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Khan MM, Badruddeen, Mujahid M, Akhtar J, Khan MI, Ahmad U. An Overview of Stroke: Mechanism, In vivo Experimental Models Thereof, and Neuroprotective Agents. Curr Protein Pept Sci 2021; 21:860-877. [PMID: 32552641 DOI: 10.2174/1389203721666200617133903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/22/2019] [Accepted: 07/30/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Stroke is one of the causes of death and disability globally. Brain attack is because of the acute presentation of stroke, which highlights the requirement for decisive action to treat it. OBJECTIVE The mechanism and in-vivo experimental models of stroke with various neuroprotective agents are highlighted in this review. METHOD The damaging mechanisms may proceed by rapid, nonspecific cell lysis (necrosis) or by the active form of cell death (apoptosis or necroptosis), depending upon the duration and severity and of the ischemic insult. RESULTS Identification of injury mediators and pathways in a variety of experimental animal models of global cerebral ischemia has directed to explore the target-specific cytoprotective strategies, which are critical to clinical brain injury outcomes. CONCLUSION The injury mechanism, available encouraging medicaments thereof, and outcomes of natural and modern medicines for ischemia have been summarized. In spite of available therapeutic agents (thrombolytics, calcium channel blockers, NMDA receptor antagonists and antioxidants), there is a need for an ideal drug for strokes.
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Affiliation(s)
- Mohd Muazzam Khan
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
| | - Badruddeen
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
| | - Mohd Mujahid
- Department of Pharmacology, College of Pharmacy, University of Hafr Al Batin, Hafr Al Batin, Saudi Arabia
| | - Juber Akhtar
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
| | | | - Usama Ahmad
- Faculty of Pharmacy, Integral University, Lucknow, Uttar Pradesh, India
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2
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Nunes RR, Duval Neto GF, Garcia de Alencar JC, Franco SB, de Andrade NQ, Holanda Dumaresq DM, Cavalcante SL. Anesthetics, cerebral protection and preconditioning. Rev Bras Anestesiol 2014; 63:119-28. [PMID: 23438807 DOI: 10.1016/s0034-7094(13)70204-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 06/16/2012] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Several studies demonstrate that cerebral preconditioning is a protective mechanism against a stressful situation. Preconditioning determinants are described, as well as the neuroprotection provided by anesthetic and non-anesthetics agents. CONTENT Review based on the main articles addressing the pathophysiology of ischemia-reperfusion and neuronal injury and pharmacological and non-pharmacological factors (inflammation, glycemia, and temperature) related to the change in response to ischemia-reperfusion, in addition to neuroprotection induced by anesthetic use. CONCLUSIONS The brain has the ability to protect itself against ischemia when stimulated. The elucidation of this mechanism enables the application of preconditioning inducing substances (some anesthetics), other drugs, and non-pharmacological measures, such as hypothermia, aimed at inducing tolerance to ischemic lesions.
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Nunes RR, Duval Neto GF, de Alencar JCG, Franco SB, de Andrade NQ, Dumaresq DMH, Cavalcante SL. Anesthetics, cerebral protection and preconditioning. Braz J Anesthesiol 2013; 63:119-28. [PMID: 24565096 DOI: 10.1016/j.bjane.2012.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 06/16/2012] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Several studies demonstrate that cerebral preconditioning is a protective mechanism against a stressful situation. Preconditioning determinants are described, as well as the neuroprotection provided by anesthetic and non-anesthetics agents. CONTENT Review based on the main articles addressing the pathophysiology of ischemia-reperfusion and neuronal injury and pharmacological and non-pharmacological factors (inflammation, glycemia, and temperature) related to the change in response to ischemia-reperfusion, in addition to neuroprotection induced by anesthetic use. CONCLUSIONS The brain has the ability to protect itself against ischemia when stimulated. The elucidation of this mechanism enables the application of preconditioning inducing substances (some anesthetics), other drugs, and non-pharmacological measures, such as hypothermia, aimed at inducing tolerance to ischemic lesions.
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Affiliation(s)
- Rogean Rodrigues Nunes
- TSA; MSc and PhD in Anesthetics; Postgraduate in Cardiology, Universidade Federal do Ceará (UFC); Jointly Responsible for the Center for Teaching and Training (CET) of Hospital Geral de Fortaleza (HGF); Medicine Professor of Fachristus; Postgraduate in Clinical Engineering, Universidade de Fortaleza (Unifor); Vice-Chair of the Research Ethics Committee, Hospital São Carlos, Fortaleza, Ceará.
| | | | | | | | | | - Danielle Maia Holanda Dumaresq
- TSA; MSc, UFC; Responsible for CET-IJF; Chairman of the Pediatric Anesthesia Committee, Sociedade Brasileira de Anestesiologia (SBA) - 2011; Medicine Professor of Fachristus, Fortaleza, Ceará
| | - Sara Lúcia Cavalcante
- PhD; Professor, Faculdade de Medicina, UFC; Corresponsible for the CET of the HGF from Hospital São Carlos, Fortaleza Ceara, Brazil
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4
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Affiliation(s)
- Dion Stub
- Heart Centre, Alfred Hospital Commercial Rd, Melbourne, Australia 3004.
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5
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Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bbttiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth W, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part II). Int Emerg Nurs 2010; 18:8-28. [DOI: 10.1016/j.ienj.2009.07.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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6
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Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bbttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A scientific statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke (Part 1). Int Emerg Nurs 2009; 17:203-25. [PMID: 19782333 DOI: 10.1016/j.ienj.2009.01.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIM OF THE REVIEW To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. METHODS Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. RESULTS The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. CONCLUSIONS A growing body of knowledge suggests that the individual components of the postcardiac arrest syndrome are potentially treatable.
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Affiliation(s)
- Jerry P Nolan
- Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom.
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7
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Neumar RW, Nolan JP, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Vanden Hoek T. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation 2008; 118:2452-83. [PMID: 18948368 DOI: 10.1161/circulationaha.108.190652] [Citation(s) in RCA: 1064] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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8
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Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RSB, Geocadin RG, Jauch EC, Kern KB, Laurent I, Longstreth WT, Merchant RM, Morley P, Morrison LJ, Nadkarni V, Peberdy MA, Rivers EP, Rodriguez-Nunez A, Sellke FW, Spaulding C, Sunde K, Hoek TV. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 2008; 79:350-79. [PMID: 18963350 DOI: 10.1016/j.resuscitation.2008.09.017] [Citation(s) in RCA: 697] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 09/22/2008] [Indexed: 12/12/2022]
Abstract
AIM OF THE REVIEW To review the epidemiology, pathophysiology, treatment and prognostication in relation to the post-cardiac arrest syndrome. METHODS Relevant articles were identified using PubMed, EMBASE and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Writing groups comprising international experts were assigned to each section. Drafts of the document were circulated to all authors for comment and amendment. RESULTS The 4 key components of post-cardiac arrest syndrome were identified as (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response, and (4) persistent precipitating pathology. CONCLUSIONS A growing body of knowledge suggests that the individual components of the post-cardiac arrest syndrome are potentially treatable.
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Affiliation(s)
- Jerry P Nolan
- Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, United Kingdom.
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9
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Hamed SA. Neuronal plasticity: implications in epilepsy progression and management. Drug Dev Res 2008. [DOI: 10.1002/ddr.20217] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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10
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Sunde K, Dunlop O, Rostrup M, Sandberg M, Sjøholm H, Jacobsen D. Determination of prognosis after cardiac arrest may be more difficult after introduction of therapeutic hypothermia. Resuscitation 2006; 69:29-32. [PMID: 16517042 DOI: 10.1016/j.resuscitation.2005.12.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Accepted: 12/09/2005] [Indexed: 10/24/2022]
Abstract
A 50-year-old patient had status epilepticus and no adequate reactions nine days after prolonged out-of-hospital cardiac arrest. The cause of the arrest was acute myocardial infarction which was treated successfully with percutaneous cardiac intervention (PCI) and a stent placement. He was treated with therapeutic hypothermia (33 degrees C) for 24h and in intensive care with respiratory support for 42 days. One year later he has fully recovered and is back to normal life and academic work. The previously reported 100% prognosis of a poor neurological outcome in the presence of seizures 72 h post arrest may need to be re-examined after introduction of therapeutic hypothermia.
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Affiliation(s)
- Kjetil Sunde
- Department of Anaesthesiology and Institute for Experimental Medical Research, Surgical Division, Ulleval University Hospital, N-0407 Oslo, Norway.
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11
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Herlitz J, Castren M, Friberg H, Nolan J, Skrifvars M, Sunde K, Steen PA. Post resuscitation care: what are the therapeutic alternatives and what do we know? Resuscitation 2006; 69:15-22. [PMID: 16488070 DOI: 10.1016/j.resuscitation.2005.08.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Accepted: 08/11/2005] [Indexed: 01/27/2023]
Abstract
A large proportion of deaths in the Western World are caused by ischaemic heart disease. Among these patients a majority die outside hospital due to sudden cardiac death. The prognosis among these patients is in general, poor. However, a significant proportion are admitted to a hospital ward alive. The proportion of patients who survive the hospital phase of an out of hospital cardiac arrest varies considerably. Several treatment strategies are applicable during the post resuscitation care phase, but the level of evidence is weak for most of them. Four treatments are recommended for selected patients based on relatively good clinical evidence: therapeutic hypothermia, beta-blockers, coronary artery bypass grafting, and an implantable cardioverter defibrillator. The patient's cerebral function might influence implementation of the latter two alternatives. There is some evidence for revascularisation treatment in patients with suspected myocardial infarction. On pathophysiological grounds, an early coronary angiogram is a reasonable alternative. Further randomised clinical trials of other post resuscitation therapies are essential.
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Affiliation(s)
- J Herlitz
- Division of Cardiology, Sahlgrenska University Hospital, Göteborg, Sweden.
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12
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Abstract
Cerebral ischemia results in a rapid depletion of energy stores that triggers a complex cascade of cellular events such as cellular depolarization and Ca2+ influx, resulting in excitotoxic cell death. The critical determinant of severity of brain injury is the duration and severity of the ischemic insult and early restoration of CBF. Induced therapeutic hypothermia following CA is the only strategy that has demonstrated improvement in outcomes in prospective, randomized clinical trials. Although pharmacologic neuro-protection has been disappointing thus far in a variety of experimental animal models, further research efforts are directed at using some agents that demonstrate marginal or moderate efficacy in combination with hypothermia. Although the signal transduction pathways and intracellular molecular events during cerebral ischemia and reperfusion are complex, potential therapeutic neuroprotective strategies hold promise for the future.
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Affiliation(s)
- Izumi Harukuni
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Division of Cardiac Anesthesiology, Tower 711, Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, USA
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13
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Weigl M, Tenze G, Steinlechner B, Skhirtladze K, Reining G, Bernardo M, Pedicelli E, Dworschak M. A systematic review of currently available pharmacological neuroprotective agents as a sole intervention before anticipated or induced cardiac arrest. Resuscitation 2005; 65:21-39. [PMID: 15797272 DOI: 10.1016/j.resuscitation.2004.11.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Revised: 10/20/2004] [Accepted: 11/01/2004] [Indexed: 11/24/2022]
Abstract
We conducted a Medline search for controlled studies evaluating currently available drugs for pharmacological neuroprotection. They had to be administered prior to transient global cerebral ischaemia without further non-pharmacological measures. We deliberately excluded focal ischaemia since its pathophysiology is substantially different from global ischaemia. A total of 45 articles conducted exclusively in laboratory animals met these criteria. The following classes of agents were evaluated: anaesthetics, GABAergic drugs, calcium-antagonists, anticonvulsives, sodium-channel blockers, potassium-channel activators, NMDA-receptor antagonists, hormones, vasodilators, dopamine- and alpha2-agonists, magnesium, xanthine oxidase- and cyclooxygenase inhibitors, a nootropic, a protease inhibitor, and immunosuppressants. Some of them were applied chronically and others administered via clinically impracticable routes. The available literature favours isoflurane, phenytoin, lamotrigine, magnesium, and potentially, nimodipine, and flunarizine. If factors like costs, toxicity, side effects, route and mode of application are considered, isoflurane and MgSO4 that have also been safely applied to patients with compromised left ventricular pump function are advantageous but their true role in human neuroprotection remains unclear.
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Affiliation(s)
- Manuela Weigl
- Department of Anaesthesiology and General Intensive Care, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, University Hospital Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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14
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Lin Z, Yan Y, Zhu D, Yu B, Wang Q. Protective effects of FBD--an experimental Chinese traditional medicinal formula on memory dysfunction in mice induced by cerebral ischemia-reperfusion. JOURNAL OF ETHNOPHARMACOLOGY 2005; 97:477-483. [PMID: 15740883 DOI: 10.1016/j.jep.2004.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Revised: 11/30/2004] [Accepted: 12/01/2004] [Indexed: 05/24/2023]
Abstract
With regards to the applications of three Chinese herbs poria, rhizoma atractylodis macrocephalae, and radix angelicae sinensis to vascular dementia (VD), the work was performed to assess the nootropic action and explore neuroprotective mechanisms of three herbs combinations (FBD) on mice injured by cerebral repetitive ischemia-reperfusion (IR). Aqueous extracts from FBD (115-460 mg/kg) administered p.o. significantly improved cognitive function through elongating latency and reducing number of errors in step-through test. Aqueous extracts from FBD inhibited lipid peroxidation (LPO), elevated activity in (Na+)-(K+)-ATPase and (Ca2+)-ATPase, reduced the production of nitric oxide (NO) in cortical tissue after IR, and artificial cerebrospinal fluid (ACSF) containing aqueous extracts from FBD (ACSF-FBD) (0.01-10 mg/L) protected also primary cortical cortex neurons (PCCN) from hypoxic and excitotoxic insult induced by sodium dithionite (1 mM) and monosodium glutamate (MSG) (0.5 mM) in vitro. Multiple anti-IR properties contributed probably FBD to ameliorate cognitive dysfunction shown in this murine model for VD.
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Affiliation(s)
- Zhihong Lin
- Department of Chinese Medicinal Prescription, China Pharmaceutical University, Nanjing 210038, PR China
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15
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Crowe SF, Hale MW. Facilitation of a weak training experience in the 1-day-old chick using diphenylhydantoin: a pharmacological and biochemical study. Pharmacol Biochem Behav 2004; 77:657-66. [PMID: 15099910 DOI: 10.1016/j.pbb.2003.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2003] [Revised: 10/19/2003] [Accepted: 11/21/2003] [Indexed: 11/18/2022]
Abstract
This series of studies used a weakly trained (20% methyl anthranilate) version of the passive avoidance learning task in the 1-day-old chick to investigate memory facilitation effects by diphenylhydantoin (DPH). The results indicated that the pairing of the weak training experience with DPH results in facilitation of memory that can be observed from 40 min following training with the weak training experience. The results from a biochemical experiment indicated that DPH facilitates the activity of Na(+)/K(+)-ATPase at the majority of times sampled in a large percentage of the sections of the chick brain. The most marked level of elevation in the activity of the enzyme was observed at the 20-min time point following weak training in the section of the chick brain, which contained several memory relevant neuroanatomical loci. This represents a 68% increase in the activity of the enzyme in those areas considered to be crucial to the processing of memory in the paradigm at a time predicted by previous investigation to be crucial in the development of the intermediate-term memory stage of memory. The results of this series of studies support the notion that Na(+)/K(+)-ATPase plays an important role in memory processing following passive avoidance training in the 1-day-old chick.
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Affiliation(s)
- Simon F Crowe
- School of Psychological Science, La Trobe University, Bundoora, Victoria 3086, Australia.
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Leker RR, Neufeld MY. Anti-epileptic drugs as possible neuroprotectants in cerebral ischemia. BRAIN RESEARCH. BRAIN RESEARCH REVIEWS 2003; 42:187-203. [PMID: 12791439 DOI: 10.1016/s0165-0173(03)00170-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many similarities exist between cerebral ischemia and epilepsy regarding brain-damaging and auto-protective mechanisms that are activated following the injurious insult. Therefore, drugs that are effective in minimizing seizure-induced brain damage may also be useful in minimizing ischemic injury. Use of such drugs in stroke victims may have important clinical and financial advantages. Therefore, the authors conducted a Medline search of studies involving the use of anti-epileptic drugs (AEDs) as possible neuroprotectants and summarize the data. Most AEDs have been tested in animal models of focal or global ischemia and some were already tested in humans, for a possible neuroprotective effect. The existing data is rather scant and insufficient but it appears that only drugs that have multiple mechanisms of action seem to have some potential in conferring a degree of neuroprotection that could be clinically applicable to stroke patients. In conclusion, some of the newer AEDs show promise as possible neuroprotectants in the setup of acute ischemic stroke but more studies are needed before clinical trials in humans could be undertaken.
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Affiliation(s)
- R R Leker
- Department of Neurology and the Agnes Ginges Center for Human Neurogenetics, Hebrew University-Hadassah Medical School, Hadassah University Hospital, Jerusalem, Israel.
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Abstract
In patients with severe liver failure, brain edema is a frequent and serious complication that may result in high intracranial pressure and brain damage. This short article focuses on basic physiologic principles that determine water flux across the blood-brain barrier. Using the Starling equation, it is evident that both the osmotic and hydrostatic pressure gradients are imbalanced across the blood-brain barrier in patients with acute liver failure. This combination will tend to favor cerebral capillary water influx to the brain. In contrast, the disequilibration of the Starling forces seems to be less pronounced in patients with cirrhosis because the regulation of cerebral blood flow is preserved and the arterial ammonia concentration is lower compared with that of patients with acute liver failure. Treatments that are known to reverse high intracranial pressure tend to decrease the osmotic pressure gradients across the blood-brain barrier. Recent studies indicate that interventions that restrict cerebral blood flow, such as hyperventilation, hypothermia, and indomethacin, are also efficient in preventing edema and high intracranial pressure, probably by decreasing the transcapillary hydrostatic pressure gradient. In our opinion, it is important to recall that rational fluid therapy, adequate ventilation, and temperature control are of direct importance to controlling cerebral capillary water flux in patients with acute liver failure. These simple interventions should be secured before more advanced experimental technologies are instituted to treat these patients.
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Crowe SF, El-Hadj D. Phenytoin ameliorates the memory deficit induced in the young chick by ethanol toxicity in association with thiamine deficiency. Pharmacol Biochem Behav 2002; 71:215-21. [PMID: 11812525 DOI: 10.1016/s0091-3057(01)00650-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The experiments reported in this series of studies demonstrate that thiamine deficiency, induced pharmacologically by oxythiamine (OT) coupled with the acute administration of ethanol can adversely affect memory processing in the young chick. The interaction between the avitaminosis and ethanol neurotoxicity exerted its effects through the inhibition of the development of the intermediate (ITM) stage of memory (i.e., following 10 min after training), consequently affecting development of the long-term stage of memory and leaving the short-term memory stage intact. The amnesic effect of OT-induced thiamine deficiency and exposure to alcohol was ameliorated by the administration of phenytoin [diphenylhydantoin (DPH)] immediately following the training experience. As the ITM stage of memory has been suggested to rely on the activities of Na(+)/K(+) ATPase, and as DPH is a facilitator of Na(+)/K(+) ATPase activity amongst its other actions, it may be that the combined effect of OT and ethanol exposure is by interfering with Na(+)/K(+) ATPase activity, thus undermining the expression and maintenance of the memory in the period from 10 min following aversant training.
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Affiliation(s)
- Simon F Crowe
- School of Psychological Science, La Trobe University, Bundoora 3083, Australia.
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Behringer W, Kentner R, Wu X, Tisherman SA, Radovsky A, Stezoski WS, Henchir J, Prueckner S, Safar P. Thiopental and phenytoin by aortic arch flush for cerebral preservation during exsanguination cardiac arrest of 20 minutes in dogs. An exploratory study. Resuscitation 2001; 49:83-97. [PMID: 11334695 DOI: 10.1016/s0300-9572(00)00336-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We are systematically exploring in our exsanguination cardiac arrest (CA) outcome model in dogs suspended animation (SA), i.e. immediate preservation of brain and heart for resuscitative surgery during CA, with delayed resuscitation. We have shown in dogs that inducing moderate cerebral hypothermia with an aortic arch flush of 500 ml normal saline solution of 4 degrees C, at start of CA 20 min no-flow, leads to normal functional outcome. We hypothesized that, using the same model, adding thiopental (or even better thiopental plus phenytoin) to the flush at ambient temperature (24 degrees C), which would be more readily available in the field, will also achieve normal functional outcome. Thirty dogs (20-28 kg) were exsanguinated over 5 min to CA of 20 min no-flow, and resuscitated by closed-chest cardiopulmonary bypass. They received assisted circulation to 2 h, 34 degrees C post-CA to 12 h, controlled ventilation to 20 h, and intensive care to 72 h. At CA 2 min, the dogs received an aortic arch flush of 500 ml saline at 24 degrees C by a balloon-tipped catheter, inserted through the femoral artery (control group 1, n=14). In group 2 (n=9), thiopental (variable total doses of 15-120 mg/kg) was added to the flush and given with reperfusion. In group 3 (n=7), thiopental (15 or 45 mg/kg) plus phenytoin (10, 20, or 30 mg/kg) was given by flush and with reperfusion. Outcome was assessed in terms of overall performance categories (OPC 1, normal; 2, moderate disability; 3, severe disability; 4, coma; 5, brain death), neurologic deficit scores (NDS 0-10%, normal; 100%, brain death), and histologic deficit scores (HDS, total and regional). The flush reduced tympanic temperature to about 36 degrees C in all groups. In control group 1, one dog achieved OPC 1, three OPC 2, six OPC 3, and four OPC 4. In thiopental group 2, two dogs achieved OPC 1, two OPC 3, and five OPC 4. In thiopental/phenytoin group 3, one dog achieved OPC 1, two OPC 3, and four OPC 4 (p=0.5). Median NDS were 36% (IQR 22-62%) in group 1; 51% (IQR 22-56%) in group 2; and 55% (IQR 38-59%) in group 3 (p=0.7). Median total HDS were 67 (IQR 56-127) in group 1; 60 (IQR 52-138) in group 2; and 76 (IQR 48-132) in group 3 (p=1.0). Thiopental and thiopental/phenytoin dogs achieved significantly lower HDS only in the putamen. Thiopental in large doses caused side effects. We conclude that neither thiopental alone nor thiopental plus phenytoin by flush, with or without additional intravenous infusion, can consistently provide 'clinically significant' cerebral preservation for 20 min no-flow. Other drugs and drug-combinations should be tested with this model in search for a breakthrough effect.
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Affiliation(s)
- W Behringer
- Department of Anesthesiology/Critical Care Medicine, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA
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Ebmeyer U, Safar P, Radovsky A, Xiao F, Capone A, Tanigawa K, Stezoski SW. Thiopental combination treatments for cerebral resuscitation after prolonged cardiac arrest in dogs. Exploratory outcome study. Resuscitation 2000; 45:119-31. [PMID: 10950320 DOI: 10.1016/s0300-9572(00)00173-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We postulate that mitigating the multifactorial pathogenesis of postischemic encephalopathy requires multifaceted treatments. In preparation for expensive definitive studies, we are reporting here the results of small exploratory series, compared with historic controls with the same model. We hypothesized that the brain damage mitigating effect of mild hypothermia after cardiac arrest can be enhanced with thiopental loading, and even more so with the further addition of phenytoin and methylprednisolone. Twenty-four dogs (four groups of six dogs each) received VF 12.5 min no-flow, reversed with brief cardiopulmonary bypass (CPB), controlled ventilation to 20 h, and intensive care to 96 h. Group 1 with normothermia throughout and randomized group 2 with mild hypothermia (from reperfusion to 2 h) were controls. Then, group 3 received in addition, thiopental 90 mg/kg i.v. over the first 6 h. Then, group 4 received, in addition to group 2 treatment, thiopental 30 mg/kg i.v. over the first 90 min (because the larger dose had produced cardiopulmonary complications), plus phenytoin 15 mg/kg i.v. at 15 min after reperfusion, and methylprednisolone 130 mg/kg i.v. over 20 h. All dogs survived. Best overall performance categories (OPC) achieved (OPC 1 = normal, OPC 5 = brain death) were better in group 2 than group 1 (< 0.05) and numerically better in groups 3 or 4 than in groups 1 or 2. Good cerebral outcome (OPC 1 or 2) was achieved by all six dogs only in group 4 (P < 0.05 group 4 vs. 2). Best NDS were 44 +/- 3% in group 1; 20 +/- 14% in group 2 (P = 0.002); 21 +/- 15% in group 3 (NS vs. group 2); and 7 +/- 8% in group 4 (P = 0.08 vs. group 2). Total brain histologic damage scores (HDS) at 96 h were 156 +/- 38 in group 1; 81 +/- 12 in group 2 (P < 0.001 vs. group 1); 53 +/- 25 in group 3 (P = 0.02 vs. group 2); and 48 +/- 5 in group 4 (P = 0.02 vs. group 2). We conclude that after prolonged cardiac arrest, the already established brain damage mitigating effect of mild immediate postarrest hypothermia might be enhanced by thiopental, and perhaps then further enhanced by adding phenytoin and methylprednisolone.
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Affiliation(s)
- U Ebmeyer
- Department of Anesthesiology/Critical Care Medicine and the Safar Center for Resuscitation Research, University of Pittsburgh Medical Center, PA 15260, USA
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Jund R, Wächtler J. Sensitivity of isolated rat facial nerve to chemical hypoxia altered by glucose availability and phenytoin. PATHOPHYSIOLOGY 1997. [DOI: 10.1016/s0928-4680(96)00159-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Jund R, Kastenbauer E. Susceptibility of isolated rat facial nerve to anaerobic stress. Eur Arch Otorhinolaryngol 1997; 254 Suppl 1:S64-7. [PMID: 9065631 DOI: 10.1007/bf02439727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Ischemic lesions are presumed to be part of many facial nerve pathologies, such as Bell's palsy. The response of facial nerve to hypoxia has not been evaluated previously in an in vitro model. In the present study, the effects of transient anaerobic stress on functional parameters and their recovery were assessed. Extratemporal rat facial nerves were desheathed and incubated in an experimental chamber using solutions containing either low (5 mM) or high (25 mM) D-glucose. In some of the experiments, 40 microM phenytoin or lidocaine was added to observe the effects of membrane stabilizing drugs. Peak height of compound nerve action potential (CNAP), extracellular direct current (DC) potential and latency were measured simultaneously during and after a 40-min period of hypoxia, induced by bubbling the solutions with N2 or application of 3 mM cyanide. This resulted in a rapid decrease of CNAP and a depolarization of the DC potential with a fast and complete post hypoxic recovery. Elevated glucose concentrations led to a slower decline in CNAP and a smaller rise of membrane potential depolarization. This was accompanied by a slower change of latency. However, post-anaerobic recovery was always diminished in the high glucose solutions. In experiments with phenytoin or lidocaine longer impulse conduction during hypoxia was observed. These findings indicate that the availability of energy-rich components underlies the complex array of physiological derangements seen in ischemia. Membrane-stabilizing drugs show an effect on signal conduction during hypoxia and need further exploration.
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Affiliation(s)
- R Jund
- Department of Otorhinolaryngology, University of Munich, Klinikum Grosshadern, Germany
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