Neuroprotection in aortic arch surgery: untold flaws and future directions

The current paradigm of brain protection in aortic surgery falls short of delivering good outcomes with minimal complications. A renewed understanding of neuroprotective methods and biomarkers to predict brain injury and aortic disease are crucial towards the development of more effective clinical management strategies. A review of current literature was carried out to identify current flaws in our approach to neuroprotection in aortic surgery. Emerging evidence surrounding neuroprotective strategies, biomarkers for brain injury, and biomarkers for predicting aortic disease are evaluated in terms of their impact for future therapeutic approaches. Current literature suggests that the prevailing methods of neuroprotection need renewal. Clinical outcomes associated with deep hypothermic circulatory arrest remain varied. Branch-first and endovascular approaches to aortic repair are particularly promising alternatives. The use of biomarkers to identify and manage brain injury, as well as to diagnose aortic disease in the nonacute and acute settings, would further help to improve our overall paradigm of neuroprotection in aortic surgery. Though much prospective research is still required, the outlook for neuroprotection in aortic surgery is promising. Adopting alternative surgical techniques and exploiting predictive novel biomarkers will help us to gradually eliminate the risk of brain damage in aortic surgery.

Oxygen, evolution and redox signalling in the human brain; quantum in the quotidian

Rising atmospheric oxygen (O₂ ) levels provided a selective pressure for the evolution of O₂ -dependent micro-organisms that began with the autotrophic eukaryotes. Since these primordial times, the respiring mammalian cell has become entirely dependent on the constancy of electron flow, with molecular O₂ serving as the terminal electron acceptor in mitochondrial oxidative phosphorylation. Indeed, the ability to 'sense' O₂ and maintain homeostasis is considered one of the most important roles of the central nervous system (CNS) and probably represented a major driving force in the evolution of the human brain. Today, modern humans have evolved with an oversized brain committed to a continually active state and, as a consequence, paradoxically vulnerable to failure if the O₂ supply is interrupted. However, our pre-occupation with O₂ , the elixir of life, obscures the fact that it is a gas with a Janus face, capable of sustaining life in physiologically controlled amounts yet paradoxically deadly to the CNS when in excess. A closer look at its quantum structure reveals precisely why; the triplet ground state diatomic O₂ molecule is paramagnetic and exists in air as a free radical, constrained from reacting aggressively with the brain's organic molecules due to its 'spin restriction', a thermodynamic quirk of evolutionary fate. By further exploring O₂ 's free radical 'quantum quirkiness', including emergent (quantum) physiological phenomena, our understanding of precisely how the human brain senses O₂ deprivation (hypoxia) and the elaborate redox-signalling defence mechanisms that defend O₂ homeostasis has the potential to offer unique insights into the pathophysiology and treatment of human brain disease.

RETRACTED ARTICLE: The quantum physiology of oxygen; from electrons to the evolution of redox signaling in the human brain

Rising atmospheric oxygen (O₂) levels provided a selective pressure for the evolution of O₂-dependent micro-organisms that began with the autotrophic eukaryotes. Since these primordial times, the respiring mammalian cell has become entirely dependent on the constancy of electron flow with molecular O₂ serving as the terminal electron acceptor in mitochondrial oxidative phosphorylation. Indeed, the ability to “sense” O₂ and maintain homeostasis is considered one of the most important roles of the central nervous system (CNS) and likely represented a major driving force in the evolution of the human brain. Today, modern humans have evolved with an oversized brain committed to a continually active state and as a consequence, paradoxically vulnerable to failure if the O₂ supply is interrupted. However, our pre-occupation with O₂, the elixir of life, obscures the fact that it is a gas with a Janus Face, capable of sustaining life in physiologically controlled amounts yet paradoxically deadly to the CNS when in excess. A closer look at its quantum structure reveals precisely why; the triplet ground state diatomic O₂ molecule is paramagnetic and exists in air as a free radical, constrained from reacting aggressively with the brain’s organic molecules due to its “spin restriction”, a thermodynamic quirk of evolutionary fate. By further exploring O₂’s free radical “quantum quirkiness” including emergent quantum physiological phenomena, our understanding of precisely how the human brain senses O₂ deprivation (hypoxia) and the elaborate redox-signaling defense mechanisms that defend O₂ homeostasis has the potential to offer unique insights into the pathophysiology and treatment of human brain disease.

Hypoxia compounds exercise-induced free radical formation in humans; partitioning contributions from the cerebral and femoral circulation

This study examined to what extent the human cerebral and femoral circulation contribute to free radical formation during basal and exercise-induced responses to hypoxia. Healthy participants (5♂, 5♀) were randomly assigned single-blinded to normoxic (21% O₂) and hypoxic (10% O₂) trials with measurements taken at rest and 30 min after cycling at 70% of maximal power output in hypoxia and equivalent relative and absolute intensities in normoxia. Blood was sampled from the brachial artery (a), internal jugular and femoral veins (v) for non-enzymatic antioxidants (HPLC), ascorbate radical (A^•-, electron paramagnetic resonance spectroscopy), lipid hydroperoxides (LOOH) and low density lipoprotein (LDL) oxidation (spectrophotometry). Cerebral and femoral venous blood flow was evaluated by transcranial Doppler ultrasound (CBF) and constant infusion thermodilution (FBF). With 3 participants lost to follow up (final n = 4♂, 3♀), hypoxia increased CBF and FBF (P = 0.041 vs. normoxia) with further elevations in FBF during exercise (P = 0.002 vs. rest). Cerebral and femoral ascorbate and α-tocopherol consumption (v < a) was accompanied by A^•-/LOOH formation (v > a) and increased LDL oxidation during hypoxia (P < 0.043-0.049 vs. normoxia) implying free radical-mediated lipid peroxidation subsequent to inadequate antioxidant defense. This was pronounced during exercise across the femoral circulation in proportion to the increase in local O₂ uptake (r = -0.397 to -0.459, P = 0.037-0.045) but unrelated to any reduction in PO₂. These findings highlight considerable regional heterogeneity in the oxidative stress response to hypoxia that may be more attributable to local differences in O₂ flux than to O₂ tension.