Bench to bedside: brain edema and cerebral resuscitation: the present and future

The Usefulness of Quantitative Analysis of Blood-Brain Barrier Disruption Measured Using Contrast-Enhanced Magnetic Resonance Imaging to Predict Neurological Prognosis in Out-of-Hospital Cardiac Arrest Survivors: A Preliminary Study

We aimed to evaluate neurological outcomes associated with blood-brain barrier (BBB) disruption using contrast-enhanced magnetic resonance imaging (CE-MRI) in out-of-hospital cardiac arrest (OHCA) survivors. This retrospective observational study involved OHCA survivors who had undergone CE-MRI for prognostication. Qualitative and quantitative analyses were performed using the presence of BBB disruption (pBD) and the BBB disruption score (sBD) in CE-MRI scans, respectively. For the sBD, 1 point was assigned for each area of BBB disruption, and 6 points were assigned when an absence of intracranial blood flow due to severe brain oedema was confirmed. The primary outcome was poor neurological outcome at 3 months (defined as cerebral performance categories 3-5). We analysed 46 CE-MRI brain scans (27 patients). Of these, 15 (55.6%) patients had poor neurological outcomes. Poor neurological outcome group patients showed a significantly higher proportion of pBD than those in the good neurological outcome group (22 (88%) vs. 6 (28.6%) patients, respectively, p < 0.001) and a higher sBD (5.0 (4.0-5.0) vs. 0.0 (0.0-1.0) patients, p < 0.001). Poor neurological outcome predictions showed that the sBD had a significantly better prognostic performance (area under the curve (AUC) 0.95, 95% confidence interval (CI) 0.84-0.99) than the pBD (AUC 0.80, 95% CI 0.65-0.90). The sBD cut-off value was >1 point (sensitivity, 96.0%; specificity, 81.0%). The sBD is a highly predictive and sensitive marker of 3-month poor neurological outcome in OHCA survivors. Multicentre prospective studies are required to determine the generalisability of these results.

Roles of blood-brain barrier integrins and extracellular matrix in stroke

Ischemicstroke is a leading cause of death and disability in the United States, but recent advances in treatments [i.e., endovascular thrombectomy and tissue plasminogen activator (t-PA)] that target the stroke-causing blood clot, while improving overall stroke mortality rates, have had much less of an impact on overall stroke morbidity. This may in part be attributed to the lack of therapeutics targeting reperfusion-induced injury after the blood clot has been removed, which, if left unchecked, can expand injury from its core into the surrounding at risk tissue (penumbra). This occurs in two phases of increased permeability of the blood-brain barrier, a physical barrier that under physiologic conditions regulates brain influx and efflux of substances and consists of tight junction forming endothelial cells (and transporter proteins), astrocytes, pericytes, extracellular matrix, and their integrin cellular receptors. During, embryonic development, maturity, and following stroke reperfusion, cerebral vasculature undergoes significant changes including changes in expression of integrins and degradation of surrounding extracellular matrix. Integrins, heterodimers with α and β subunits, and their extracellular matrix ligands, a collection of proteoglycans, glycoproteins, and collagens, have been modestly studied in the context of stroke compared with other diseases (e.g., cancer). In this review, we describe the effect that various integrins and extracellular matrix components have in embryonic brain development, and how this changes in both maturity and in the poststroke environment. Particular focus will be on how these changes in integrins and the extracellular matrix affect blood-brain barrier components and their potential as diagnostic and therapeutic targets for ischemic stroke.

Prognostication after cardiac arrest

Hypoxic-ischaemic brain injury (HIBI) is the main cause of death in patients who are comatose after resuscitation from cardiac arrest. A poor neurological outcome-defined as death from neurological cause, persistent vegetative state, or severe neurological disability-can be predicted in these patients by assessing the severity of HIBI. The most commonly used indicators of severe HIBI include bilateral absence of corneal and pupillary reflexes, bilateral absence of N₂O waves of short-latency somatosensory evoked potentials, high blood concentrations of neuron specific enolase, unfavourable patterns on electroencephalogram, and signs of diffuse HIBI on computed tomography or magnetic resonance imaging of the brain. Current guidelines recommend performing prognostication no earlier than 72 h after return of spontaneous circulation in all comatose patients with an absent or extensor motor response to pain, after having excluded confounders such as residual sedation that may interfere with clinical examination. A multimodal approach combining multiple prognostication tests is recommended so that the risk of a falsely pessimistic prediction is minimised.

Phosphorylated recombinant HSP27 protects the brain and attenuates blood-brain barrier disruption following stroke in mice receiving intravenous tissue-plasminogen activator

Loss of integrity of the blood-brain barrier (BBB) in ischemic stroke victims initiates a devastating cascade of events causing brain damage. Maintaining the BBB is important to preserve brain function in ischemic stroke. Unfortunately, recombinant tissue plasminogen activator (tPA), the only effective fibrinolytic treatment at the acute stage of ischemic stroke, also injures the BBB and increases the risk of brain edema and secondary hemorrhagic transformation. Thus, it is important to identify compounds that maintain BBB integrity in the face of ischemic injury in patients with stroke. We previously demonstrated that intravenously injected phosphorylated recombinant heat shock protein 27 (prHSP27) protects the brains of mice with transient middle cerebral artery occlusion (tMCAO), an animal stroke-model. Here, we determined whether prHSP27, in addition to attenuating brain injury, also decreases BBB damage in hyperglycemic tMCAO mice that had received tPA. After induction of hyperglycemia and tMCAO, we examined 4 treatment groups: 1) bovine serum albumin (BSA), 2) prHSP27, 3) tPA, 4) tPA plus prHSP27. We examined the effects of prHSP27 by comparing the BSA and prHSP27 groups and the tPA and tPA plus prHSP27 groups. Twenty-four hours after injection, prHSP27 reduced infarct volume, brain swelling, neurological deficits, the loss of microvessel proteins and endothelial cell walls, and mortality. It also reduced the rates of hemorrhagic transformation, extravasation of endogenous IgG, and MMP-9 activity, signs of BBB damage. Therefore, prHSP27 injection attenuated brain damage and preserved the BBB in tPA-injected, hyperglycemic tMCAO experimental stroke-model mice, in which the BBB is even more severely damaged than in simple tMCAO mice. The attenuation of brain damage and BBB disruption in the presence of tPA suggests the effectiveness of prHSP27 and tPA as a combination therapy. prHSP27 may be a novel therapeutic agent for ischemic stroke patients whose BBBs are injured following tPA injections.

Hypothermia and brain inflammation after cardiac arrest

The cessation (ischemia) and restoration (reperfusion) of cerebral blood flow after cardiac arrest (CA) induce inflammatory processes that can result in additional brain injury. Therapeutic hypothermia (TH) has been proven as a brain protective strategy after CA. In this article, the underlying pathophysiology of ischemia-reperfusion brain injury with emphasis on the role of inflammatory mechanisms is reviewed. Potential targets for immunomodulatory treatments and relevant effects of TH are also discussed. Further studies are needed to delineate the complex pathophysiology and interactions among different components of immune response after CA and identify appropriate targets for clinical investigations.

Mild hypothermia alleviates brain oedema and blood-brain barrier disruption by attenuating tight junction and adherens junction breakdown in a swine model of cardiopulmonary resuscitation

Mild hypothermia improves survival and neurological recovery after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR). However, the mechanism underlying this phenomenon is not fully elucidated. The aim of this study was to determine whether mild hypothermia alleviates early blood-brain barrier (BBB) disruption. We investigated the effects of mild hypothermia on neurologic outcome, survival rate, brain water content, BBB permeability and changes in tight junctions (TJs) and adherens junctions (AJs) after CA and CPR. Pigs were subjected to 8 min of untreated ventricular fibrillation followed by CPR. Mild hypothermia (33°C) was intravascularly induced and maintained at this temperature for 12 h, followed by active rewarming. Mild hypothermia significantly reduced cortical water content, decreased BBB permeability and attenuated TJ ultrastructural and basement membrane breakdown in brain cortical microvessels. Mild hypothermia also attenuated the CPR-induced decreases in TJ (occludin, claudin-5, ZO-1) and AJ (VE-cadherin) protein and mRNA expression. Furthermore, mild hypothermia decreased the CA- and CPR-induced increases in matrix metalloproteinase-9 (MMP-9) and vascular endothelial growth factor (VEGF) expression and increased angiogenin-1 (Ang-1) expression. Our findings suggest that mild hypothermia attenuates the CA- and resuscitation-induced early brain oedema and BBB disruption, and this improvement might be at least partially associated with attenuation of the breakdown of TJ and AJ, suppression of MMP-9 and VEGF expression, and upregulation of Ang-1 expression.

Cerebral Vascular Disease and Neurovascular Injury in Ischemic Stroke

The consequences of cerebrovascular disease are among the leading health issues worldwide. Large and small cerebral vessel disease can trigger stroke and contribute to the vascular component of other forms of neurological dysfunction and degeneration. Both forms of vascular disease are driven by diverse risk factors, with hypertension as the leading contributor. Despite the importance of neurovascular disease and subsequent injury after ischemic events, fundamental knowledge in these areas lag behind our current understanding of neuroprotection and vascular biology in general. The goal of this review is to address select key structural and functional changes in the vasculature that promote hypoperfusion and ischemia, while also affecting the extent of injury and effectiveness of therapy. In addition, as damage to the blood-brain barrier is one of the major consequences of ischemia, we discuss cellular and molecular mechanisms underlying ischemia-induced changes in blood-brain barrier integrity and function, including alterations in endothelial cells and the contribution of pericytes, immune cells, and matrix metalloproteinases. Identification of cell types, pathways, and molecules that control vascular changes before and after ischemia may result in novel approaches to slow the progression of cerebrovascular disease and lessen both the frequency and impact of ischemic events.

Levodopa improves learning and memory ability on global cerebral ischemia-reperfusion injured rats in the Morris water maze test

Previous studies have shown that levodopa (L-dopa) for 1-7days improved the consciousness level of certain patients who suffered from ischemia-reperfusion injury and were comatose for a long time period after cerebral resuscitation treatment. It also has an awakening effect on patients with disorders of consciousness. This study aimed to investigate whether L-dopa, which is used clinically to treat Parkinson's disease, might also ameliorate the behavior of rats following global cerebral ischemia-reperfusion injury. Fifty-six healthy adult male Sprague-Dawley rats were randomly divided into four groups: shamoperated, global cerebral ischemia mode, 25mg/kg/d L-dopa intervention, and 50mg/kg/d L-dopa intervention. The level of consciousness and modified neurological severity score (NSS) of the rats in each group were measured before reperfusion and 6, 24, and 72h and 1-4 weeks after reperfusion. The Morris water maze test was used to assess behavior of rats 1 week after reperfusion and 2 weeks after reperfusion in each group. The results showed that after global cerebral ischemiareperfusion injury, neurological deficits of rats are severe, and space exploration capacity and learning and memory capacity are significantly decreased. L-dopa can shorten the duration of coma in rats following global cerebral ischemia-reperfusion injury and improve the symptoms of neurological deficits and advanced learning and memory. In the range of the selected doses, the relationship between L-dopa and improvement of the neurological behavior in rats was not dose-dependent. Dopamine may be useful for treating severe ischemia-reperfusion brain injury.

Assessment of the Correlations Between Brain Weight and Brain Edema in Experimental Subarachnoid Hemorrhage

Because brain edema is correlated with poor outcome in clinical subarachnoid hemorrhage (SAH), appropriate evaluation methods for brain edema are important in experimental SAH studies. Although brain water content (BWC) is widely used to evaluate brain edema in stroke research, the usefulness of brain weight is undetermined. In this study, we examined the role of brain weight in the evaluation of brain edema in experimental SAH. The endovascular perforation model of SAH was used, and rats were assessed by neurological scoring (NS). The brains were quickly removed at 24 h after the operation, and the weights of wet cerebrum (WWC) and dry cerebrum (WDC) were measured to determine the brain water content (BWC). The correlations of those values with each other and to body weight (BW) were then examined to reveal the significance of brain weight. The rats were assigned to sham-operated (n = 8) and SAH (n = 16) groups. There were no significant differences in WWC between the groups (p = 0.61). WWC was correlated with BWC but not with NS in all rats. In addition, WWC was clearly correlated with BW and WDC, which is thought to substitute for the original brain weight. From these results, we suggest that the measurement of brain weight as an evaluation of brain edema is limited and that BW and original brain volume can be confounding factors in evaluation.

Improving neurological outcome after cardiac arrest: Therapeutic hypothermia the best treatment

Cardiac arrest, irrespective of its etiology, has a high mortality. This event is often associated with brain anoxia which frequently causes severe neurological damage and persistent vegetative state. Only one out of every six patients survives to discharge following in-hospital cardiac arrest, whereas only 2-9% of patients who experience out of hospital cardiac arrest survive to go home. Functional outcomes of survival are variable, but poor quality survival is common, with only 3-7% able to return to their previous level of functioning. Therapeutic hypothermia is an important tool for the treatment of post-anoxic coma after cardiopulmonary resuscitation. It has been shown to reduce mortality and has improved neurological outcomes after cardiac arrest. Nevertheless, hypothermia is underused in critical care units. This manuscript aims to review the mechanism of hypothermia in cardiac arrest survivors and to propose a simple protocol, feasible to be implemented in any critical care unit.

Genetic Deletion of Prostacyclin IP Receptor Exacerbates Transient Global Cerebral Ischemia in Aging Mice

Transient global cerebral ischemia causes delayed neuronal death in the hippocampal CA1 region. It also induces an up regulation of cyclooxygenase 2 (COX-2), which generates several metabolites of arachidonic acid, known as prostanoids, including Prostaglandin I2 (PGI2). The present study investigated whether the PGI2 IP receptor plays an important role in brain injury after global cerebral ischemia in aged mice. Adult young (2-3 months) and aged (12-15 months) male C57Bl/6 wild-type (WT) or IP receptor knockout (IP KO) mice underwent a 12 min bilateral common carotid artery occlusion (BCCAO) or a sham surgery. Behavior tests (neurologic deficit and T-maze) were performed 3 and 7 days after BCCAO. After seven days of reperfusion, the numbers of cells positive for markers of neurons, astrocytes, microglia, myeloperoxidase (MPO) and phosphorylated CREB (p-CREB) were evaluated immunohistochemically. Interestingly, in young and aged IP KO ischemic mice, there was a significant increase (p < 0.01) in cognitive deficit, hippocampal CA1 pyramidal neuron death, microglia and MPO activation, while p-CREB was reduced as compared to their corresponding WT controls. These data suggest that following ischemia, IP receptor deletion contributes to memory and cognitive deficits regulated by the CREB pathway and that treatment with IP receptor agonists could be a useful target to prevent harmful consequences.

Erythropoietin: powerful protection of ischemic and post-ischemic brain

Ischemic brain injury inflicted by stroke and cardiac arrest ranks among the leading causes of death and long-term disability in the United States. The brain consumes large amounts of metabolic substrates and oxygen to sustain its energy requirements. Consequently, the brain is exquisitely sensitive to interruptions in its blood supply, and suffers irreversible damage after 10-15 min of severe ischemia. Effective treatments to protect the brain from stroke and cardiac arrest have proven elusive, due to the complexities of the injury cascades ignited by ischemia and reperfusion. Although recombinant tissue plasminogen activator and therapeutic hypothermia have proven efficacious for stroke and cardiac arrest, respectively, these treatments are constrained by narrow therapeutic windows, potentially detrimental side-effects and the limited availability of hypothermia equipment. Mounting evidence demonstrates the cytokine hormone erythropoietin (EPO) to be a powerful neuroprotective agent and a potential adjuvant to established therapies. Classically, EPO originating primarily in the kidneys promotes erythrocyte production by suppressing apoptosis of proerythroid progenitors in bone marrow. However, the brain is capable of producing EPO, and EPO's membrane receptors and signaling components also are expressed in neurons and astrocytes. EPO activates signaling cascades that increase the brain's resistance to ischemia-reperfusion stress by stabilizing mitochondrial membranes, limiting formation of reactive oxygen and nitrogen intermediates, and suppressing pro-inflammatory cytokine production and neutrophil infiltration. Collectively, these mechanisms preserve functional brain tissue and, thus, improve neurocognitive recovery from brain ischemia. This article reviews the mechanisms mediating EPO-induced brain protection, critiques the clinical utility of exogenous EPO to preserve brain threatened by ischemic stroke and cardiac arrest, and discusses the prospects for induction of EPO production within the brain by the intermediary metabolite, pyruvate.

Lettuce glycoside B ameliorates cerebral ischemia reperfusion injury by increasing nerve growth factor and neurotrophin-3 expression of cerebral cortex in rats

AIMS

The aim of the study was to investigate the effects of LGB on cerebral ischemia-reperfusion (I/R) injury in rats and the mechanisms of action of LGB.

MATERIALS AND METHODS

The study involved extracting LGB from P. laciniata, exploring affects of LGB on brain ischemia and action mechanism at the molecular level. The cerebral ischemia reperfusion injury of middle cerebral artery occlusion was established. We measured brain histopathology and brain infarct rate to evaluate the effects of LGB on brain ischemia injury. The expressions of nerve growth factor (NGF) and neurotrophin-3 (NT-3) were also measured to investigate the mechanisms of action by the real-time polymerase chain reaction and immunohistochemistry.

STATISTICAL ANALYSIS

All results were mentioned as mean ± standard deviation. One-way analysis of variance was used to determine statistically significant differences among the groups. Values of P < 0.05 were considered to be statistically significant.

RESULTS

Intraperitoneal injection of LGB at the dose of 12, 24, and 48 mg/kg after brain ischemia injury remarkably ameliorated the morphology of neurons and brain infarct rate (P < 0.05, P < 0.01). LGB significantly increased NGF and NT-3 mRNA (messenger RNA) and both protein expression in cerebral cortex at the 24 and 72 h after drug administration (P < 0.05, P < 0.01).

CONCLUSIONS

LGB has a neuroprotective effect in cerebral I/R injury and this effect might be attributed to its upregulation of NGF and NT-3 expression ability in the brain cortex during the latter phase of brain ischemia.

Mesenchymal stem cells transplantation suppresses inflammatory responses in global cerebral ischemia: contribution of TNF-α-induced protein 6

AIM

To investigate the effects of mesenchymal stem cells (MSCs) transplantation on rat global cerebral ischemia and the underlying mechanisms.

METHODS

Adult male SD rats underwent asphxial cardiac arrest to induce global cerebral ischemia, then received intravenous injection of 5×10(6) cultured MSCs of SD rats at 2 h after resuscitation. In another group of cardiac arrest rats, tumor necrosis factor-α-induced protein 6 (TSG-6, 6 μg) was injected into the right lateral ventricle. Functional outcome was assessed at 1, 3, and 7 d after resuscitation. Donor MSCs in the brains were detected at 3 d after resuscitation. The level of serum S-100B and proinflammatory cytokines in cerebral cortex were assayed using ELISA. The expression of TSG-6 and proinflammatory cytokines in cerebral cortex was assayed using RT-PCR. Western blot was performed to determine the levels of TSG-6 and neutrophil elastase in cerebral cortex.

RESULTS

MSCs transplantation significantly reduced serum S-100B level, and improved neurological function after global cerebral ischemia compared to the PBS-treated group. The MSCs injected migrated into the ischemic brains, and were observed mainly in the cerebral cortex. Furthermore, MSCs transplantation significantly increased the expression of TSG-6, and reduced the expression of neutrophil elastase and proinflammatory cytokines in the cerebral cortex. Intracerebroventricular injection of TSG-6 reproduced the beneficial effects of MSCs transplantation in rats with global cerebral ischemia.

CONCLUSION

MSCs transplantation improves functional recovery and reduces inflammatory responses in rats with global cerebral ischemia, maybe via upregulation of TSG-6 expression.

Effect of melatonin on intracranial pressure and brain edema following traumatic brain injury: role of oxidative stresses

BACKGROUND AND AIMS

Traumatic brain injury (TBI) is one of the main causes of brain edema and increased intracranial pressure (ICP). In the clinic it is essential to limit the development of ICP after TBI. In the present study, the effects of melatonin on these parameters at different time points and alterations of oxidant factors as one of the probable involved mechanisms have been evaluated.

METHODS

Albino N-Mary rats were divided into five groups of sham, TBI, TBI + vehicle, TBI + Mel5 and TBI + Mel20. Brain injury was induced by Marmarou method. Melatonin was injected i.p. at 1, 24, 48 and 72 h after brain trauma. Brain water and Evans blue dye contents as well as oxidant/antioxidant factors were measured 72 h after TBI. ICP and neurological scores were determined at -1, 1, 24, 48 and 72 h post-TBI.

RESULTS

Brain water and Evans blue dye contents in melatonin-treated groups decreased as compared to the TBI + vehicle group (p <0.001). Veterinary coma scale (VCS) at 24, 48 and 72 h after TBI showed a significant increase in melatonin groups (TBI + Mel5: p <0.01 and TBI + Mel20: p <0.001) in comparison to the TBI + vehicle group. ICP at 24, 48 and 72 h after TBI decreased in melatonin groups as compared to the TBI + vehicle group (p <0.001). Superoxide dismutase and glutathione peroxidase activities showed a significant increase, whereas malondialdehyde level in these groups was significantly lower in melatonin groups in comparison to the TBI + vehicle group (p <0.001).

CONCLUSION

Melatonin decreases brain edema, BBB permeability and ICP, but increases VCS after TBI. These effects are probably due to inhibition of oxidative stress.

[Non-invasive evaluation of intracranial pressure: how and for whom?]

The invasive monitoring of intracranial pressure is useful in circumstances associated with high-risk of raised intracranial pressure. However the placement of intracranial probe is not always possible and non-invasive assessment of intracranial pressure may be useful, particularly in case of emergencies. Transcranial Doppler measurements allow the estimation of perfusion pressure with the pulsatility index. Recently, new ultrasonographic methods of cerebral monitoring have been developed: the diameter of the optic nerve sheath diameter, a surrogate marker of raised intracranial pressure and the estimation of median shift line deviation.

Electro-acupuncture can alleviate the cerebral oedema of rat after ischemia

PRIMARY OBJECTIVE

This study was designed to determine whether electro-acupuncture (EA) could alleviate cerebral oedema after cerebral ischemia.

RESEARCH DESIGN

EA has been widely used for cerebrovascular disease in East Asian countries. However, whether EA might reduce cerebral oedema after stroke remains unclear. In the current study, diffusion-weighted MRI, which is a reliable method for detecting cerebral oedema, was used to determine whether EA could ameliorate cerebral oedema.

METHODS AND PROCEDURES

Twelve rats with induced strokes were divided into two groups: one group with EA treatment (EA group) and one group without EA treatment (non-EA group). Both groups of rats underwent MRI scanning at the same time point following ischemia.

MAIN OUTCOMES AND RESULTS

Diffusion-weighted imaging showed that the relative apparent diffusion coefficient increased significantly in the cortical and sub-cortical areas of the EA group relative to the non-EA group, indicating that EA can alleviate cerebral oedema after ischemic stroke.

CONCLUSIONS

Electro-acupuncture can alleviate cerebral oedema in rats following ischemia.

Nicotine aggravates the brain postischemic inflammatory response

A substantial body of evidence suggests that nicotine adversely affects cerebral blood flow and the blood-brain barrier and is a risk factor for stroke. The present study investigated the effect of nicotine on cerebrovascular endothelium under basal and ischemia/reperfusion injury under in vivo condition. Nicotine (2 mg/kg sc) was administered to mice over 14 days, which resulted in plasma nicotine levels of ∼100 ng/ml, reflecting plasma concentrations in average to heavy smokers. An analysis of the phenotype of isolated brain microvessels after nicotine exposure indicated higher expression of inflammatory mediators, cytokines (IL-1β, TNF-α, and IL-18), chemokines (CCL2 and CX(3)CL1), and adhesion molecules (ICAM-1, VCAM-1, and P-selectins), and this was accompanied by enhanced leukocyte infiltration into brain during ischemia/reperfusion (P < 0.01). Nicotine had a profound effect on ischemia/reperfusion injury; i.e., increased brain infarct size (P < 0.01), worse neurological deficits, and a higher mortality rate. These experiments illuminate, for the first time, how nicotine regulates brain endothelial cell phenotype and postischemic inflammatory response at the brain-vascular interface.

Hypothermic modulation of anoxic brain injury in adult survivors of cardiac arrest: a review of the literature and an algorithm for emergency physicians

Anoxic brain injury is a common outcome after cardiac arrest. Despite substantial research into the pathophysiology and management of this injury, a beneficial treatment modality has not been previously identified. Recent studies show that induced hypothermia reduces mortality and improves neurological outcomes in patients resuscitated from ventricular fibrillation. This article reviews the literature on induced hypothermia for anoxic brain injury and summarizes a treatment algorithm proposed by the Canadian Association of Emergency Physicians Critical Care Committee for hypothermia induction in cardiac arrest survivors.

Lipocalin-prostaglandin D synthase is a critical beneficial factor in transient and permanent focal cerebral ischemia

Prostaglandin D(2) (PGD(2)) is the most abundant prostaglandin produced in the brain. It is a metabolite of arachidonic acid and synthesized by prostaglandin D(2) synthases (PGDS) via the cyclooxygenase pathway. Two distinct types of PGDS have been identified: hematopoietic prostaglandin D synthase (H-PGDS) and lipocalin-type prostaglandin D synthase (L-PGDS). Because relatively little is known about the role of L-PGDS in the CNS, here we examined the outcomes in L-PGDS knockout and wild-type (WT) mice after two different cerebral ischemia models, transient middle cerebral artery (MCA) occlusion (tMCAO) and permanent distal middle cerebral artery occlusion (pMCAO). In the tMCAO model, the MCA was occluded with a monofilament for 90 min and then reperfused for 4 days. In the pMCAO model, the distal part of the MCA was permanently occluded and the mice were sacrificed after 7 days. Percent corrected infarct volume and neurological score were determined after 4 and 7 days, respectively. L-PGDS knockout mice had significantly greater infarct volume and brain edema than did WT mice after tMCAO (P<0.01). Similarly, L-PGDS knockout mice showed greater infarct volume and neurological deficits as compared to their WT counterparts after pMCAO (P<0.01). Using the two models enabled us to study the role of L-PGDS in both early (tMCAO) and delayed (pMCAO) ischemic processes. Our findings suggest that L-PGDS is beneficial for protecting the brain against transient and permanent cerebral ischemia. These results provide a better understanding of the role played by the enzymes that control eicosanoid synthesis and how they can be utilized as potential targets to prevent damage following either acute or potentially chronic neurological disorders.

Changes in experimental stroke outcome across the life span

Acute ischemic stroke is a leading cause of mortality and disability in the elderly. Age is the most important nonmodifiable risk factor for stroke, yet many preclinical models continue to examine only young male animals. It remains unclear how experimental stroke outcomes change with aging and with biologic sex. If sex differences are present, it is not known whether these reflect an intrinsic differing sensitivity to stroke or are secondary to the loss of estrogen with aging. We subjected both young and aging mice of both sexes to middle cerebral artery occlusion (MCAO). Young female mice had smaller strokes compared with age-matched males, an effect that was reversed by ovariectomy. Stroke damage increased with aging in female mice, whereas male mice had decreased damage after MCAO. Blood-brain barrier (BBB) permeability changes are correlated with infarct size. However, aging mice had significantly less edema formation, an effect that was independent of sex and histologic damage. Differences in the cellular response to stroke occur across the life span in both male and female mice. These differences need to be considered when developing relevant therapies for stroke patients, the majority of whom are elderly.

Naloxone combined with epinephrine decreases cerebral injury in cardiopulmonary resuscitation

BACKGROUND

Cardiopulmonary arrest is a serious disease that claims many lives every day; 30% of the patients suffer irreversible central nervous system injury after restoration of systemic circulation (ROSC).

OBJECTIVES

Naloxone combined with epinephrine was tested in a cardiac arrest rat model in which asphyxia was induced to determine if this drug combination could increase the resuscitation rate (survival) and decrease the cerebral damage.

METHODS

Twenty-four male Wistar rats were randomly assigned to one of three groups: the group treated with 1 mL saline (SA group; n = 8), the group treated with only epinephrine 5 microg/100 g (EP group; n = 8), or the group treated with epinephrine 5 microg/100 g combined with naloxone 1 mg/kg (NA group; n = 8). Eight minutes after arrest, cardiopulmonary resuscitation was initiated and the different drugs were administered to the rats in their respective groups at the same time. Mean arterial pressure (MAP), heart rate (HR), and neurodeficit score (NDS) were measured.

RESULTS

The HR in the NA group (414 +/- 45 beats/min) was faster than in the EP group (343 +/- 29 beats/min) at the 5-min time point (P < 0.01). The HR in the NA group was 392 +/- 44 beats/min and 416 +/- 19 beats/min at the 60-min and 180-min time points, respectively. There were no statistically significant differences in MAP before or after ROSC. The rates of ROSC were 2 of 8, 6 of 8, and 7 of 8 animals in the SA group, EP group, and NA group, respectively. Three days later, the rates decreased to 1, 3, and 5 in the SA group, EP group, and NA group, respectively. The average resuscitation time in the NA group was significantly shorter than in the other two groups. The NDS in the NA group was 57 +/- 13, higher than in the EP group (45 +/- 13) and SA group (38).

CONCLUSION

Naloxone combined with epinephrine significantly increased the resuscitation rate in a rat model. Furthermore, the combination of naloxone and epinephrine increased the NDS after cardiopulmonary resuscitation.

The use of induced hypothermia after cardiac arrest: a survey of Canadian emergency physicians

OBJECTIVE

Inducing mild hypothermia in survivors of cardiac arrest has been demonstrated to improve outcomes. Despite this, other studies have found that few resuscitation physicians have used hypothermia in clinical practice. The objective of this study was to characterize the use of induced hypothermia by Canadian emergency physicians.

METHODS

An internet-based survey was distributed to all members of the Canadian Association of Emergency Physicians (CAEP). Participants were asked about their experience with, methods for and barriers to inducing hypothermia.

RESULTS

Of the 1328 CAEP members surveyed, 247 (18.6%) responded, with the majority working in academic centres (60.3%). Ninety-five out of 202 respondents (47.0%, 95% confidence interval [CI] 40.8%-53.2%) indicated that they had induced hypothermia in clinical practice and 86 of 212 (40.6%, 95% CI 34.0%-47.2%) worked in a department that had a policy or protocol for the use of induced hypothermia. The presence of a departmental policy or protocol was strongly associated with the use of induced hypothermia (unadjusted odds ratio 10.5, 95% CI 5.3-20.8). Barriers against induced hypothermia cited by respondents included a lack of institutional policies and protocols (38.9%), and of resources (29.4%). Lack of support from consultants was relatively uncommon (8.7%) in Canadian practice.

CONCLUSION

Only one-half of Canadian emergency physicians report that they have used therapeutic hypothermia in practice. Emergency departments should develop policies or protocols for inducing hypothermia in cardiac arrest survivors to optimize patient outcomes.

Near-infrared spectroscopy: a tool to monitor cerebral hemodynamic and metabolic changes after cardiac arrest in rats

INTRODUCTION

Cardiac arrest (CA) is associated with poor neurological outcome and is associated with a poor understanding of the cerebral hemodynamic and metabolic changes. The objective of this study was to determine the applicability of near-infrared spectroscopy (NIRS), to observe the changes in cerebral total hemoglobin (T-Hb) reflecting cerebral blood volume, oxygenation state of Hb, oxidized cytochrome oxidase (Cyto-C), and brain water content following CA.

METHODS

Fourteen rats were subjected to normothermic (37.5 degrees C) or hypothermic (34 degrees C) CA induced by 8 min of asphyxiation. Animals were resuscitated with ventilation, cardiopulmonary resuscitation (CPR), and epinephrine (adrenaline). Hypothermia was induced before CA. NIRS was applied to the animal head to measure T-Hb with a wavelength of 808 nm (n = 10) and oxygenated/deoxygenated Hb, Cyto-C, and brain water content with wavelengths of 620-1120 nm (n = 4).

RESULTS

There were no technical difficulties in applying NIRS to the animal, and the signals were strong and consistent. Normothermic CA caused post-resuscitation hyperemia followed by hypoperfusion determined by the level of T-Hb. Hypothermic CA blunted post-resuscitation hyperemia and resulted in more prominent post-resuscitation hypoperfusion. Both, normothermic and hypothermic CA resulted in a sharp decrease in oxygenated Hb and Cyto-C, and the level of oxygenated Hb was higher in hypothermic CA after resuscitation. There was a rapid increase in brain water signals following CA. Hypothermic CA attenuated increased water signals in normothermic CA following resuscitation.

CONCLUSION

NIRS can be applied to monitor cerebral blood volume, oxygenation state of Hb, Cyto-C, and water content following CA in rats.

A potassium channel-linked mechanism of glial cell swelling in the postischemic retina

The cellular mechanisms underlying glial cell swelling, a central cause of edema formation in the brain and retina, are not yet known. Here, we show that glial cells in the postischemic rat retina, but not in control retina, swell upon hypotonic stress. Swelling of control cells could be evoked when their K(+) channels were blocked. After transient ischemia, glial cells strongly downregulated their K(+) conductance and their prominent Kir4.1 protein expression at blood vessels and the vitreous body. In contrast, the expression of the aquaporin-4 (AQP4) (water channel) protein was only slightly altered after ischemia. Activation of D(2) dopaminergic receptors prevents the hypotonic glial cell swelling. The present results elucidate the coupling of transmembraneous water fluxes to K(+) currents in glial cells and reveal the role of altered K(+) channel expression in the development of cytotoxic edema. We propose a mechanism of postischemic glial cell swelling where a downregulation of their K(+) conductance prevents the emission of intracellularly accumulated K(+) ions, resulting in osmotically driven water fluxes from the blood into the glial cells via aquaporins. Inhibition of these water fluxes may be beneficial to prevent ischemia-evoked glial cell swelling.

Effect of ifenprodil, a polyamine site NMDA receptor antagonist, on brain edema formation following asphyxial cardiac arrest in rats

OBJECTIVE

Brain edema occurs in experimental and clinical cardiac arrest (CA) and is predictive of a poor neurological outcome. N-Methyl--aspartate (NMDA) receptors contribute to brain edema elicited by focal cerebral ischemia/reperfusion (I/R). Ifenprodil, a NMDA receptor antagonist, attenuates brain edema and injury size in rats after focal cerebral I/R. We assessed the hypothesis that ifenprodil reduces CA-elicited brain edema.

METHODS

Eighteen male Sprague-Dawley rats were assigned to group 1 (normal control, n=6), group 2 (placebo-treated CA, n=6), or group 3 (ifenprodil-treated CA, n=6). CA was induced by 8 min of asphyxiation and the animals were resuscitated with cardiopulmonary resuscitation (CPR), ventilation, epinephrine (adrenaline), and sodium bicarbonate (NaHCO3). Ifenprodil of 10 mg/kg or a placebo vehicle was given intraperitoneally 5 min before CA. Brain edema was determined by brain wet-to-dry weight ratio at 1 h after resuscitation.

RESULTS

There were no differences between groups 2 and 3 in all physiological variables at baseline. Time from asphyxiation to CA was 201.5 +/- 7.5 s in group 2 and 160.7 +/- 10.4 s in group 3 (P<0.001). Resuscitation time was 68.2 +/- 13.3 s in group 2 and 92.8 +/- 18.2 s in group 3 (P<0.05). Ifenprodil decreased mean arterial pressure (MAP) before asphyxiation, from 128 +/- 7 in group 2 to 82 +/- 15 mmHg in group 3 (P<0.001), and negated immediate post-resuscitation hypertension. Brain wet-to-dry weight ratio was 5.64 +/- 0.44 in group 1, 7.34 +/- 0.95 in group 2 (P<0.01 versus group 1), and 5.93 +/- 0.40 in group 3 (P<0.05 versus group 2).

CONCLUSIONS

Ifenprodil reduces CA-elicited brain edema. In addition, we observed significant hemodynamic changes caused by ifenprodil.

Matrix metalloproteinases are not involved in early brain edema formation after cardiac arrest in rats

INTRODUCTION

Resuscitation from cardiac arrest (CA) often results in a poor neurological outcome possibly due to an incomplete understanding of the pathophysiology of brain injury following CA-induced global cerebral ischemia. Brain edema is an important manifestation after CA and is associated with significant morbidity and mortality. The matrix metalloproteinases (MMPs) contribute to brain edema formation following focal cerebral ischemia. The objective of this study was to investigate the role of an MMP inhibitor, GM6001, in CA-elicited brain edema.

METHODS

Eighteen rats were subjected to normothermic (37.5 +/- 0.5 degrees C) CA induced by eight minutes of asphyxiation and assigned to a CA-control group (CA), an alcohol-placebo group (CA + ETOH), or a GM6001-treated group (CA + GM6001). GM6001 in 100% alcohol or a vehicle was given i.v. before CA to achieve a whole blood concentration of 10 microM. Animals were resuscitated with CPR, ventilation and epinephrine. Brain edema was determined by brain wet-to-dry weight ratio at one hour after resuscitation.

FINDINGS

Brain wet-to-dry weight ratio was 4.86 +/- 0.09 in CA, 4.76 +/- 0.12 in CA + ETOH (p = 0.30 vs. CA), and 4.72 +/- 0.03 in CA + GM6001 (p = 0.17 vs. CA and 0.42 vs. CA + ETOH).

INTERPRETATION

MMPs are not involved in brain edema formation one hour following CA.

Brain edema induced by in vitro ischemia: causal factors and neuroprotection

Decreased cerebral blood flow, hence decreased oxygen and glucose, leads to ischemic brain injury via complex pathophysiological events, including excitotoxicity, mitochondrial dysfunction, increased intracellular Ca2+, and reactive oxygen species (ROS) generation. Each of these could also contribute to cerebral edema, which is the primary cause of patient mortality after stroke. In vitro brain slices are widely used to study ischemia. Here we introduce a slice model to investigate ischemia-induced edema. Significant water gain was induced in coronal slices of rat brain by 5 min of oxygen and glucose deprivation (OGD) at 35 degrees C, with progressive edema formation after return to normoxic, normoglycemic medium. Edema increased with increasing injury severity, determined by OGD duration (5-30 min). Underlying factors were assessed using glutamate-receptor antagonists (AP5/CNQX), blockade of mitochondrial permeability transition [cyclosporin A (CsA) versus FK506], inhibition of Na+/Ca2+ exchange (KB-R7943), and ROS scavengers (ascorbate, Trolox, dimethylthiourea, Tempol). All agents except KB-R7943 and FK506 significantly attenuated edema when applied after OGD; KB-R7943 was effective when applied before OGD. Significantly, complete prevention of ischemia-induced edema was achieved with a cocktail of AP5/CNQX, CsA and Tempo applied after OGD, which demonstrates the involvement of multiple, additive mechanisms. The efficacy of this cocktail further shows the potential value of combination therapies for the treatment of cerebral ischemia.