimentally induced fatty liver to heat stress in rats

BACKGROUND

The aim of this study was to confirm the vulnerability of fatty liver to heat stress using fatty liver rats from the viewpoint of the induction of apoptosis.

METHODS

We exposed rats with and without a fatty liver to heat stress and then looked for apoptotic cells within the liver tissue using two apoptosis detection kits. We also determined the mRNA expression of heat shock protein (HSP) 70, caspase-3, bcl-2, and bax using a quantitative reverse transcription-polymerase chain reaction method.

RESULTS

Following heat stress, apoptosis was strongly visible in the fatty liver comparing with that noted in the normal liver. The expression of HSP70 was increased following heat stress in both livers, but the volume of its expression was significantly less in the fatty liver than in the normal liver. The ratio of bcl-2/bax expression tended to increase in the normal liver but decrease in the fatty liver following heat stress. Caspase-3 demonstrated no significant change following heat stress in both livers.

CONCLUSIONS

The detection of apoptosis, together with changes in the mRNA expression of HSP70 and the expression ratio bcl-2/bax mRNA may indicate vulnerability of a fatty liver to heat stress and may support the hypothesis that morphologic change is induced in a fatty liver by exposure to heat stress. These results suggest that fatty liver may be more vulnerable to heat stress than normal liver.

Pathophysiological factors underlying heatstroke

Heatstroke is a life-threatening illness characterized by an elevated core body temperature (>40 degrees C) and dysfunction of central nervous system, which results in delirium, convulsions, or coma. Despite adequate hypothermia or other care-therapy, heatstroke is often fatal. On the basis of our knowledge of the pathophysiology on heatstroke, we hypothesized that heatstroke is a form of hyperthermia associated with the acute physiological alterations, the cytotoxicity of heat, systemic inflammatory response, oxidative damage and attenuated heat-shock response leading to a syndrome of multi-organ dysfunction. In view of above-mentioned situation, the physiological factors underlying heatstroke and the corresponding possible therapeutic strategies to avert the complications of this disorder would be summarized in this review so as to provide some therapeutic guidelines for heatstroke. Heatstroke is a very complicated process. Acute physiological alterations, such as low arterial hypotension, intracranial hypertension, cerebral hypoperfusion, cerebral ischemia, and increased intracellular metabolism rate, occurred while exposed to a high ambient temperature. Hyperpyrexia caused cytotoxicity, resulting the degradation and aggregation of extensive intracellular proteins, influencing the change of membrane stability and fluidity, damaging the transmembrane transport of protein and the function of surface receptor, and inducing different cytoskeletal changes. Heatstroke resembles sepsis in many aspects, and endotoxemia and cytokines may be implicated in its pathogenesis. The concentration of interleukin-6 was positively correlated with the severity of heatstroke. The excessive accumulation of cytotoxic free radicals and oxidative damage may occur in the brain tissues during the genesis and development of heatstroke. The circulatory shock and cerebral ischemia resultant from heatstroke correlated closely with the free radicals (especially free radicals of peroxide and superoxide), the peroxidation of lipids, and low activity of antioxidase in the brain. Heat-shock proteins (Hsps) played a critical role during the process obtaining thermotolerance, therefore, protected from stress-induce cellular damage. Host factors or physiologically limiting factors, for instance, aging, existing illness, dehydration, deep insomnia, lack of acclimation to heat, inadequate physical fitness, and certain genetic polymorphisms were associated with a low level of Hsps expression and might favor the progression from heat stress to heatstroke. Some measures, such as molecular chaperonines, anti-inflammatory agents, antioxidant agents, and modulators of Hsps would be good for the patients with heatstroke.

Resuscitation from experimental heatstroke by transplantation of human umbilical cord blood cells

OBJECTIVE

Human umbilical cord blood cells (HUCBCs) are effective in the treatment of conventional stroke in experimental models. In the study described herein, we administered HUCBCs into the femoral vein or directly into the cerebral ventricular system and assessed their effects on circulatory shock, cerebral ischemia, and damage during heatstroke.

DESIGN

Controlled, prospective study.

SETTING

Hospital medical research laboratory.

SUBJECTS

Sprague-Dawley rats (287 +/- 16 g body weight, males).

INTERVENTIONS

Anesthetized rats, immediately after the onset of heatstroke, were divided into four major groups and given the following: a) normal saline or AIM-V medium intravenously (0.3 mL) or intracerebroventricularly (10 microL); b) peripheral blood mononuclear cells (5 x 10 in 0.3 mL AIM-V medium, intravenously, or 5 x 10 in 10 microL AIM-V medium, intracerebroventricularly); or c) HUCBCs (5 x 10 in 0.3 mL AIM-V medium, intravenously, or 5 x 10 in 10 microL AIM-V medium, intracerebroventricularly). Another group of rats, under urethane anesthesia, were exposed to room temperature (26 degrees C) and used as normothermic controls. Urethane-anesthetized animals were exposed to an ambient temperature of 43 degrees C to induce heatstroke. Their physiologic and biochemical parameters were continuously monitored.

MEASUREMENTS AND MAIN RESULTS

When the vehicle-treated rats underwent heat exposure, their survival time values were found to be 21-23 mins. Resuscitation with intravenous or intracerebroventricular doses of HUCBCs, but not peripheral blood mononuclear cells, immediately at the onset of heatstroke significantly improved survival during heatstroke (61-148 mins). As compared with values for normothermic controls, the vehicle-treated heatstroke rats had lower mean arterial pressure, cerebral blood flow, and brain PO2 values but higher intracranial pressure and cerebral ischemia values and more injury markers. The circulatory shock, intracranial hypertension, cerebral hypoperfusion and hypoxia, increment of cerebral ischemia, and damage markers during heatstroke were all significantly attenuated by intravenous or intracerebroventricular delivery of HUCBCs but not peripheral blood mononuclear cells.

CONCLUSIONS

We successfully demonstrate that HUCBC therapy may resuscitate heatstroke victims by reducing circulatory shock and cerebral ischemic injury; central delivery of HUCBCs seems superior to systemic delivery of HUCBCs in resuscitating patients with heatstroke.

Resuscitation from experimental heatstroke by hyperbaric oxygen therapy

OBJECTIVE

Heatstroke is characterized by hyperthermia, vasoplegic shock, and cerebral ischemia and hypoxia. Hyperbaric oxygen (HBO) has been shown to reduce brain ischemia and behavioral dysfunction during cerebral artery occlusion. The efficacy of HBO therapy for resuscitation from heatstroke remains to be determined in the laboratory.

DESIGN

Anesthetized rats were randomized to several groups and administered: 1) no resuscitation (normobaric air) after onset of heatstroke, 2) HBO for 1 hr (100% oxygen at 253 kPa for 1 hr), 3) cyclic HBO intermitted by a 5-min air break for 1 hr of treatment (100% oxygen at 253 kPa), 4) hyperbaric air (air at 253 kPa for 1 hr), 5) normobaric hyperoxia (100% oxygen at 101 kPa for 1 hr), or 6) 8% HBO (hyperbaric 8% oxygen at 253 kPa for 1 hr).

SETTING

Laboratory investigation.

SUBJECTS

Sprague-Dawley rats (300- to 400-g males).

INTERVENTIONS

Rats were exposed to an ambient temperature of 43 degrees C to induce heatstroke. Their colonic temperature; mean arterial pressure; heart rate; arterial blood levels of pH, Paco2, Pao2, So2%, and tumor necrosis factor-alpha; the cortical levels of ischemic and damage markers, and cortical neuronal damage scores were determined. The moment at which mean arterial pressure began to decrease from peak levels was arbitrarily taken as the onset of heatstroke.

MAIN RESULTS

Survival time (interval between onset of heatstroke and animal death) was 19 +/- 1 (n = 10), 131 +/- 18 (n = 14), 159 +/- 28 (n = 13), 72 +/- 14 (n = 10), 68 +/- 12 (n = 10), and 45 +/- 11 (n = 10) mins, respectively, for normobaric air, HBO for 1 hr, cyclic HBO, hyperbaric air, normobaric hyperoxia, and 8% HBO groups. The heatstroke induced arterial hypotension and bradycardia, decreased arterial levels of pH, Pao2, and So2%, increased arterial levels of tumor necrosis factor-alpha, and increased values of cellular ischemia and damage markers. In addition, neuronal damage scores in the cortex were significantly reduced by HBO for 1 hr and cyclic HBO resuscitation.

CONCLUSION

We successfully demonstrated that HBO and, to some extent, hyperbaric air, normobaric hyperoxia, or HBO 8% was found beneficial in resuscitating rats with experimental heatstroke. HBO effectively reduced heatstroke-induced arterial hypotension, hypoxia, plasma tumor necrosis factor-alpha overproduction, and cerebral ischemia and damage and improved survival.

Pulmonary fat embolism induced by exposure to high ambient temperature in rats with a fatty liver

The aim of this study was to investigate whether a fatty liver contributes to pulmonary embolism under a high ambient temperature. As an experimental model, we exposed fatty liver rats to a high temperature (45 degrees C) and then looked for fat emboli in the alveolar capillaries using the fat-staining method. Fat emboli were detected in the alveolar capillaries of the fatty liver rats, but not in those of the normal liver rats. Moreover, the degree of pulmonary fat embolism tended to become more severe in proportion to the severity of the fatty liver. In addition, fat emboli did not appear at a core body temperature of 40 degrees C, but were detected at a core body temperature of 44 degrees C. From these results, we conclude that a fatty liver may contribute to the formation of pulmonary fat embolism and that high temperatures act as a trigger for the onset of pulmonary embolism. Moreover, it is possible that fatty liver affects the development of heat stroke induced by exposure to a high ambient temperature and that pulmonary fat embolism is a significant finding which helps to enable a diagnosis of heat stroke in autopsy cases.

Shengmai San, a Chinese Herbal Medicine Protects Against Rat Heat Stroke by Reducing Inflammatory Cytokines and Nitric Oxide Formation

The aim of the present study was to ascertain whether the possible occurrence of overproduction of inducible nitric oxide synthase (iNOS)-dependent nitric oxide (NO) in the brain and inflammatory cytokines in the peripheral blood exhibited during heat stroke can be reduced by prior administration of Shengmai San, a Chinese herbal medicine. Aminoguanidine, an iNOS inhibitor, was evaluated at the same time as a reference (positive control). Urethane-anesthetized rats were exposed to heat stress (ambient temperature of 43 degrees C) to induce heat stroke. Control rats were exposed to 24 degrees C. Mean arterial pressure and cerebral blood flow after the onset of heat stroke were all significantly lower than in control rats. However, cerebral iNOS immunoreactivity and NO levels were all greater after the onset of heat stroke. The serum levels of interleukin-1beta, interleukin-6, and tumor necrosis factor-alpha were all increased after the onset of heat stroke. Shengmai San (1.2 g/ml per rat) or aminoguanidine (30 micromol/ml per rat) was administered orally, daily, and consecutively for 7 days before the initiation of heat stress; and this significantly attenuated the heat stress-induced arterial hypotension, cerebral ischemia, and increased levels of brain iNOS-dependent NO production and serum cytokines formation. Shengmai San shared with the aminoguanidine almost the same efficacy in reducing iNOS-dependent NO and cytokines overproduction during heat stroke. These results suggest that Shengmai San or aminoguanidine protects against heat stroke-induced arterial hypotension and cerebral ischemia by inhibition of iNOS-dependent NO overproduction in the brain and excessive accumulation of several inflammatory cytokines in the peripheral blood stream.

Naltrexone Protects Against Hypotension, Hyperthermia, and β-Endorphin Overproduction During Heatstroke in the Rat

Heat stroke is characterized by hyperthermia, arterial hypotension, decreased baroreflex sensitivity, and increased serum levels of beta-endorphin. Whereas naltrexone may have therapeutic potential in heat stroke, the underlying mechanism remains unclear. We tested the hypothesis that naltrexone may attenuate heat stroke by reducing hyperthermia, hypotension, decreased baroreceptor sensitivity, and/or increased serum levels of beta-endorphin. Heat stroke was induced by exposing the anesthetized adult Sprague-Dawley rats in an incubator at 43 degrees C. The moment in which the mean arterial pressure dropped irreversibly from the peak level was taken as the onset of heat stroke. Control rats were exposed to 24 degrees C. Mean arterial pressure, baroreceptor sensitivity, and maximal reflex bradycardia, after the onset of heat stroke, were all significantly lower than in control rats. However, rectal temperature and serum levels of beta-endorphin were all greater after the onset of heat stroke. Intravenous delivery of naltrexone (10 mg/kg) 20 min before the initiation of heat stress, but not immediately at the onset of heat stroke, significantly attenuated the above-mentioned reactions. Accordingly, naltrexone improved survival during heat stroke. These results suggest that naltrexone protects against hypotension and decrement of both baroreceptor sensitivity and maximal reflex bradycardia during heat stroke by reducing both hyperthermia and increment of serum beta-endorphin and thus improves survival.

Chinese Herbal Medicine, Shengmai San, Is Effective for Improving Circulatory Shock and Oxidative Damage in the Brain During Heatstroke

The aim of this study was to investigate the effect of Shengmai San (SMS), a traditional Chinese herbal medicine, on heatstroke-induced circulatory shock and oxidative damage in the brain in rats. Anesthetized rats were exposed to a high ambient temperature (43 degrees C) to induce heatstroke. After the onset of heatstroke, the values of mean arterial pressure, cerebral perfusion pressure, cerebral blood flow, and brain partial pressure of O(2) were all significantly lower than those in normothermic controls. However, the values of intracranial pressure, brain and colonic temperatures, and brain levels of free radicals, lipid peroxidation, and cellular ischemia and damage markers were all greater in heatstroke rats compared with those of normothermic controls. Pretreatment or post-treatment with SMS significantly reduced the hypotension, intracranial hypertension, cerebral hypoperfusion and hypoxia and increased levels of ischemia and damage markers in the brain during heatstroke. The protective effects exerted by SMS pretreatment is superior to those of SMS post-treatment. The results demonstrate that SMS is effective for prevention and repair of circulatory shock and ischemic and oxidative damage in the brain during heatstroke.

Hypothermic retrograde jugular vein flush in heatstroke rats provides brain protection by maintaining cerebral blood flow but not by hemodilution

OBJECTIVE

To determine the fundamental mechanism of brain protection by hypothermic retrograde jugular vein flush (HRJVF) in heatstroke rats.

DESIGN

Randomized, controlled, and prospective study.

SETTING

University physiology research laboratory.

SUBJECTS

Sprague-Dawley rats (270-320 g, males).

INTERVENTIONS

Rats were randomized into four groups as follows: a) normothermic control (NC, n = 8); b) heatstroke rats without cold saline delivery (HS, n = 8); c) heatstroke rats treated with cold saline via femoral vein (HS+F, n = 8); and d) heatstroke rats treated with HRJVF (HS+J, n = 8). Right external jugular vein and right femoral vein were cannulated in each rat. The cannulation in the jugular vein was with cranial direction. To produce heatstroke, rats were placed in a chamber with an ambient temperature of 43 degrees C. The cold saline (4 degrees C, 1.7 mL/100 g) was delivered via the cannula in either the femoral vein or jugular vein immediately after the onset of heatstroke. Glutamate release in the brain, cerebral blood flow (CBF), and hematocrit of arterial blood were determined.

MEASUREMENTS AND MAIN RESULTS

After onset of heatstroke, HRJVF significantly decreased the glutamate release. In contrast, cold saline delivery via femoral vein could only delay the elevation of glutamate release in the brain. The CBF of HS and HS+F rats decreased rapidly after the onset of heatstroke, but the CBF of HS+J rats was initially elevated by HRJVF and was maintained at baseline 30 mins after onset of heatstroke. Hematocrit in all the rats did not change after testing.

CONCLUSIONS

HRJVF protects the brain by maintaining cerebral blood flow in rats after heatstroke. To preserve brain function and prolong survival after severe heatstroke, maintenance of cerebral blood flow is important in the management of heatstroke.

Aminoguanidine Protects Against Intracranial Hypertension and Cerebral Ischemic Injury in Experimental Heatstroke

The aim of the present study was to ascertain whether aminoguanidine attenuated intracranial hypertension and cerebral ischemic injury in experimental heatstroke. Urethane-anesthetized rats were exposed to heat stress (ambient temperature of 43 degrees C) to induce heatstroke. Control rats were exposed to 24 degrees C. Mean arterial pressure, cerebral perfusion pressure, and cerebral blood flow after the onset of heatstroke were all significantly lower than in control rats. However, colonic temperature, intracranial pressure, heart rate, cerebral inducible nitric oxide synthase (iNOS)-dependent NO, and neuronal damage score were greater after the onset of heatstroke. Aminoguanidine (30 micromol/kg, i.v.; 30 min before the start of heat exposure) pretreatment significantly attenuated the heatstroke-induced hyperthermia, arterial hypotension, intracranial hypertension, cerebral ischemia and neuronal damage, and increased iNOS-dependent NO formation in the brain. The extracellular concentrations of ischemic (e.g., glutamate and lactate/pyruvate ratio) and damage (e.g., glycerol) markers in the hypothalamus were also increased after the onset of heatstroke. Aminoguanidine pretreatment significantly attenuated the increase in hypothalamic ischemia and damage markers associated with heatstroke. Delaying onset of aminoguanidine administration (i.e., 0 or 30 min after the start of heat exposure) reduced the preventive efficiency on heatstroke-induced hyperthermia, arterial hypotension, intracranial hypertension, cerebral ischemia, and increased iNOS-dependent NO formation in brain. These results suggest that aminoguanidine protects against heatstroke-induced intracranial hypertension and cerebral ischemic injury by inhibition of cerebral iNOS-dependent NO production.

Hypothermic retrograde jugular perfusion reduces brain damage in rats with heatstroke

OBJECTIVE

To determine whether direct retrograde ice saline infusion in the jugular vein without cardiopulmonary bypass protects rat brains after heatstroke.

DESIGN

Randomized, controlled, prospective study.

SETTING

University physiology research laboratory.

SUBJECTS

Sprague-Dawley rats (270-320 g, males).

INTERVENTIONS

Rats were randomized into three groups and given a) no resuscitation after onset of heat stroke (HS, n = 8); b) ice saline infusion in the femoral vein after onset of heat stroke (HS + F, n = 8); or c) retrograde ice saline infusion in the external jugular vein after onset of heat stroke (HS + J, n = 8). Rats were exposed to an ambient temperature of 43 degrees C after vessel cannulation. Their mean arterial pressure, heart rate, colonic temperature, and brain temperature were continuously recorded. Survival time and brain pathology were checked.

MEASUREMENTS AND MAIN RESULTS

Although colonic temperature decreased 0.8-1.0 degrees C 15 mins after heatstroke in all groups, no treatment-related changes in colonic temperature were noted in any group. However, significant changes were observed in brain temperature. Fifteen minutes after heatstroke, brain temperature was 37.6 +/- 0.4 degrees C, 36.1 +/- 0.4 degrees C, and 33.6 +/- 0.8 degrees C in HS, HS + F, and HS + J, respectively. Survival time was 16.1 +/- 2.1, 33.0 +/- 3.8, and >120 mins in these groups, respectively. Neuron damage score was significantly lower in HS + J and without lateralization.

CONCLUSIONS

We successfully demonstrated that direct retrograde hypothermic perfusion via the jugular vein without cardiopulmonary bypass protected the brain after heat stroke. This technique cooled the brain but did not significantly interfere with body temperature.

Naltrexone attenuates plasma nitric oxide release following acute heat stress

Previous studies have shown that naltrexone attenuates morbidity and mortality in heat stress by inhibiting endogenous opioids. In this study, we hypothesized that naltrexone can decrease heat stress by attenuating nitric oxide release. Male Sprague-Dawley rats were pretreated with naltrexone or normal saline, and exposed to 45 degrees C for 25 min; controls were exposed to 25 degrees C. Colonic temperatures were recorded and plasma samples from an in-dwelling i.v. cannula were analyzed for nitrate/nitrite levels. Following heat stress, peak colonic temperature was significantly diminished (P < 0.05) in naltrexone-treated rats compared to saline-treated rats. Plasma nitrate/nitrite levels were significantly lower (P < 0.05) in naltrexone-treated rats compared to saline-treated rats. These findings suggest that naltrexone is able to attenuate the rise in plasma nitric oxide levels commonly observed after heat stress.

Chronic hypoxia preconditioning increases survival in rats suffering from heatstroke

1. In the present study, we assessed the protective effects of chronic hypoxia preconditioning against heatstroke-induced injury in urethane-anaesthetized rats. Heatstroke was induced by exposing the animals to an ambient temperature of 42 degrees C. The time at which both the mean arterial pressure (MAP) and local cerebral blood flow (CBF) in the striatum began to decrease from peak levels was taken as the onset of heatstroke. Control rats were exposed to a temperature of 24 degrees C. 2. Mean arterial pressure, CBF, blood pH, PaO2, PaCO2 and survival time (the interval between onset of heatstroke and cardiac arrest) after heat stress were all lower than in control rats (in which 'survival time' was defined as > 360 min). However, blood lactate concentrations were greater in rats exposed to heat. Rats placed at high altitude (HA), when exposed to the same heat stress (42 degrees C) survived much longer (113 +/- 26 min; n = 8) than rats maintained at sea level (SL; 20 +/- 2 min; n = 8). 3. After the onset of heatstroke, blood pH and lactate concentrations were found to be significantly higher and lower, respectively, in HA rats than in SL rats. 4. Western blot assay revealed that chronic hypoxia preconditioning induced heat shock protein (HSP) 72 expression in both the kidneys and lungs. 5. Thus, it appears that the observed benefit of chronic hypoxia preconditioning is related to attenuation of tissue acidification and elevations of HSP72 expression in both kidneys and lungs during heatstroke.

Oxidative stress in rats with heatstroke-induced cerebral ischemia

BACKGROUND AND PURPOSE

Heatstroke is associated with cerebral ischemia as well as increased levels of interleukin-1beta, dopamine, and glutamate in the brain. These factors are known to increase free radical production. This study attempted to ascertain whether an excessive accumulation of cytotoxic free radicals in the brain and oxidative stress can occur during heatstroke.

METHODS

Urethane-anesthetized rats underwent instrumentation for the measurement of mean arterial pressure, cerebral blood flow, neuronal damage score, and colonic temperature. Rats were exposed to heat stress (ambient temperature, 42 degrees C) until mean arterial pressure and cerebral blood flow began to decrease from their peak levels, which was arbitrarily defined as the onset of heatstroke. Controlled rats were exposed to 24 degrees C. Concentrations of dihydroxybenzoic acid, lipid peroxidation, rate of O2*- generation, superoxide dismutase, and catalase activity of the brain or other vital organs were assessed during heatstroke.

RESULTS

The values of mean arterial pressure and cerebral blood flow after heatstroke onset were all significantly lower than those in control rats. However, the values of colonic temperature, dihydroxybenzoic acid levels in the striatum, and neuronal damage score were greater. The extent of lipid peroxidation in the brain and the rate of O2*- generation in the brain, liver, and heart were all greater in rats after heatstroke onset. In contrast, the values of total superoxide dismutase in the brain, liver, and heart and the catalase activity in the brain were lower.

CONCLUSIONS

Taken together, these results indicate that hydroxyl radicals mediate cerebral ischemic injury associated with heatstroke.