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Scheller C, Strauss C, Leisz S, Hänel P, Klemm A, Kowoll S, Böselt I, Rahne T, Wienke A. Prophylactic nimodipine treatment for hearing preservation after vestibular schwannoma surgery: study protocol of a randomized multi-center phase III trial-AkniPro 2. Trials 2021; 22:475. [PMID: 34294114 PMCID: PMC8296656 DOI: 10.1186/s13063-021-05417-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/02/2021] [Indexed: 11/11/2022] Open
Abstract
Background A previously performed phase III trial on 112 subjects investigating prophylactic nimodipine treatment in vestibular schwannoma (VS) surgery showed no clear beneficial effects on preservation of facial and cochlear nerve functions, though it should be considered that protection of facial nerve function was the primary outcome. However, the risk for postoperative hearing loss was halved in the nimodipine group compared to the control group (OR 0.49; 95% CI 0.18–1.30; p = 0.15). Accordingly, this phase III extension trial investigates the efficacy and safety of prophylactic nimodipine for hearing preservation in VS surgery. Methods This is a randomized, multi-center, two-armed, open-label phase III trial with blinded expert review and two-stage with interim analysis. Three hundred thirty-six adults with the indication for microsurgical removal of VS (Koos I–IV) and serviceable preoperative hearing (Gardner-Robertson scale (GR) 1–3) are assigned to either the therapy (intravenous nimodipine 1–2 mg/h from the day before surgery until the fifth postoperative day and standard of care) or the control group (surgery only and standard of care). The primary endpoint of the trial is postoperative cochlear nerve function measured before discharge according to GR 1–3 versus GR 4–5 (binary). Hearing function will be determined by pre- and postoperative audiometry with speech discrimination, which will be evaluated by a blinded expert reviewer. Furthermore, patient-reported outcomes using standardized questionnaires will be analyzed. Discussion Prophylactic parenteral nimodipine treatment may have a positive effect on hearing preservation in VS surgery and would improve patient’s quality of life. Further secondary analyses are planned. Except for dose-depending hypotension, nimodipine is known as a safe drug. In the future, prophylactic nimodipine treatment may be recommended as a routine medication in VS surgery. VS can be considered as an ideal model for clinical evaluation of neuroprotection, since hearing outcome can be classified by well-recognized criteria. The beneficial effect of nimodipine may be transferable to other surgical procedures with nerves at risk and may have impact on basic research. Trial registration EudraCT 2019-002317-19, DRKS00019107. 8th May 2020.
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Affiliation(s)
- Christian Scheller
- Department of Neurosurgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle (Saale), Germany.
| | - Christian Strauss
- Department of Neurosurgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle (Saale), Germany
| | - Sandra Leisz
- Department of Neurosurgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle (Saale), Germany
| | - Pia Hänel
- Department of Neurosurgery, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06097, Halle (Saale), Germany
| | - Ariane Klemm
- Coordination Centre for Clinical Trials, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Simone Kowoll
- Coordination Centre for Clinical Trials, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Iris Böselt
- Coordination Centre for Clinical Trials, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Torsten Rahne
- Department of Otorhinolaryngology, Head and Neck Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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Abstract
Nimodipine has been shown to improve outcomes following aneurysmal subarachnoid hemorrhage. Guidelines recommend that all patients receive a fixed dose of oral nimodipine for 21 days. However, pharmacokinetic studies have suggested variability of nimodipine pharmacokinetics in subarachnoid hemorrhage and in other patient populations. The clinical relevance of such variability is unknown. Therefore, the objective of the present review is, first, to conduct a literature review and summarize nimodipine pharmacokinetic data and sources of variability in various patient groups. Second, to determine if there is any evidence reporting an association between nimodipine exposure and clinical outcomes in patients with subarachnoid hemorrhage. A systematic literature search was performed in MEDLINE and EMBASE. The following keywords were used: ("nimodipine" OR "nymalize" OR "nimotop") AND ("pharmacokinetic*", OR "PK"). The search results were limited to English language and human studies. A large interpatient variability in nimodipine pharmacokinetics has been reported. Patient-specific factors that had an influence on pharmacokinetic parameters are age, comorbidities, variabilities in metabolism due to genetic polymorphism and co-administered medications, as well as nimodipine administration technique. The association between nimodipine exposure and clinical outcomes remains unclear and data available are too scarce to reach a firm conclusion. Here, we present a narrative review with a systematic literature search discussing nimodipine pharmacokinetic variability in various patient populations. It is not clear if minimal or lack of systemic exposure to nimodipine denies its benefit and contributes to worsening outcomes in patients with subarachnoid hemorrhage. Further studies are needed to determine if such an association exists.
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Nimodipine-Dependent Protection of Schwann Cells, Astrocytes and Neuronal Cells from Osmotic, Oxidative and Heat Stress Is Associated with the Activation of AKT and CREB. Int J Mol Sci 2019; 20:ijms20184578. [PMID: 31527507 PMCID: PMC6770698 DOI: 10.3390/ijms20184578] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/06/2019] [Accepted: 09/14/2019] [Indexed: 02/08/2023] Open
Abstract
Clinical and experimental data assumed a neuroprotective effect of the calcium channel blocker nimodipine. However, it has not been proven which neuronal or glial cell types are affected by nimodipine and which mechanisms underlie these neuroprotective effects. Therefore, the aim of this study was to investigate the influence of nimodipine treatment on the in vitro neurotoxicity of different cell types in various stress models and to identify the associated molecular mechanisms. Therefore, cell lines from Schwann cells, neuronal cells and astrocytes were pretreated for 24 h with nimodipine and incubated under stress conditions such as osmotic, oxidative and heat stress. The cytotoxicity was measured via the lactate dehydrogenase (LDH) activity of cell culture supernatant. As a result, the nimodipine treatment led to a statistically significantly reduced cytotoxicity in Schwann cells and neurons during osmotic (p ≤ 0.01), oxidative (p ≤ 0.001) and heat stress (p ≤ 0.05), when compared to the vehicle. The cytotoxicity of astrocytes was nimodipine-dependently reduced during osmotic (p ≤ 0.01), oxidative (p ≤ 0.001) and heat stress (not significant). Moreover, a decreased caspase activity as well as an increased proteinkinase B (AKT) and cyclic adenosine monophosphate response element-binding protein (CREB) phosphorylation could be observed after the nimodipine treatment under different stress conditions. These results demonstrate a cell type-independent neuroprotective effect of the prophylactic nimodipine treatment, which is associated with the prevention of stress-dependent apoptosis through the activation of CREB and AKT signaling pathways and the reduction of caspase 3 activity.
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Abstract
BACKGROUND Except for glucocorticoids there is a lack of neuroprotective medication in neurosurgical interventions. OBJECTIVE An overview of clinical trials investigating administration of the calcium antagonist nimodipine and hydroxyethyl starch (HES) in vestibular schwannoma (VS) surgery is given. Basic research is addressed and potential neuroprotective effect mechanisms are discussed, as are perspectives for application of the concept to other types of surgery with a risk postoperative impairment of nerve function. MATERIALS AND METHODS A selective PubMed search was performed and all 10 clinical trials corresponding to the search criteria were included. RESULTS Four trials with an intraoperative start of the medication showed a positive effect for the preservation of facial nerve function and hearing preservation. A pilot study showed superiority of prophylactic treatment over intraoperative application. There were no significant results in a prospective multicenter phase III trial. After 1 year, postoperative facial nerve preservation rates were excellent in both groups. However, the risk of hearing loss was twice as high in the control group. A combined analysis of the phase III trial with its pilot study showed significant results for better hearing preservation rates in the treatment group (probably by increasing the case load). CONCLUSION Prophylactic nimodipine can be recommended in VS surgery in patients with good preoperative hearing. The effect mechanisms of nimodipine and modifications to prophylaxis should be clarified in basic research.
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Affiliation(s)
- C Scheller
- Universitätsklinik und Poliklinik für Neurochirurgie, Universitätsklinikum, Universität Halle-Wittenberg, Halle (Saale), Deutschland.
| | - E Herzfeld
- Universitätsklinik und Poliklinik für Neurochirurgie, Universitätsklinikum, Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - C Strauss
- Universitätsklinik und Poliklinik für Neurochirurgie, Universitätsklinikum, Universität Halle-Wittenberg, Halle (Saale), Deutschland
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Albanna W, Weiss M, Conzen C, Clusmann H, Schneider T, Reinsch M, Müller M, Wiesmann M, Höllig A, Schubert GA. Systemic and Cerebral Concentration of Nimodipine During Established and Experimental Vasospasm Treatment. World Neurosurg 2017; 102:459-465. [PMID: 28344178 DOI: 10.1016/j.wneu.2017.03.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/10/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Oral nimodipine is an established prophylactic agent for cerebral vasospasm after subarachnoid hemorrhage (SAH). In highly selected cases, intra-arterial (IA) or intravenous (IV) application of nimodipine may be considered; however, the optimum dosage and modality of application remain a matter of debate. The purpose of this investigation is analysis of nimodipine concentration in serum, cerebrospinal fluid, and cerebral microdialysate in the context of currently effective dose and route of application (oral, IA, IV). METHODS We prospectively collected 156 samples from 37 patients treated for aneurysmal SAH from May 2014 to July 2015. Treatment groups were stratified according to modality of application and low-dose or high-dose treatment. At time of sampling, current dose and modality of application effectively sustained cerebral perfusion as documented by common diagnostics. Samples were analyzed for nimodipine concentration via high-performance liquid chromatography and tandem mass spectrometry. RESULTS In most cases (94.3%), nimodipine remained below the limit of quantification (0.5 ng/mL) within the brain (microdialysis, cerebrospinal fluid), even during targeted, local application (IA nimodipine). The median serum concentration for all treatment groups was 17.3 ng/mL. Modality of application (oral, IA, IV) was not associated with significant differences in serum concentrations (P = 0.712), even after stratification for dosage (P = 0.371), implying a comparable systemic distribution, if not efficacy. CONCLUSIONS Nimodipine does not accumulate sufficiently within the target organ for treatment monitoring. Comparable systemic concentrations can be observed irrespective of application modality and dosing. Future studies will clarify the role of efficacy-driven treatment algorithms, in which lowest dose and least invasive mode of application still effective should be identified.
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Affiliation(s)
- Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Catharina Conzen
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Toni Schneider
- Department of Neurophysiology, University of Cologne, Cologne, Germany
| | | | - Marguerite Müller
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
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Scheller C, Wienke A, Tatagiba M, Gharabaghi A, Ramina KF, Ganslandt O, Bischoff B, Zenk J, Engelhorn T, Matthies C, Westermaier T, Antoniadis G, Pedro MT, Rohde V, von Eckardstein K, Kretschmer T, Kornhuber M, Steighardt J, Richter M, Barker FG, Strauss C. Prophylactic nimodipine treatment and improvement in hearing outcome after vestibular schwannoma surgery: a combined analysis of a randomized, multicenter, Phase III trial and its pilot study. J Neurosurg 2017; 127:1376-1383. [PMID: 28298021 DOI: 10.3171/2016.8.jns16626] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE In clinical routines, neuroprotective strategies in neurosurgical interventions are still missing. A pilot study (n = 30) and an analogously performed Phase III trial (n = 112) pointed to a beneficial effect of prophylactic nimodipine and hydroxyethyl starch (HES) in vestibular schwannoma (VS) surgery. Considering the small sample size, the data from both studies were pooled. METHODS The patients in both investigator-initiated studies were assigned to 2 groups. The treatment group (n = 70) received parenteral nimodipine (1-2 mg/hour) and HES (hematocrit 30%-35%) from the day before surgery until the 7th postoperative day. The control group (n = 72) was not treated prophylactically. Facial and cochlear nerve functions were documented preoperatively, during the inpatient care, and 1 year after surgery. RESULTS Pooled raw data were analyzed retrospectively. Intent-to-treat analysis revealed a significantly lower risk for hearing loss (Class D) 12 months after surgery in the treatment group compared with the control group (OR 0.46, 95% CI 0.22-0.97; p = 0.04). After exclusion of patients with preoperative Class D hearing, this effect was more pronounced (OR 0.38, 95% CI 0.17-0.83; p = 0.016). Logistic regression analysis adjusted for tumor size showed a 4 times lower risk for hearing loss in the treatment group compared with the control group (OR 0.25, 95% CI 0.09-0.63; p = 0.003). Facial nerve function was not significantly improved with treatment. Apart from dose-dependent hypotension (p < 0.001), the study medication was well tolerated. CONCLUSIONS Prophylactic nimodipine is safe and may be recommended in VS surgery to preserve hearing. Prophylactic neuroprotective treatment in surgeries in which nerves are at risk seems to be a novel and promising concept. Clinical trial registration no.: DRKS 00000328 ( https://drks-neu.uniklinik-freiburg.de/drks_web/ ).
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Affiliation(s)
- Christian Scheller
- Departments of 1 Neurosurgery and.,Translational Centre for Regenerative Medicine, University of Leipzig
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics, and Informatics, and
| | | | | | | | | | | | | | | | - Cordula Matthies
- Department of Neurosurgery, Würzburg University Hospital, Würzburg
| | | | - Gregor Antoniadis
- Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Maria Teresa Pedro
- Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Veit Rohde
- Department of Neurosurgery, University of Göttingen; and
| | | | - Thomas Kretschmer
- Department of Neurosurgery, Evangelisches Krankenhaus, University of Oldenburg, Germany ; and
| | | | - Jörg Steighardt
- Coordination Centre for Clinical Trials, University of Halle-Wittenberg, Halle (Saale)
| | - Michael Richter
- Coordination Centre for Clinical Trials, University of Halle-Wittenberg, Halle (Saale)
| | - Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
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Tang YD, Zheng XS, Ying TT, Yuan Y, Li ST. Nimodipine-mediated re-myelination after facial nerve crush injury in rats. J Clin Neurosci 2015; 22:1661-8. [PMID: 26169537 DOI: 10.1016/j.jocn.2015.03.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/13/2015] [Accepted: 03/14/2015] [Indexed: 12/19/2022]
Abstract
This study aimed to investigate the mechanism of nimodipine-mediated neural repair after facial nerve crush injury in rats. Adult Sprague-Dawley rats were divided into three groups: healthy controls, surgery alone, and surgery plus nimodipine. A facial nerve crush injury model was constructed. Immediately after surgery, the rats in the surgery plus nimodipine group were administered nimodipine, 6 mg/kg/day, for a variable numbers of days. The animals underwent electromyography (EMG) before surgery and at 3, 10, or 20 days after surgery. After sacrifice, nerve samples were stained with hematoxylin and eosin (H&E) and luxol fast blue. The EMG at 20 days revealed an apparent recovery of eletroconductivity, with the surgery plus nimodipine group having a higher amplitude and shorter latency time than the surgery only group. H&E staining showed that at 20 days, the rats treated with nimodipine had an obvious recovery of myelination and reduction in the number of infiltrating cells, suggesting less inflammation, compared with the rats in the surgery only group. Luxol fast blue staining was relatively even in the surgery plus nimodipine group, indicating a protective effect against injury-induced demyelination. Staining for S100 calcium-binding protein B (S-100β) was not evident in the surgery alone group, but was evident in the surgery plus nimodipine group, indicating that nimodipine reversed the damage of the crush injury. After a facial nerve crush injury, treatment with nimodipine for 20 days reduced the nerve injury by mediating remyelination by Schwann cells. The protective effect of nimodipine may include a reduction of inflammation and an increase in calcium-binding S-100β protein.
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Affiliation(s)
- Yin-da Tang
- Department of Neurosurgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Floor 16, Building 8, 1665 Kongjiang Road, Shanghai 200092, China
| | - Xue-sheng Zheng
- Department of Neurosurgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Floor 16, Building 8, 1665 Kongjiang Road, Shanghai 200092, China
| | - Ting-ting Ying
- Department of Neurosurgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Floor 16, Building 8, 1665 Kongjiang Road, Shanghai 200092, China
| | - Yan Yuan
- Department of Neurosurgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Floor 16, Building 8, 1665 Kongjiang Road, Shanghai 200092, China
| | - Shi-ting Li
- Department of Neurosurgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Floor 16, Building 8, 1665 Kongjiang Road, Shanghai 200092, China.
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Nimodipine enhances neurite outgrowth in dopaminergic brain slice co-cultures. Int J Dev Neurosci 2014; 40:1-11. [PMID: 25447789 DOI: 10.1016/j.ijdevneu.2014.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 10/24/2014] [Accepted: 10/26/2014] [Indexed: 11/24/2022] Open
Abstract
Calcium ions (Ca(2+)) play important roles in neuroplasticity and the regeneration of nerves. Intracellular Ca(2+) concentrations are regulated by Ca(2+) channels, among them L-type voltage-gated Ca(2+) channels, which are inhibited by dihydropyridines like nimodipine. The purpose of this study was to investigate the effect of nimodipine on neurite growth during development and regeneration. As an appropriate model to study neurite growth, we chose organotypic brain slice co-cultures of the mesocortical dopaminergic projection system, consisting of the ventral tegmental area/substantia nigra and the prefrontal cortex from neonatal rat brains. Quantification of the density of the newly built neurites in the border region (region between the two cultivated slices) of the co-cultures revealed a growth promoting effect of nimodipine at concentrations of 0.1μM and 1μM that was even more pronounced than the effect of the growth factor NGF. This beneficial effect was absent when 10μM nimodipine were applied. Toxicological tests revealed that the application of nimodipine at this higher concentration slightly induced caspase 3 activation in the cortical part of the co-cultures, but did neither affect the amount of lactate dehydrogenase release or propidium iodide uptake nor the ratio of bax/bcl-2. Furthermore, the expression levels of different genes were quantified after nimodipine treatment. The expression of Ca(2+) binding proteins, immediate early genes, glial fibrillary acidic protein, and myelin components did not change significantly after treatment, indicating that the regulation of their expression is not primarily involved in the observed nimodipine mediated neurite growth. In summary, this study revealed for the first time a neurite growth promoting effect of nimodipine in the mesocortical dopaminergic projection system that is highly dependent on the applied concentrations.
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Herzfeld E, Strauss C, Simmermacher S, Bork K, Horstkorte R, Dehghani F, Scheller C. Investigation of the neuroprotective impact of nimodipine on Neuro2a cells by means of a surgery-like stress model. Int J Mol Sci 2014; 15:18453-65. [PMID: 25318050 PMCID: PMC4227225 DOI: 10.3390/ijms151018453] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/09/2014] [Accepted: 09/23/2014] [Indexed: 12/14/2022] Open
Abstract
Nimodipine is well characterized for the management of SAH (subarachnoid hemorrhage) and has been shown to promote a better outcome and less DIND (delayed ischemic neurological deficits). In rat experiments, enhanced axonal sprouting and higher survival of motoneurons was demonstrated after cutting or crushing the facial nerve by nimodipine. These results were confirmed in clinical trials following vestibular Schwannoma surgery. The mechanism of the protective competence of nimodipine is unknown. Therefore, in this study, we established an in vitro model to examine the survival of Neuro2a cells after different stress stimuli occurring during surgery with or without nimodipine. Nimodipine significantly decreased ethanol-induced cell death of cells up to approximately 9% in all tested concentrations. Heat-induced cell death was diminished by approximately 2.5% by nimodipine. Cell death induced by mechanical treatment was reduced up to 15% by nimodipine. Our findings indicate that nimodipine rescues Neuro2a cells faintly, but significantly, from ethanol-, heat- and mechanically-induced cell death to different extents in a dosage-dependent manner. This model seems suitable for further investigation of the molecular mechanisms involved in the neuroprotective signal pathways influenced by nimodipine.
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Affiliation(s)
- Eva Herzfeld
- Department of Neurosurgery, Martin-Luther University of Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany.
| | - Christian Strauss
- Department of Neurosurgery, Martin-Luther University of Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany.
| | - Sebastian Simmermacher
- Department of Neurosurgery, Martin-Luther University of Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany.
| | - Kaya Bork
- Institute for Physiological Chemistry, Martin-Luther University of Halle-Wittenberg, Hollystr. 1, 06114 Halle (Saale), Germany.
| | - Rüdiger Horstkorte
- Institute for Physiological Chemistry, Martin-Luther University of Halle-Wittenberg, Hollystr. 1, 06114 Halle (Saale), Germany.
| | - Faramarz Dehghani
- Department of Anatomy and Cell Biology, Martin-Luther University of Halle-Wittenberg, Große Steinstraße 52, 06108 Halle (Saale), Germany.
| | - Christian Scheller
- Department of Neurosurgery, Martin-Luther University of Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany.
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