The effect of asphyxia upon the lactate, pyruvate and bicarbonate concentrations of brain tissue and cisternal CSF, and upon the tissue concentrations of phosphocreatine and adenine nucleotides in anesthetized rats

Fluid and ion transfer across the blood-brain and blood-cerebrospinal fluid barriers; a comparative account of mechanisms and roles

The two major interfaces separating brain and blood have different primary roles. The choroid plexuses secrete cerebrospinal fluid into the ventricles, accounting for most net fluid entry to the brain. Aquaporin, AQP1, allows water transfer across the apical surface of the choroid epithelium; another protein, perhaps GLUT1, is important on the basolateral surface. Fluid secretion is driven by apical Na+-pumps. K+ secretion occurs via net paracellular influx through relatively leaky tight junctions partially offset by transcellular efflux. The blood-brain barrier lining brain microvasculature, allows passage of O2, CO2, and glucose as required for brain cell metabolism. Because of high resistance tight junctions between microvascular endothelial cells transport of most polar solutes is greatly restricted. Because solute permeability is low, hydrostatic pressure differences cannot account for net fluid movement; however, water permeability is sufficient for fluid secretion with water following net solute transport. The endothelial cells have ion transporters that, if appropriately arranged, could support fluid secretion. Evidence favours a rate smaller than, but not much smaller than, that of the choroid plexuses. At the blood-brain barrier Na+ tracer influx into the brain substantially exceeds any possible net flux. The tracer flux may occur primarily by a paracellular route. The blood-brain barrier is the most important interface for maintaining interstitial fluid (ISF) K+ concentration within tight limits. This is most likely because Na+-pumps vary the rate at which K+ is transported out of ISF in response to small changes in K+ concentration. There is also evidence for functional regulation of K+ transporters with chronic changes in plasma concentration. The blood-brain barrier is also important in regulating HCO3- and pH in ISF: the principles of this regulation are reviewed. Whether the rate of blood-brain barrier HCO3- transport is slow or fast is discussed critically: a slow transport rate comparable to those of other ions is favoured. In metabolic acidosis and alkalosis variations in HCO3- concentration and pH are much smaller in ISF than in plasma whereas in respiratory acidosis variations in pHISF and pHplasma are similar. The key similarities and differences of the two interfaces are summarized.

Randomized, double-blind, placebo controlled, multicentre study of idebenone in patients suffering from multi-infarct dementia

In this randomized double-blind, placebo controlled, multicentre study on 108 elderly patients with mild to moderate mental deterioration of vascular origin, idebenone - a benzoquinone derivative with a hydroxyalkyl side chain - proved to be therapeutically effective in the treatment of multi-infarct dementia. The oral administration of idebenone 45 mg/day b.i.d. for 120 days significantly improved the scores of the following test in comparison with placebo: Mini Mental State, Randt Memory Test, Gottfries Rating Scale, Token Test, Toulouse Piéron Test, indicating improvements in memory attention and cognitivity. The drug was well tolerated and effective in patients with multi-infarct dementia. No changes in laboratory parameters were observed either before or after treatment.

High-dose phenobarbital therapy in term newborn infants with severe perinatal asphyxia: a randomized, prospective study with three-year follow-up

OBJECTIVE

To determine whether 40 mg/kg phenobarbital given to term infants with severe asphyxia would result in a lower incidence of seizures in the newborn period and an improved neurologic outcome.

METHODS

We conducted a randomized, controlled, prospective study. Entry criteria included (1) an initial arterial pH less than or equal to 7.0 with a base deficit 15 mEq/L or more, (2) Apgar score less than or equal to 3 at 5 minutes of age, or (3) failure to initiate spontaneous respiration by 10 minutes of age. Sample size was calculated to detect a 50% reduction in the incidence of neonatal seizures.

RESULTS

No differences were present between treatment and control groups with respect to severity of asphyxia assessed by initial arterial pH, base excess, cerebrospinal fluid lactate dehydrogenase concentration or detection of CSF creatine kinase of its BB isoenzyme. Seizures occurred in 9 of 15 infants in the treatment group and 14 of 16 infants in the control group (p = 0.11). No adverse effects were observed from phenobarbital on heart rate, respiratory rate, blood pressure, or arterial blood gas values. Three-year follow-up revealed normal outcome in 11 of 15 infants in the treatment group and 3 of 16 in the control group (p = 0.003).

CONCLUSION

Phenobarbital, when administered in a dose of 40 mg/kg intravenously over 1 hour in term, severely asphyxiated newborn infants appeared to be safe and was associated with a 27% reduction in the incidence of seizures and a significant improvement in neurologic outcome at 3 years of age.

Use of the Morris water maze and acoustic startle chamber to evaluate neurologic injury after asphyxial arrest in rats

The study was performed to assess the utility of the Morris water maze (MWM) and acoustic startle reflex (ASR) for evaluating neurologic outcome in a rat model of asphyxial cardiac arrest. Rats were anesthetized, intubated, and chemically paralyzed. Control animals were decannulated and, after awakening, were extubated and returned to their housing. Experimental animals were asphyxiated by disconnecting the ventilator. Approximately 3.5 min after the disconnection, there was no measurable pulse. After 7 min of asphyxia, they were then resuscitated with resumed ventilation, chest compressions, epinephrine, and sodium bicarbonate. All animals were assigned to either MWM or ASR testing. The MWM is a 6-ft diameter tank filled with opaque water. In a fixed location of the tank, a 4-inch diameter escape platform is submerged just below the surface. MWM animals were tested on post-injury d 16-21 by recording the path and time taken to escape from three randomly assigned locations per d. ASR animals had s.c. leads placed over the right triceps and tibialis anterior muscles. The latency and rectified amplitude of the ASR was measured by recording the electromyographic impulse generated when the animal was startled by an acoustic stimulus. Animals were tested on post-injury d 6 and 7. After the last test session for each group, the animals' brains were removed for histopathologic examination. Asphyxiated MWM animals took longer to find the platform, and their paths were less direct than control animals (analysis of variance p < 0.05). The ASR of asphyxiated ASR animals had greater amplitude and shorter latency compared with controls (analysis of variance p < 0.05). Histologic examination revealed no abnormalities in control animals, but 80% of asphyxiated brains showed hippocampal neuronal injury and/or reactive gliosis in the CA1 segment. Abnormalities were more commonly detected in animals killed 7 d post-injury (ASR protocol) compared with animals killed 21 d post-injury (MWM protocol). We conclude that the MWM and ASR are useful for detecting neuronal injury in asphyxiated rats.

Role of magnesium and calcium in alcohol-induced hypertension and strokes as probed by in vivo television microscopy, digital image microscopy, optical spectroscopy, 31P-NMR, spectroscopy and a unique magnesium ion-selective electrode

It is not known why alcohol ingestion poses a risk for development of hypertension, stroke and sudden death. Of all drugs, which result in body depletion of magnesium (Mg), alcohol is now known to be the most notorious cause of Mg-wasting. Recent data obtained through the use of biophysical (and noninvasive) technology suggest that alcohol may induce hypertension, stroke, and sudden death via its effects on intracellular free Mg2+ ([Mg2+]i), which in turn alter cellular and subcellular bioenergetics and promote calcium ion (Ca2+) overload. Evidence is reviewed that demonstrates that the dietary intake of Mg modulates the hypertensive actions of alcohol. Experiments with intact rats indicates that chronic ethanol ingestion results in both structural and hemodynamic alterations in the microcirculation, which, in themselves, could account for increased vascular resistance. Chronic ethanol increases the reactivity of intact microvessels to vasoconstrictors and results in decreased reactivity to vasodilators. Chronic ethanol ingestion clearly results in vascular smooth muscle cells that exhibit a progressive increase in exchangeable and cellular Ca2+ concomitant with a progressive reduction in Mg content. Use of 31P-NMR spectroscopy coupled with optical-backscatter reflectance spectroscopy revealed that acute ethanol administration to rats results in dose-dependent deficits in phosphocreatine (PCr), the [PCr]/[ATP] ratio, intracellular pH (pHi), oxyhemoglobin, and the mitochondrial level of oxidized cytochrome oxidase aa3 concomitant with a rise in brain-blood volume and inorganic phosphate. Temporal studies performed in vivo, on the intact brain, indicate that [Mg2+]i is depleted before any of the bioenergetic changes. Pretreatment of animals with Mg2+ prevents ethanol from inducing stroke and prevents all of the adverse bioenergetic changes from taking place. Use of quantitative digital imaging microscopy, and mag-fura-2, on single-cultured canine cerebral vascular smooth muscle, human endothelial, and rat astrocyte cells reveals that alcohol induces rapid concentration-dependent depletion of [Mg2+]i. These cellular deficits in [Mg2+]i seem to precipitate cellular and subcellular disturbances in cytoplasmic and mitochondrial bioenergetic pathways leading to Ca2+ overload and ischemia. A role for ethanol-induced alterations in [Mg2+]i should also be considered in the well-known behavioral actions of alcohol.

Early postanoxic changes of polyphosphoinositides and bound Ca2+ content in relation to neuronal activity in brain cortex

We studied the changes in the content of membrane-bound calcium (Cab) and the polyphosphoinositides (poly-PI): bis- and trisphosphoinositide (PIP and PIP2) in the cat brain cortex during the early period (up to 30 min) of reoxygenation after 2.5 min and 5 min of anoxia. In vivo experiments were performed on a living cat cortical preparation. Studies included Cab estimation with clortetracycline, a calcium fluorescent chelate probe, and simultaneous registration of neuronal activity. Anoxia resulted in a significant drop of Cab and PIP2 in the cortex along with an absence of neuronal activity. During reoxygenation after 2.5 min of anoxia we observed an increase of Cab, however the Cab did not recover to the preanoxic level. An elevation of PIP and PIP2 content to 20% above the preanoxic level and recovery of neuronal activity with symptoms of hyperactivation were also observed. After 5 min of anoxia two qualitatively different types of changes were disclosed for the 30 min period of reoxygenation. In one half of the animals only slight symptoms of recovery in some of the indices were found. In the other group Cab and PIP2 content increased to a level significantly exceedingly the preanoxic one and abnormal spike activity appeared. Based on these results we suggest that disturbances in Ca- and poly-PI-related second messenger systems may significantly affect the recovery of neuronal function after anoxia.

Sustained damage to energy metabolism of brain regions after microsphere embolism in rats

BACKGROUND AND PURPOSE

Information on sustained damage to cerebral function and metabolism after cerebral ischemia is useful for prophylaxis and therapeutics of cerebral infarction. The purpose of the present study was to induce sustained damage to brain regions after cerebral ischemia in experimental animals. For this purpose, we examined animal behavior and cerebral energy metabolism following microsphere embolism in rats.

METHODS

We injected 900 microspheres (48 microns in diameter) into the right internal carotid artery of 110 rats and determined the time course of changes in the rats' behavior and the energy metabolism of the cortex, striatum, and hippocampus of both hemispheres. We injected the same volume of vehicle, without microspheres, into 28 sham-operated rats; there were 14 nonoperated control rats.

RESULTS

Peak increase in lactate content and decrease in adenosine triphosphate and creatine phosphate of these brain regions of the right hemisphere were seen on the first day after microsphere embolism, whereas peak increases in glucose and glycogen contents of these regions were observed on the third day. Most of the metabolic alterations in all these regions continued for up to 28 days after operation, although they recovered toward control levels with time after the operation. The extent and trend of metabolite changes of the right hemisphere after microsphere embolism were similar in the three brain regions. In the left hemisphere, similar metabolic changes were observed, but to a lesser degree. The time course of changes in behavioral scores following microsphere embolism revealed marked stroke-like symptoms on the first day and relatively rapid disappearance of the symptoms with time after embolism.

CONCLUSIONS

Microsphere embolism is capable of inducing widespread, sustained damage to energy metabolism of brain regions.

Effects of hypoxia on fetal rat brain metabolism studied in utero by 31P-NMR spectroscopy

An animal model of perinatal asphyxia, in which near-term fetal rats are subjected to-short periods of hypoxia, has been investigated by 31P-NMR spectroscopy. Changes in the high-energy phosphates and intracellular pH of the fetal rat brain were measured in utero following ligation of the placental blood vessels, and during reperfusion after a 20-min period of occlusion. The hypoxia-induced changes observed in the fetal brain were substantially slower than in the adult, and were completely reversible after 20 min of hypoxia.

In vivo time-resolved brain phosphorus nuclear magnetic resonance

Methods used to obtain and quantify high-quality time-resolved dog brain phosphorus nuclear magnetic resonance (31P NMR) spectra are described. In eight animals the normoxic dog brain spectra showed 10% of total phosphorus in ATP, 14% in phosphocreatine (PCr), and 38% in brain phospholipids containing phosphodiesters. The chemical shift between PCr and inorganic phosphate, 5.09, corresponded to an intracellular brain pH of 7.2. During hypoxia, PCr declined to 0.5 +/- 0.3 (n = 8) of starting levels, prior to any changes in brain ATP. Simultaneous recording of the EEG was obtained in two animals. During hypoxia, progressive PCr depletion was associated with progressive slowing of the EEG, which was essentially silent before significant changes occurred in brain ATP. Finally, the brain 31P NMR spectrum and pH were measured at 90-s intervals, and the sequential changes that followed respiratory arrest were monitored in one dog until high-energy phosphate depletion was complete.

Changes in the brain surface pH and cisternal cerebrospinal fluid acid-base variables in respiratory arrest

Using flat-surface pH electrodes we continuously measured changes in the brain surface pH during respiratory arrest in anesthetized and paralyzed dogs which were previously ventilated with pure oxygen. Respiratory arrest was induced by halting the respirator. The mean arterial PO2 fell from 502.7 +/- 15.9 (1 SD) to 23.7 +/- 18.5, and the mean arterial PCO2 rose from 36.4 +/- 3.5 to 80.4 +/- 7.1 mm Hg, 10 min after asphyxia. The arterial blood pressure increased gradually over several minutes but fell relatively abruptly and profoundly at the end, due to circulatory failure. Initially, and as long as the arterial blood pressure and, therefore, cerebral blood flow were upheld (phase 1), changes in the brain surface pH were small (delta pH/delta t= -0.026 pH unit/min) in spite of severe hypercapnia. When cerebral perfusion pressure fell due to circulatory failure (phase 2), cerebral ischemia occurred and there was an abrupt fall in brain surface pH (delta pH/delta t= -0.067 pH unit/min). Changes in cisternal CSF [H+] grossly underestimated the magnitude of brain surface acidosis during the period of respiratory arrest; the initial difference between the mean brain surface fluid and cisternal CSF [H+] which was 8.9, rose to 15.1 and 47.4 nmol/L, respectively, 5 and 10 min after asphyxia. Changes in sagittal venous blood acid-base variables were more pronounced than those observed in the arterial blood or cisternal CSF; 5 min after respiratory arrest, arterial and sagittal venous blood and cisternal CSF and brain surface pH were 7.20, 7.09, 7.19 and 7.11, respectively. We conclude that (1) in the course of respiratory arrest cerebral outcome can potentially be determined by circulatory failure as evidenced by simultaneous changes in the arterial blood pressure and brain surface pH; (2) cisternal CSF acid-base changes lag behind those on the brain surface and CSF analyses provide unreliable information about the severity of brain acid-base changes during asphyxia; (3) changes in cerebral venous blood acid-base variables best represent the severity of metabolic aberrations in the brain during respiratory arrest.

Lactate and pyruvate content of the human cisternal cerebrospinal fluid. Normal values, age and sex dependency, correlations with glucose concentrations

Cisternal CSF specimens were obtained from 144 fasted individuals free from organic brain disease (42 males and 102 females; mean age 41 +/- 10.3 years, range 16-69 years). In 30 cases a simultaneous lumbar puncture was also performed. The concentration of CSF glucose (G1) was measured by the o-toluidine method, and that of lactate (La) and pyruvate (Py) by enzymatic tests. No significant difference was found between the mean G1 and Py values of the lumbar and cisternal CSF but the lumbar La was somewhat higher than the cisternal one (P less than 0.10). In the cisternal CSF the frequency distribution of G1, La and Py samples was a Gaussian one (P less than 0.05). The normal ranges, as mean +/- 2SD, were for La 0.680-2.100 mM/1, and for Py lower limits of the range (between mean +/- 2 SD and mean +/- 1 SD) are considered to be potentially pathological. No significant difference was found between the mean G1, La and Py values in males and females. Consistent age-related changes could not be detected either in the G1 or Py levels, however, a tendency for La increase was observed in the oldest-age-group (over 54 years). A negative correlation was found between the G1 and La concentrations of the cisternal CSF (r = 0.375; P less than 0.001).

Reduced ATP concentration as a basis for synaptic transmission failure during hypoxia in the in vitro guinea-pig hippocampus

1. Experiments were performed to determine whether a decrease in tissue ATP contributes to the rapid failure of cerebral synaptic transmission during hypoxia. Transmission between the perforant path and the dentate granule cells in the in vitro hippocampus was studied.2. Hippocampal slice ATP is decreased by approximately 15% at the time that the evoked response begins to diminish in standard Krebs bicarbonate buffer. This is about 2 min after the onset of hypoxia.3. When transmission failure is accelerated by increasing extracellular K(+) from 4.4 to 13.4 mM, the evoked response begins to decay about 30 sec after exposure to hypoxia. There is no decrease in hippocampal slice ATP at this time.4. However, ATP in the molecular layer (the synaptic region of the tissue) is decreased by approximately 15% at the time the evoked response begins to decay in the slices exposed to elevated K(+) concentration.5. Exposing the hippocampal slice to 25 mM-creatine for 3 hr elevates molecular layer phosphocreatine fourfold. Synaptic transmission during hypoxia survives three times as long as it does in the absence of creatine.6. In the creatine fortified medium, molecular layer ATP no longer declines within 30 sec of hypoxia. However the molecular layer ATP does decline within 90 sec of hypoxia, the time at which the evoked response begins to decay in this creatine-fortified buffer.7. The results establish that ATP in the region of the active synapses is lowered when the first signs of electrophysiological failure appear during hypoxia. They also show that maintaining ATP for longer than normal during hypoxia is associated with a prolonged maintenance of the evoked response. They thus suggest that a decline in ATP is one factor causing hypoxic block of synaptic transmission.8. It is further suggested that the very rapid failure of the electroencephalogram during anoxia may also result from a decline in ATP.

Survival of the ischemic brain: a progress report

The number of patients with cerebral infarctions increases as the population ages, despite campaigns against hypertension, the greatest risk factor. Cerebral ischemia initiates events that are presumed to defer the stage of irreversible injury. These events cause an increase of perfusion around the central ischemic zone and trigger the Bohr effect, both of which preserve tissue viability. Almost simultaneously, mitochondrial function fails, resulting in insufficient energy for the enzyme systems to control Na and K ion equilibrium. At the same time, protein synthesis slows and cellular respiratory enzymes decrease their activity, initiating an irreversible state of tissue change. Tissue fatty acids increase as a result of dissolution of cell membrane lipoprotein structure. Barbiturates reduce the extent of experimental infarction. Resperine and aminophylline are also effective, but there are no corroborative clinical trials. That ischemic brain damage may be the result of toxic substances in the ischemic tissue represents a new concept.

Protein synthesis in rat brain in hypoxia, anoxia and hypoglycemia

The effect of cerebral hypoxia on protein synthesis was investigated by exposing rats to 5% O2, and examining polypeptide synthesis and size distribution profiles of ribosomes. The findings were compared with the results from cerebral anoxia (decapitation) and hypoglycemia. In cerebral hypoxia there was suppression of polypeptide synthesis, though to a lesser extent than in cerebral anoxia, while no effect was detected in hypoglycemia. Among 4 different ribosomal fractions used for polypeptide synthesis, the microsome was the most sensitive for hypoxia and anoxia, and the polyribosome after short centrifugation was the least sensitive. The size distribution profiles of 3 different ribosomes revealed an increase in the size of the monomere-dimer complex and a decrease of the polysome peak both in cerebral hypoxia and anoxia. Comparison of the energy state and the extent of lactic acidosis in cerebral hypoxia, anoxia and hypoglycemia available in the literature and the functional and structural state of polyribosomes in the present investigation suggests that intracellular acidosis may be the main cause of the suppression of polypeptide synthesis and disaggregation of polyribosomes in hypoxia, and the depletion of energy reserve may be the main cause in anoxia-ischemia.

Experimental stroke in gerbils: effect on translation and transcription

The effect of cerebral ischemia on polypeptide synthesis with isolated microsomes and DNA-dependent RNA polymerase activity with isolated nuclei was investigated by occlusion of right common carotid artery of gerbils. There was a prompt decline of microsomal polypeptide synthesis already at 30 min after occlusion of the artery, and at 4--5 h the specific radioactivity (dpm per microgram protein) was 50% of the control value. At 24 h, when the animals were only slightly responsive to external stimuli, the specific radioactivity of ischemic brain was only 20% of the control value. DNA-dependent RNA polymerase activity was unaffected for 1 h, and clear suppression did not appear until 3 h after occlusion. However, the extent of suppression was similar between polypeptide synthesis and RNA polymerase activity beyond 3 h after occlusion. Although more selective vulnerability of polypeptide synthesis thus exists in cerebral ischemia, the difference between two biochemical processes was not as striking as seen in cerebral anoxia. Focal progression of cerebral ischemia to diffuse infarction in gerbils was suggested as a possible explanation for the disparity in comparison to the diffuse effect in cerebral anoxia along with the difference in the magnitude of acidosis and depletion of energy reserve.

Brain energy metabolism in global brain oedema

Different degrees of severity in global brain oedema were induced by varying amounts of water intoxication (50, 100, 150, and 200 ml Aqua dest./kg b.wt. intravenously) in groups of six cats, which were functionally nephrectomized. Animals loaded with physiological saline and sham-operated served as controls. Two hours following the water load, the tissue concentrations of CrP, ATP, ADP, AMP, pyruvate, glucose, and lactate were determined by optical enzymatic analysis. The results show disturbances in brain energy metabolism dependent on the severity of the brain oedema. The high energy compounds and in consequence the ATP/ADP-ratio, and respectively the energy charge potential, fall in direct relationship to the severity of the brain oedema. Lactate and lactate-pyruvate ratio increase. The energy source of the cell, glucose as well as pyruvate, significantly falls in the group with severe brain oedema. The results of the brain energy metabolism were compared with our previous study concerning the brain water content, rCBF and CPP in global brain oedema (Meinig et al. 1973). The results show that the disturbances of energy metabolism are directly related to the rCBF and are not dependent on CPP over a wide range.

Cerebral glucose and energy metabolism, cerebral oxygen consumption, and blood flow in arterial hypoxaemia

The influence of moderately reduced arterial oxygen tension (aPO2 of about 45 Torr) on the metabolism and the blood flow of the brain was tested in 20 anaesthetized, artificially ventilated normotensive, normocapnic beagle dogs. It is demonstrated that the decrease in systemic oxygen delivery to the brain is countered by an appropriate increase in flow (CBF being 60.3 ml/100 g min at normoxia and 84.5 mg/100 g min in hypoxaemia) which maintained the cerebral oxygen consumption unchanged (CMRO2 3.80 versus 3.32 ml/100 g min). The cortical tissue content of energy-rich phosphates such as ATP, ADP, AMP, and phosphocreatine was also found to be unaltered. Neuropathological examinations excluded any hypoxic cell damage. This reactive vasodilatory reaction of the cerebral vessels is apparently a sensitive regulatory process which protects the brain against marked oxygen lack. However, a normal carbohydrate metabolism is not restored by this cerebrovascular mechanism. For, significantly increased CMRlactate (0.32 versus 1.46 ml/100 g min) indicated raised cerebral glycolysis, and the tissue metabolites of glucose suggested an increased glycolytic flux in the brain. It is concluded that in moderate arterial hypoxaemia, which is not uncommon in clinical practice, cerebral blood flow plays an effective homeostatic role in preventing a disturbance of the energy metabolism of the brain.

Mediated transport and metabolism of lactate in rat aorta

1. Under appropriate conditions L- and D-lactate enter the cells of rat aorta and are metabolized. Oxidation of lactate to CO2 occurs under aerobic conditions. 2. L- and D-lactate are taken up into the cells when oxygen, glucose, or both oxygen and glucose are present in the incubation medium. Both L- and D-lactate are excluded from the cells when neither oxygen nor glucose is present. 3. D,L-Glyceraldehyde prevents the uptake of L-lactate. The effect is apparently not due to the inhibition of glucose metabolism by L-glyceraldehyde. 4. L-lactate (20 mM) markedly inhibits the uptake of 5 mM D-lactate, but 20 mM D-lactate fails to inhibit the uptake of 5 mM L-lactate. 5. Raising the pH of the incubation medium markedly depresses the uptake of L-lactate. 6. The results provide evidence that L- and D-lactate enter the cells of rat aorta by a mediated transport system.

Regions of cerebral ischemia located by pyridine nucleotide fluorescence

The fluorescence of the reduced form of the endogenous pyridine nucleotide nicotinamide adenine dinucleotide was used to map regions of ischemia in cat brain. A remarkably microheterogeneous pattern of increased fluorescence resulted from a critical level of incomplete cerebral ischemia. The fluorescence pattern suggests that ischemia occurs initially in microwatershed zones between penetrating cerebral arteries.

Postmortem changes in stereological parameters of cerebral capillaries

The present study investigated the influence of different postmortem times on stereological parameters of capillaries in the cerebral cortex. For the human investigation different brain regions of two 77 and 79 year-old subjects were examined. The animal experiment, carried out on 10 male cats, allowed a comparison between intravitam deep-frozen cerebral cortex and tissue obtained after decapitation. The parameters were diameter Di, volume fraction VVi, surface-to-volume ratio Si/Vi, mean minimal distance between capillary centers of gravity deltaAB, length per unit cortex volume LVi, and number of fragments per measuring field Ni, AT. Neither the cat experiment nor the human investigation yielded a noteworthy change of the capillary diameter in the postmortem cortical tissue. Nevertheless, a significantly enlarged mean minimal distance between capillaries in the cat cerebral cortex shortly after decapitation (30 sec) suggests the formation of edema which then regresses. Furthermore the experiment revealed that 22 hours after death there is a significantly (p less than 0.01) diminished volume fraction and length per unit cortex volume with an augmented surface-to-volume ratio. These changes are thought to be a consequence of water loss. In contrast to the animal experiment the human cerebral capillaries showed no changes in stereological parameters at two different postmortem times. These results encourage continuation of further stereological investigations on human brains obtained at autopsy and may contribute to the understanding of the aging process in the human cerebral cortex.

Cerebral blood flow and oxidative brain metabolism during and after moderate and profound arterial hypoxaemia

In anaesthetized artificially ventilated dogs, the effect of graded arterial hypoxaemia on cerebral blood flow (CBF) and on the oxidative carbohydrate metabolism of the brain was tested. It is shown that the hypoxic vasodilatory influence on cerebral vessels is present even at moderate systemic hypoxaemia, provide that PaCO2 is kept within normal limits. At PaO2 of about 50 Torr, CBF increased from 56.6 to 89.7 ml/100g/min. With increasing cerebral hyperamia (CBF increased to 110.9 ml/100g/min, at PaO2 of 30 Torr), CMRO2 (4.2 ml/100g/min) was not significantly raised above its normal level (4.7 ml/100g/min) even with profound arterial hypoxaemia. This shows that CMRO2 levels are poor indices of hypoxic hypoxia. A disproportionately high increase in cerebral glucose uptake (CMR glucose levels rose from 4.4 to 10.4 mg/100g/min) and enhanced cerebral glycolysis (CMR lactate changed from 0.2 to 1.6 mg/100g/min) at moderately reduced PaO2 (50 Torr) indicated early metabolic changes which became more marked with further falls in arterial oxygen tension. However, 60 minutes after restoration of a normal PaO2 level, CBF and brain metabolism were found to have completely recovered. It is concluded that a short period of profound systemic hypoxaemia does not produce long lasting metabolic and circulatory disorders of the brain provided the cerebral perfusion pressure does not vary, and is kept at normal levels.

XIII. Cerebral circulation and metabolism in stroke. Cerebral circulation and metabolism in stroke study group

An understanding of the cerebral circulation is so fundamental to comprehension of the pathogenesis of stroke that cerebral blood flow and metabolism merit review in this series of reports. The authors recognize that the research described here is very technical in nature and may appear to have little practical application to clinical medicine. Nevertheless, these matters are basic to the development of precise methods for the measurement of regional cerebral blood flow in man which could be used to monitor the therapy of stroke with greater success than is possible at present.

Brain energy metabolism during the process of dying and after cardiopulmonary resuscitation

In order to study the problem of how fast and to what degree severe hypoxic brain tissue changes are reversed after reoxygenation, we challenged the viability of the brain by exposing experimental animals to anoxia of such a duration that cardiopulmonary resuscitation was just possible. The brain tissue concentrations of glucose, lactate, pyruvate and of ATP, ADP, AMP and phosphocreatine were determined. Two series of experiments were carried out. In the first, groups of rats deprived of oxygen for 1, 2, 4 and 6 min were studied in order to show brain tissue changes in the period of impending death as well as the changes coinciding with the onset of clinical death (blood pressure zero). In addition, one group maintained at a rectal temperature of 37 +/- 0.5 degrees C and ventilated for 60 min with an oxygen free gas mixture was included aimed at representing a state of irreversibility. In the second series, restitution after 6 min of no oxygen supply was studied 10 min, 1/2 h, 1 h, and 2 h after cardiopulmonary resuscitation. Attempts were also made to correlate biochemical changes to EEG status and to clinical recovery. The restitution study showed that oxidative phosphorylation of the brain tissue was rapidly resumed with normalization of the adenylate energy charge in all animals in which the pump function of the heart could be restored by our artificial means. However, there was a strikingly poor correlation between recovery of mitochondrial function and restitution of EEG or clinical recovery. Thus, it seems likely that a delayed functional restitution is not due to energy failure but to other biochemical changes or to biophysical alterations not revealed by the present type of study.

Cerebrospinal-fluid acid-base and electrolyte changes resulting from cerebral anoxia in man

To study metabolic changes in the central nervous system after profound anoxia, we measured changes in cisternal and lumbar cerebrospinal fluid. Acid-base values and electrolyte concentrations were determined in cisternal and lumbar fluid from 12 severely anoxic patients (cardiac arrest), and from 15 within 24 hours after cardiac resuscitation. In the severely anoxia patients the normal cisternal-lumbar pH gradient was reversed, cisternal fluid was more acid (pH 6.815 vs. 6.953), and cisternal potassium concentration was twice that of lumbar (6.7 vs 3.5 mEq per liter). These findings indicate that during anoxia potassium and hydrogen ion flow from brain cells into the brain extracellular fluid, and that acute changes are reflected more accurately by cisternal than by lumbar fluid. In resuscitated patients cisternal fluid was normal, and normal cisternal-lumbar differences were found; thus, the normal milieu of brain cells is rapidly reestablished after resuscitation.

Mechanisms of seizures and coma in hypoglycemia. Evidence for a direct effect of insulin on electrolyte transport in brain

The mechanisms involved in the production of hypoglycemic coma were studied in rabbits. Measurements were made in brain, cerebrospinal fluid (CSF), and plasma of osmolality, Na(+), K(+), Cl(-), water content, exogenous insulin, glucose, lactate, and glutamate, while pH, Pco(2), Po(2), and bicarbonate were evaluated in arterial blood, 35 min after i.v. injection of insulin (50 U/kg), plasma glucose did not change, but brain K(+) content increased significantly. Grand mal seizures were observed in unanesthetized animals (+/-SD) 133+/-37 min after administration of insulin, at a time when brain glucose was normal, but brain tissue content of Na(+), K(+), osmoles, and water was significantly greater than normal. Coma supervened 212+/-54 min after insulin injection, at which time brain glucose, lactate, and glutamate were significantly decreased. At both 35 and 146 min after insulin administration, exogenous insulin was present in brain, but not in the CSF. After 208 min of insulin administration, animals were given i.v. glucose and sacrificed 35 min later. Most changes in the brain produced by hypoglycemia were reversed by the administration of glucose. Hypoxia (Po(2) = 23 mm Hg) was produced and maintained for 35 min in another group of animals. Hypoxia caused brain edema but did not affect brain electrolyte content. However, brain lactate concentration was significantly greater than normal. The data indicate that the seizures noted early in the course of insulin-induced hypoglycemia are temporally related to a rise in brain osmolality secondary to an increased net transport into brain of Na(+) and K(+), probably caused by insulin, per se. As hypoglycemia persists, there is also depletion of energy-supplying substrates (glucose, lactate, glutamate) in the brain, an event which coincides with the onset of coma. The brain edema observed during hypoxia is largely due to an increase in brain osmolality secondary to accumulation of lactate.

Cerebral blood flow and oxygen uptake, and cerebrospinal fluid biochemistry in severe coma

Thirty-eight patients in coma due to head trauma, cerebrovascular accidents, hypoxia, hypoglycaemia, or barbiturate intoxication, and 15 cases of brain death were studied. Cerebral metabolic rate of oxygen (CMRO(2)) was obtained from the arteriovenous oxygen difference and cerebral blood flow (CBF) measured by intra-arterial (133)Xenon method. If hypothermia and CNS depressants were excluded, CMRO(2) below one-third of normal was incompatible with regaining of consciousness, but this was seen in only three comatose patients. Irrespective of the clinical outcome (death, vegetative survival, or recovery), CMRO(2) values of one-third to two-thirds of normal were seen in the majority of coma patients. CMRO(2) measurements were of no practical value to predict the prognosis in coma, even when the effect of temperature and sedatives were considered. In brain death the CBF studies gave indirect evidence of cerebral circulatory arrest. The cerebrospinal fluid (CSF) was obtained for analysis of lactate, pyruvate, and bicarbonate in 29 cases. Increased CSF lactate levels were found in all groups except barbiturate intoxication. The finding of a negative correlation between CSF bicarbonate and log CBF suggests that the CSFpH determines the wide range of CBF in coma.

Cerebrospinal fluid pH and monoamine and glucolytic metabolites in Alzheimer's disease

Determinations of acid monoamine metabolites, such as homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA), in cerebrospinal fluid (CSF) give valid information on the metabolism of the corresponding amines in the brain tissue (Moir et al., 1970; Roos, 1970). The monoamine metabolites in the CSF are related to age. The concentrations of HVA and 5-HIAA increase with age (Gottfries et al., 1971). Probenecid blocks the elimination of HVA and 5-HIAA from brain tissue to blood (Neff et al., 1964, 1967; Werdinius, 1966) and from CSF to blood (Guldberg et al., 1966; Olsson and Roos, 1968). Probenecid thus normally induces an increase in the concentrations of the acid monoamine metabolites in the CSF, which is related to the turnover of monoamines in the brain tissue.

Energy state and glycolysis in human cerebral edema

✓ A new freeze-stop device using a liquid nitrogen reservoir and an automatic biopsy mechanism has been developed, suitable for rapid, sterile, and standardized sampling of cerebral tissue in man. In animal experiments a 200 mg piece of cerebral cortex was cooled from a room temperature of 18°C to −40°C within 7 sec which is twice as fast as when it was immersed in liquid N2. The method was then applied to metabolic tissue studies of perifocal edematous cortex from patients undergoing neurosurgery for intracranial tumors. Energy-rich phosphate compounds or parameters of the energy state were found to be less affected in this type of brain edema than the glycolytic activity which was markedly enhanced, indicated by lactic and pyruvic acid determinations. The tissue water content correlated closely with the lactic acid concentration, and very little with measurements of the energy state such as the energy charge potential or the adenosinetriphosphate-adenosinediphosphate (ATP/ADP) ratio. It is suggested that in perifocal brain edema increased levels of lactic acid are associated with mechanisms leading to an increased water uptake.

Barbiturate protection in acute focal cerebral ischemia

We have found that anesthetic technique modifies the neurological and pathological sequelae of unilateral middle cerebral artery and internal carotid artery occlusion in dogs. Occlusion was performed in seven groups of six dogs during each of the following anesthetic regimens: light (0.8%) halothane, "awake," deep (1.9%) halothane, deep halothane with mean arterial pressure reduced to 55 torr, pentobarbital (56 mg per kilogram), light halothane plus 40 mg per kilogram thiopental begun just before cerebral artery occlusion, and light halothane plus 40 mg per kilogram thiopental begun 15 minutes after occlusion. Body temperature, arterial P co co 2 P o o 2 pH, and blood pressure (except as noted above) were maintained normal. Neurological examinations were performed daily. On the seventh day the dogs were killed and their brains removed for pathological study. Hemiparesis occurred in five of six dogs under light halothane and five of six awake dogs; a mean of 10.8% and 9.6%, respectively, of their right hemispheres were infarcted. In the deep halothane groups, all of the normotensive and five of the six hypotensive dogs became severely hemiplegic; mean infarction size was 28.2% and 34.1%, respectively. Only one of the 18 dogs who received a barbiturate sustained a neurological deficit -- a transient unilateral weakness. Means of 1.4%, 2.7%, and 0.1% of the right hemisphere were infarcted in the barbiturate animals. The protective action of barbiturates in canine acute focal cerebral ischemia suggests that they should be considered for anesthesia in surgery requiring cerebral vessel occlusion and perhaps even for treatment of acute stroke.