Cerebral autoregulation during moderate hypothermia in rats

The Critical Role of Spreading Depolarizations in Early Brain Injury: Consensus and Contention

BACKGROUND

When a patient arrives in the emergency department following a stroke, a traumatic brain injury, or sudden cardiac arrest, there is no therapeutic drug available to help protect their jeopardized neurons. One crucial reason is that we have not identified the molecular mechanisms leading to electrical failure, neuronal swelling, and blood vessel constriction in newly injured gray matter. All three result from a process termed spreading depolarization (SD). Because we only partially understand SD, we lack molecular targets and biomarkers to help neurons survive after losing their blood flow and then undergoing recurrent SD.

METHODS

In this review, we introduce SD as a single or recurring event, generated in gray matter following lost blood flow, which compromises the Na⁺/K⁺ pump. Electrical recovery from each SD event requires so much energy that neurons often die over minutes and hours following initial injury, independent of extracellular glutamate.

RESULTS

We discuss how SD has been investigated with various pitfalls in numerous experimental preparations, how overtaxing the Na⁺/K⁺ ATPase elicits SD. Elevated K⁺ or glutamate are unlikely natural activators of SD. We then turn to the properties of SD itself, focusing on its initiation and propagation as well as on computer modeling.

CONCLUSIONS

Finally, we summarize points of consensus and contention among the authors as well as where SD research may be heading. In an accompanying review, we critique the role of the glutamate excitotoxicity theory, how it has shaped SD research, and its questionable importance to the study of early brain injury as compared with SD theory.

Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass

Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.

Cerebrovascular reactivity is not associated with therapeutic intensity in adult traumatic brain injury: a CENTER-TBI analysis

BACKGROUND

Impaired cerebrovascular reactivity in adult traumatic brain injury (TBI) is known to be associated with poor outcome. However, there has yet to be an analysis of the association between the comprehensively assessed intracranial hypertension therapeutic intensity level (TIL) and cerebrovascular reactivity.

METHODS

Using the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit (ICU) cohort, we derived pressure reactivity index (PRx) as the moving correlation coefficient between slow-wave in ICP and mean arterial pressure, updated every minute. Mean daily PRx, and daily % time above PRx of 0 were calculated for the first 7 days of injury and ICU stay. This data was linked with the daily TIL-Intermediate scores, including total and individual treatment sub-scores. Daily mean PRx variable values were compared for each TIL treatment score via mean, standard deviation, and the Mann U test (Bonferroni correction for multiple comparisons). General fixed effects and mixed effects models for total TIL versus PRx were created to display the relation between TIL and cerebrovascular reactivity.

RESULTS

A total of 249 patients with 1230 ICU days of high frequency physiology matched with daily TIL, were assessed. Total TIL was unrelated to daily PRx. Most TIL sub-scores failed to display a significant relationship with the PRx variables. Mild hyperventilation (p < 0.0001), mild hypothermia (p = 0.0001), high levels of sedation for ICP control (p = 0.0001), and use vasopressors for CPP management (p < 0.0001) were found to be associated with only a modest decrease in mean daily PRx or % time with PRx above 0.

CONCLUSIONS

Cerebrovascular reactivity remains relatively independent of intracranial hypertension therapeutic intensity, suggesting inadequacy of current TBI therapies in modulating impaired autoregulation. These findings support the need for investigation into the molecular mechanisms involved, or individualized physiologic targets (ICP, CPP, or Co2) in order to treat dysautoregulation actively.

Functional Connectivity in Term Neonates With Hypoxic-Ischemic Encephalopathy Undergoing Therapeutic Hypothermia

BACKGROUND

We investigated whether therapeutic hypothermia and rewarming impact functional connectivity using electroencephalography (EEG) as a measure in neonates with hypoxic-ischemic encephalopathy. We hypothesized that EEG coherence and voltage correlations would be lower and phase lag greater in infants with hypoxic-ischemic encephalopathy than control subjects and that functional connectivity would evolve during therapeutic hypothermia with the greatest improvement occurring during rewarming.

METHODS

This study was a retrospective study of 14 term neonates (greater than 37 weeks) with moderate hypoxic-ischemic encephalopathy who underwent therapeutic hypothermia and rewarming. Continuous EEG and video monitoring was conducted for 96 hours during therapeutic hypothermia and rewarming. The primary quantitative EEG measures of functional connectivity were coherence, phase lag, and voltage correlations. These EEG parameters were compared with a cohort of normal age-matched neonates.

RESULTS

Neonates with hypoxic-ischemic encephalopathy had marked decreases in power, coherences, and voltage correlation and increases in phase lag when compared with control neonates. However, there were no significant changes in these measures between therapeutic hypothermia and rewarming.

CONCLUSIONS

Neonates with hypoxic-ischemic encephalopathy demonstrate significant abnormalities in functional connectivity compared with control subjects. These abnormalities persist through therapeutic hypothermia and rewarming and are not altered after rewarming. Although hypoxic-ischemic encephalopathy is associated with impaired functional brain connectivity, there is no evidence, using quantitative EEG measures, that therapeutic hypothermia or rewarming either improves or exacerbates these abnormalities in connectivity.

Hypothermia Used in Medical Applications for Brain and Spinal Cord Injury Patients

Despite more than 80 years of animal experiments and clinical practice, efficacy of hypothermia in improving treatment outcomes in patients suffering from cell and tissue damage caused by ischemia is still ongoing. This review will first describe the history of utilizing cooling in medical treatment, followed by chemical and biochemical mechanisms of cooling that can lead to neuroprotection often observed in animal studies and some clinical studies. The next sections will be focused on current cooling approaches/devices, as well as cooling parameters recommended by researchers and clinicians. Animal and clinical studies of implementing hypothermia to spinal cord and brain tissue injury patients are presented next. This section will review the latest outcomes of hypothermia in treating patients suffering from traumatic brain injury (TBI), spinal cord injury (SCI), stroke, cardiopulmonary surgery, and cardiac arrest, followed by a summary of available evidence regarding both demonstrated neuroprotection and potential risks of hypothermia. Contributions from bioengineers to the field of hypothermia in medical treatment will be discussed in the last section of this review. Overall, an accumulating body of clinical evidence along with several decades of animal research and mathematical simulations has documented that the efficacy of hypothermia is dependent on achieving a reduced temperature in the target tissue before or soon after the injury-precipitating event. Mild hypothermia with temperature reduction of several degrees Celsius is as effective as modest or deep hypothermia in providing therapeutic benefit without introducing collateral/systemic complications. It is widely demonstrated that the rewarming rate must be controlled to be lower than 0.5 °C/h to avoid mismatch between local blood perfusion and metabolism. In the past several decades, many different cooling methods and devices have been designed, tested, and used in medical treatments with mixed results. Accurately designing treatment protocols to achieve specific cooling outcomes requires collaboration among engineers, researchers, and clinicians. Although this problem is quite challenging, it presents a major opportunity for bioengineers to create methods and devices that quickly and safely produce hypothermia in targeted tissue regions without interfering with routine medical treatment.

Can Therapeutic Hypothermia Be Guided by Advanced Neuromonitoring in Neurocritical Care Patients? A Review

The impact of therapeutic hypothermia (TH) on long-term neurological outcome is still controversial. Data on the effects of TH on brain homeostasis are mostly derived from experimental research. Invasive multimodal neuromonitoring techniques may provide additional insight into pathophysiological changes associated with primary or secondary brain injury in humans. In this study we describe the principles of multimodal neuromonitoring and its potential in the clinical setting of TH. We call for more research using multimodal neuromonitoring techniques in patients undergoing TH to optimize cooling and rewarming strategies.

Neuroprotective efficacy of selective brain hypothermia induced by a novel external cooling device on permanent cerebral ischemia in rats

OBJECTIVES

This study was aimed at examining whether hypothermia is neuroprotective against permanent cerebral ischemia in rats.

METHODS

A total of 32 male Sprague--Dawley rats were subjected to a middle cerebral artery occlusion. In the hypothermic group, rats (n=10) underwent selective brain hypothermia for 5 hours with the use of a novel surface coil with coolant circulating inside. In the control (n=13) and sham groups (n=9), the rats were maintained at normothermia. After a period of 168 hours ischemia, animals were killed to measure the infarction volume of the brain stained with hematoxylin-eosin.

RESULTS

There were no significant differences in physiological parameters except for the temperature. The present style of hypothermia significantly reduced infarction volume in the cortex and caudoputamen.

DISCUSSION

The present results endorse the neuroprotective effect of our method of hypothermia in permanent focal cerebral ischemia at an endpoint of 1 week under the following two conditions: (1) reduction of muscle and caudoputamen temperature to 29 and 31 degrees C, respectively; (2) maintenance of the mean arterial blood pressure above 90 mmHg during hypothermia.

Increased blood oxygen level-dependent (BOLD) sensitivity in the mouse somatosensory cortex during electrical forepaw stimulation using a cryogenic radiofrequency probe

Functional MRI (fMRI) based on the blood oxygen level-dependent (BOLD) contrast is widely used in preclinical neuroscience. The small dimensions of rodent brain place high demands on spatial resolution, and hence on the sensitivity of the fMRI experiment. This work investigates the performance of a 400-MHz cryogenic quadrature transceive radiofrequency probe (CryoProbe) with respect to the enhancement of the BOLD sensitivity. For this purpose, BOLD fMRI experiments were performed in mice during electrical forepaw stimulation using the CryoProbe and a conventional room temperature surface coil of comparable dimensions. Image signal-to-noise ratio (SNR) and temporal SNR were evaluated as quality measures for individual images and for fMRI time series of images, resulting in gains (mean ± standard deviation) with factors of 3.1 ± 0.7 and 1.8 ± 1.0 when comparing the CryoProbe and room temperature coil. The CryoProbe thermal shield temperature did not affect the noise characteristics, with temporal noise levels being 63 ± 16% of the corresponding room temperature value. However, a significant effect on BOLD amplitudes was found, which was attributed to temperature-dependent baseline cerebral blood volumes. Defined local thermal conditions were found to be a critical parameter for achieving an optimal and reproducible fMRI signal. In summary, the CryoProbe represents an attractive alternative for the enhancement of image SNR, temporal SNR and BOLD sensitivity in mouse fMRI experiments.

Elevated vertebrobasilar artery resistance in neonatal spontaneously hypertensive rats

There is a strong correlation between increased vertebral artery resistance and arterial blood pressure in humans. The reasons for this increased resistance at high systemic pressure remain unknown, but may include raised sympathetic activity. With the recent finding that prehypertensive spontaneously hypertensive (PHSH) rats, which have raised sympathetic nerve activity, but a blood pressure comparable to normotensive rat strains, we hypothesized that its vertebrobasilar vascular resistance would already be raised and, as a consequence, would exhibit a more responsive Cushing response (e.g., brain ischemia evoked sympathoexcitation and a pressor response). We report that PHSH rats exhibited a remodeling of the basilar artery (i.e., increased wall thickness and lower lumen-to-wall thickness ratio) that occurred before the onset of hypertension. In a novel in vitro vascularly isolated, arterially perfused brain stem preparation of PHSH rats of 4-5 wk of age, brain stem vascular resistance was raised by ∼35% relative to age- and sex-matched normotensive rats (P < 0.05). In the in situ arterial perfused working heart-brain stem preparation, occlusion of both vertebral arteries in the PHSH rat resulted in a significantly greater increase in sympathetic activity (57 vs. 20%, PHSH vs. control; P < 0.01) that triggered a greater increase in arterial perfusion pressure (8 vs. 3 mmHg, PHSH vs. control; P < 0.01) compared with normotensive rats. These data indicate raised vertebrobasilar artery resistance before the onset of hypertension in the PHSH rat. With the raised responsiveness of the Cushing response in the PHSH rat, we discuss the possibility of brain stem perfusion as a central nervous system determinant of the set point of vasomotor sympathetic tone in the hypertensive condition.

Hypothermia reduces early hypoperfusion and metabolic alterations during the acute phase of massive subarachnoid hemorrhage: a laser-Doppler-flowmetry and microdialysis study in rats

Morbidity and mortality of subarachnoid hemorrhage (SAH) are correlated with the severity of the patient's acute neurological deficit. This initial presentation has been attributed to cerebral hypoperfusion in the acute phase, and we investigated the impact of moderate hypothermia on the early changes in perfusion and metabolism following massive experimental SAH. SAH was induced in 61 anesthetized rats by rapid injection of 0.5 mL of arterial blood into the cisterna magna. In normothermia (NT), animals were kept at 37 degrees C, while in the primary hypothermia (pHT) group, temperature was lowered to 32 degrees C prior to SAH, and in the secondary hypothermia (sHT) group, cooling was started immediately after SAH. From 30 min prior to 180 min after SAH, Laser-Doppler-flowmetry (LDF) probes allowed online recording of cerebral blood flow (CBF) while parenchymal dialysate was collected by microdialysis probes within the frontoparietal cortex. In NT, the acute phase was characterized by impaired autoregulation and prolonged hypoperfusion. In pHT and sHT, autoregulation was preserved and acute hypoperfusion rapidly improved. SAH also caused a highly significant reduction in glucose in NT only. pHT significantly reduced accumulation of lactate, glutamate, and aspartate. Comparable trends were present for histidine, GABA, and taurine, while glutamine consumption was ameliorated. Early perfusion deficits caused by acute hypoperfusion and disruption of cerebral autoregulation can be ameliorated by hypothermia. Also, the acute phase of experimental SAH is characterized by glucose depletion, lactate accumulation, and release of excitatory amino acids, which can be influenced favorably by hypothermia.

Neurodevelopmental and neuroradiologic outcomes in patients with univentricular heart aged 5 to 7 years: Related risk factor analysis

OBJECTIVE

Despite improved survival and neurodevelopmental outcome, children with hypoplastic left heart syndrome and other forms of univentricular heart remain at increased risk for cognitive, motor, and other neurologic deficits.

METHODS

We examined 27 children with hypoplastic left heart syndrome or other forms of univentricular heart at a median age of 5.70 years (range 4.99-7.51 years) and performed brain computed tomography or magnetic resonance imaging on 20. Possible risk factors were correlated with outcome.

RESULTS

Mean full-scale IQ among patients with hypoplastic left heart syndrome was 86.7; that among patients with other forms of univentricular heart was 89.1, with both differing significantly from the expected population mean (P = .015 and P = .029, respectively). Cerebral palsy was diagnosed in 1 of 7 patients with hypoplastic left heart syndrome and 2 of 20 with other forms of univentricular heart. Brain computed tomography or magnetic resonance imaging revealed ischemic changes and infarcts or atrophy in 5 of 8 patients who had undergone the Norwood procedure and in 2 of 12 of those who had not (P = .062). Abnormal computed tomographic findings correlated significantly with lower full-scale IQ (P = .045) and verbal IQ (P = .02). In the multiple linear regression model, diuresis the third day after the primary operation and cardiopulmonary bypass time in the bidirectional Glenn operation correlated significantly with the primary outcome of full-scale IQ.

CONCLUSION

In children with univentricular heart, intellectual and neurologic deficits are common. Perioperative and postoperative risk factors related to the primary phase and bidirectional Glenn operation contribute to these deficits.

Valsartan improves the lower limit of cerebral autoregulation in rats

The effects of angiotensin II type 1 receptor blockers (ARBs) on cerebral blood flow (CBF) autoregulation have not been fully clarified. Thus, we examined the acute effect of valsartan, the most selective ARB, on CBF autoregulation in spontaneously hypertensive rats. Intravenous administration of valsartan (0.3 mg/kg) reduced the mean arterial pressure (MAP) from 184+/-5 (mean+/-SEM) to 174+/-5 mmHg (p<0.001) without affecting CBF as measured by laser-Doppler flowmetry. The lower limit of CBF autoregulation (the MAP at which the CBF was 80% of the baseline value) in the valsartan-treated group (122+/-3 mmHg) was significantly lower than that in the control group (135+/-4 mmHg, p<0.05). Reverse transcribed-polymerase chain reaction and immunohistochemical staining demonstrated that both angiotensin II type 2 receptors and angiotensin II type 1 receptors (AT1Rs) were expressed in endothelial and smooth muscle cells of the rat cerebral arteries. These results suggest that specific inhibition of AT1Rs in the cerebral circulation causes the leftward shift of the lower limit of autoregulation.

Temperature distribution and blood perfusion response in rat brain during selective brain cooling

A rat model was used in this study to examine the transient temperature distribution and blood flow response in the brain during selective brain cooling (SBC) and rewarming. SBC was induced by a head cooling helmet with circulating water of 18 degrees C or 0 degrees C. It has been shown that the brain temperature reductions were 1.7+/-0.2 degrees C (5 mm beneath the brain surface) and 3.2+/-1.1 degrees C (2 mm beneath the brain surface) when the temperature of the water was 18 degrees C (moderate cooling). The cooling of the brain tissue was more evident when the circulating water was colder (0 degrees C, deep cooling). The characteristic time that it took for the tissue temperatures to reach a new steady state after the initiation of cooling varied from 5 to more than 35 min and it depended strongly on the blood flow response to the cooling. We used an ultrasound flow meter to measure continuously the blood flow rate in the common carotid artery during the cooling and rewarming. The blood flow rate dropped by up to 22% and 44% during the cooling from its baseline in the moderate cooling group and in the deep cooling group, respectively. Although all brain temperatures recovered to their baseline values 50 min after the helmet was removed, the blood flow rate only recovered to 92% and 77% of its baseline values after the moderate and deep cooling, respectively, implying a possible mismatch between the blood perfusion and metabolism in the brain. The current experimental results can be used to study the feasibility of inducing brain hypothermia by SBC if the blood flow responses in the rat are applicable to humans. The simultaneous recordings of temperature and blood flow rate in the rat brain can be used in the future to validate the theoretical model developed previously.

Cerebral pressure autoregulation is intact and is not influenced by hypothermia after traumatic brain injury in rats

In head-injured patients and experimental traumatic brain injury (TBI), important cerebrovascular abnormalities include decreases in cerebral blood flow (CBF) and impairment of cerebral pressure autoregulation. We evaluated CBF and pressure autoregulation after fluid percussion injury (FPI) and hypothermia in rats with the hypothesis that hypothermia would ameliorate changes in posttraumatic CBF. Male Sprague-Dawley rats, intubated and mechanically ventilated, were prepared for parasagittal FPI (1.8 atm) and laser Doppler CBF flow (LDF) measurement. The abdominal aorta was cannulated for rapid removal and reinfusion of blood. Baseline autoregulatory testing in all groups consisted of LDF measurements at normothermia and a mean arterial pressure (MAP) of 100 mm Hg, followed by randomly ordered changes of MAP to 80, 60, and 40 mm Hg. Animals were then randomized to one of five groups: normothermic control without FPI; normothermia with FPI; hypothermic control (32 degrees C) without FPI; hypothermia initiated before FPI; and hypothermia initiated immediately after FPI injury. For each group, a complete, randomly ordered autoregulatory sequence was performed at 30 and 60 min after FPI or sham TBI. In a second study, rats were prepared identically, maintained at normothermic temperatures and autoregulation was tested before and after TBI using a set of randomly ordered levels of hypotension or using progressive reductions in MAP (i.e., 80, 60, 40 mm Hg) with the hypothesis that the technical manner and timing of decreasing of the blood pressure would effect CBF after TBI. Due to high acute mortality, the group in which hypothermia was induced before FPI was excluded from the analysis. At baseline, autoregulation was similar in all groups. There was no change in CBF or autoregulation in the normothermic control group at 30 and 60 min. In the other groups at 30 and 60 min, there was a similar, statistically significant decrease in absolute CBF (i.e., a decrease of 27-57% of baseline values), but pressure autoregulation was intact except at the lowest blood pressure tested at 60 min, where there was a slight improvement in the hypothermic group. Thus, in these experiments, absolute CBF decreased with hypothermia and FPI, while neither hypothermia nor FPI significantly altered autoregulation. In the second study, autoregulatory function was not different before TBI when comparing random and sequential blood pressure changes, but, when comparing the groups after TBI at the 60 mm Hg blood pressure level, CBF was significantly lower in the sequential group than in the random order group. This suggests that the mechanism of creating hypotension, whether random or sequential, significantly affects the measurement of CBF and autoregulation after TBI in rats.

Les variations thermiques modifient les paramètres des gaz du sang : quelles conséquences en pratique clinique ?

OBJECTIVE

To understand changes in blood gases results with core temperature.

METHODS

Analysis from two case reports.

RESULTS

Hypothermia induces a decrease in PaCO(2) with a related increase in pH, thus a physiologic alkalosis. Decrease in PaCO(2) is due to an increase of gas solubility and a decrease of peripheral consumption that can be estimated from comparison between corrected and non-corrected for temperature blood gases. For O(2), variations of temperature induce variations of solubility but also of haemoglobin affinity for O(2). During hyperthermia, haemoglobin affinity for O(2) is decreased with a decreased SvO(2) for a same PvO(2). SvO(2) ischemic or therapeutic thresholds are thus modified with core temperature.

CONCLUSION

Blood gases cannot be understood without patient core temperature. Physiologic variations of PaCO(2) and pH must probably be tolerated. Ischemic threshold should be estimated on PvO(2), not only on PvO(2).

Regional Heterogeneity of Cerebral Blood Flow Response to Graded Pressure-Controlled Hemorrhage

BACKGROUND

Little is known about the regional distribution of cerebral blood flow (CBF) in nonanesthetized animals during periods of lowered blood pressure. The present investigation addresses the specific reaction patterns of local cerebral blood flow (LCBF) in comparison with mean CBF during graded pressure-controlled hemorrhagic shock in conscious rats.

METHODS

Conscious rats were subjected to graded pressure-controlled hemorrhage (to 85, 70, 55, or 40 mm Hg) by arterial blood withdrawal. After a period of 30 minutes, blood pressure was stabilized by withdrawal or reinfusion of blood. LCBF was determined autoradiographically by the iodo(14C)antipyrine method in 34 brain structures, and mean CBF was calculated and compared with the values of nonhemorrhaged control animals.

RESULTS

Mean CBF remained unchanged except for the group with the lowest blood pressure of 40 mm Hg (decrease in CBF of 28%). Otherwise, LCBF was increased in some brain structures at an unchanged mean CBF. Congruently, at 40 mm Hg, the decrease in mean CBF did not show up in all brain structures, the local pattern of CBF varying between an unchanged and a profoundly decreased CBF. The mean coefficient of variation of CBF was increased with the severity of hemorrhagic shock, which indicates an enhanced heterogeneity of CBF.

CONCLUSION

Because of the substantial heterogeneity in the responses of LCBF to pressure-controlled hemorrhage, autoregulation of CBF during pressure-controlled hemorrhagic shock has to be reconsidered on a regional basis.

Hypothermia and stroke: the pathophysiological background

Hypothermia to mitigate ischemic brain tissue damage has a history of about six decades. Both in clinical and experimental studies of hypothermia, two principal arbitrary patterns of core temperature lowering have been defined: mild (32-35 degrees C) and moderate hypothermia (30-33 degrees C). The neuroprotective effectiveness of postischemic hypothermia is typically viewed with skepticism because of conflicting experimental data. The questions to be resolved include the: (i) postischemic delay; (ii) depth; and (iii) duration of hypothermia. However, more recent experimental data have revealed that a protected reduction in brain temperature can provide sustained behavioral and histological neuroprotection, especially when thermoregulatory responses are suppressed by sedation or anesthesia. Conversely, brief or very mild hypothermia may only delay neuronal damage. Accordingly, protracted hypothermia of 32-34 degrees C may be beneficial following acute cerebral ischemia. But the pathophysiological mechanism of this protection remains yet unclear. Although reduction of metabolism could explain protection by deep hypothermia, it does not explain the robust protection connected with mild hypothermia. A thorough understanding of the experimental data of postischemic hypothermia would lead to a more selective and effective clinical therapy. For this reason, we here summarize recent experimental data on the application of hypothermia in cerebral ischemia, discuss problems to be solved in the experimental field, and try to draw parallels to therapeutic potentials and limitations.

Appropriate cerebral perfusion pressure during rewarming after therapeutic hypothermia

This study evaluated the cerebral ischemic parameters during the rewarming period after therapeutic hypothermia to determine the critical cerebral perfusion pressure (CPP) threshold to avoid ischemic deterioration. Cat experimental head injury was induced by inflation of an epidural rubber balloon to maintain intracranial pressure at 30 mmHg under hypothermia. During the rewarming period, CPP was maintained at > or = 120 mmHg, 90 mmHg, and 60 mmHg by controlling the blood pressure. CBF, CMRO2, AVDO2, and cerebral venous oxygen saturation (ScvO2) were measured. Brain extracellular glutamate concentrations were also measured by a dialysis electrode. Histological preparations of all brains were examined under an electron microscope. The cerebral metabolic parameters in animals with CPP of more than 90 mmHg returned to the base values after rewarming. However, ScvO2 was significantly lower (27 +/- 6%) and AVDO2 was significantly higher (9.4 +/- 1.8 ml/100 g/min) after rewarming in the animals with CPP = 60 mmHg, which indicated misery perfusion. Animals with CPP = 60 mmHg also showed increased extracellular glutamate concentration and histological ischemic damage (mitochondrial swelling). CPP of 60 mmHg during the rewarming period is associated with irreversible ischemia, which indicates continuation of cerebral vasoconstriction. Therefore, a CPP of greater than 90 mmHg is required to avoid cerebral ischemia.

Changes in cerebrovascular response during brain hypothermia after traumatic brain injury

OBJECTIVE

Transcranial Doppler sonography (TCD) provides a rapid and noninvasive assessment of cerebral hemodynamics after traumatic brain injury. This study evaluates the change of cerebrovascular response at the rewarming stage of brain hypothermia using TCD.

MATERIAL AND METHODS

Seventeen patients who had suffered from closed brain injury were investigated with daily TCD recordings and the changes in flow velocities were evaluated to determine whether they reflected the temperature during brain hypothermia. All patients who had treated brain hypothermia underwent continuous monitoring of SjO2, mean arterial blood pressure, and intracranial pressure (ICP).

RESULTS

No significant changes in ICP and cerebral perfusion pressure (CPP) were recorded in all cases. Of 17 patients, 5 had a significant increase in SjO2 > 75% or more, retrospectively, with a robust increase in flow velocities of the middle cerebral artery (P < .01) at the rewarming stage. These cases marked a decrease in pulsatility index (P < .05) concomitant with an increase in SjO2 values. The CT scan revealed acute brain swelling in these cases.

CONCLUSION

These data suggest cerebral vasoactivity could be altered at the rewarming stage. Hypothermia runs a risk of hyperemia at the rewarming stage, which induced a decrease in cerebral vasoresistance.

Effect of mild hypothermia on inodilator-induced vasodilation of pial arterioles in cats

BACKGROUND

Mild hypothermia has been proposed as a means of providing cerebral protection after traumatic brain injury. However, hypothermia has been shown to alter not only physiologic but also pharmacologic responses. The purpose of this study was to investigate whether mild hypothermia (3-4 degrees C temperature reduction) could alter cerebral vasodilation induced by inodilators, which are characterized by having an inotropic effect in addition to a vasodilatory effect. Isoproterenol (a beta-adrenergic receptor agonist), colforsin dapropate (an adenylate cyclase stimulant), and amrinone (a phosphodiesterase inhibitor) were chosen as inodilators.

METHODS

The cranial window technique, combined with microscopic video recording, was used. Forty-eight cats were randomly assigned to either a normothermic or a hypothermic group (33 degrees C). Isoproterenol, colforsin dapropate, or amrinone was topically applied in the cranial window and the diameter of pial arterioles was measured.

RESULTS

Topical administration of isoproterenol, colforsin dapropate, and amrinone produced a significant dilation in a dose-dependent manner during normothermia. The vasodilation induced by these inodilators was not affected by mild hypothermia.

CONCLUSION

The vasodilation induced by topical administration of isoproterenol, colforsin dapropate, and amrinone was not affected by mild hypothermia.

Cerebral ischemia and trauma-different etiologies yet similar mechanisms: neuroprotective opportunities

Cerebral ischemia leads to brain damage caused by pathogenetic mechanisms that are also activated by neurotrauma. These mechanisms include among others excitotoxicity, over production of free radicals, inflammation and apoptosis. Furthermore, cerebral ischemia and trauma both trigger similar auto-protective mechanisms including the production of heat shock proteins, anti-inflammatory cytokines and endogenous antioxidants. Neuroprotective therapy aims at minimizing the activation of toxic pathways and at enhancing the activity of endogenous neuroprotective mechanisms. The similarities in the damage-producing and endogenous auto-protective mechanisms may imply that neuroprotective compounds found to be active against one of these conditions may indeed be also protective in the other. This review summarizes the pathogenetic events of ischemic and traumatic brain injury and reviews the neuroprotective strategies employed thus far in each of these conditions with a special emphasize on their clinical relevance and on future directions in the field of neuronal protection.

Adequate cerebral perfusion pressure during rewarming to prevent ischemic deterioration after therapeutic hypothermia

Ischemic deterioration during rewarming is one of the most notable clinical complications after successful therapeutic cerebral hypothermia, but the mechanism is not completely understood. Hypothermia may cause vasoconstriction and relative ischemia, especially with insufficient cerebral perfusion pressure (CPP). Various parameters were evaluated to determine the critical CPP threshold to avoid ischemia during rewarming. Cat experimental head injury was induced by inflating an epidural rubber balloon, and intracranial pressure was maintained at 30 mmHg. During rewarming after cerebral hypothermia, CPP was maintained at >120 mmHg (n = 16), 90 mmHg (n = 11), 60 mmHg (n = 11), and 40 mmHg (n=4) by controlling the blood pressure. Cerebral blood flow, cerebral metabolic rate for oxygen, arteriovenous difference of oxygen (AVDO2), cerebral venous oxygen saturation (ScvO2), and extracellular glutamate concentrations were monitored by glutamate oxidase electrode. After rewarming, the cerebral metabolic parameters were almost restored to the pre-injury level in animals with CPP of more than 90mmHg. However, in the animals with CPP= 60 mmHg, all parameters significantly deteriorated and indicated misery perfusion; ScvO2 was low (29.5+/-1.1%), AVDO2 was significantly high (9.9+/-0.8 ml 100 g(-1) min(-1)) (one-way analysis of variance, p<0.05), and electron microscopic features showed subcellular ischemic change. Extracellular glutamate significantly increased during the rewarming period only in the CPP= 40 mmHg group. CPP less than 60 mmHg during rewarming causes secondary ischemic insult, which might indicate continuation of cerebral vasoconstriction in hypothermia. CPP higher than 90 mmHg is required to avoid the potential risk of relative ischemia after hypothermia.

Spinal cord blood flow changes following systemic hypothermia and spinal cord compression injury: an experimental study in the rat using Laser-Doppler flowmetry

STUDY DESIGN

It is well known that changes of the body temperature as well as trauma influence the blood flow in the brain and spinal cord. However, there is still a lack of knowledge concerning the levels of blood flow changes, especially during hypothermia.

OBJECTIVES

This investigation was carried out to examine the effects of systemic hypothermia and trauma on spinal cord blood flow (SCBF).

METHODS

Twenty-four rats were randomized either to thoracic laminectomy only (Th VII-IX) or to 35 g spinal cord compression trauma. The animals were further randomized to either constant normothermia (38 degrees C) or to a systemic cooling procedure, ie reduction of the esophageal temperature from 38 to 30 degrees C. SCBF was recorded 5 mm caudal to the injury zone using Laser-Doppler flowmetry which allows a non-invasive continuous recording of local changes in the blood flow. The autoregulation ability was tested at the end of the experiments by inducing a 30-50 mmHg blood-pressure fall, using blood-withdrawal from the carotid artery.

RESULTS

The mean SCBF decreased 2.8% and 3.5% per centigrade reduction of esophageal temperature in the animals sustained to hypothermia with and without trauma, respectively. This could be compared to a decrease of 0.2%/min when only trauma was applied. No significant differences were seen between the groups concerning auto regulatory ability.

CONCLUSIONS

Our results indicate that the core temperature has a high impact on the SCBF independent of previous trauma recorded by Laser-Doppler flowmetry. This influence exceeds the response mediated by moderate compression trauma alone.

Intraischemic mild hypothermia increases hippocampal CA1 blood flow during forebrain ischemia

The hippocampal CA1 sector is selectively vulnerable to forebrain ischemia but protected by mild hypothermia. However, the consequence of intraischemic hypothermia on CA1 blood flow during the insult has not been adequately characterized. The effects of mild intraischemic hypothermia on relative changes in regional hippocampal CA1 blood flow were recorded continuously using laser Doppler flowmetry (LDF) during and 30 min after 6 min of forebrain ischemia. Six experimental groups (n=6/group) of fasted male Wistar rats were compared. Groups 1, 3 and 5 consisted of normothermic rats that underwent either 6 (for CBF measurements) and 6 or 10 (for 7 day survival-CA1 neuronal death measurements) min of transient forebrain ischemia using bilateral carotid clamping and hemorrhagic hypotension. Groups 2, 4 and 6 rats were subjected to mild hypothermia (34 degrees C) before, during, and 30 min after 6 (for CBF measurements) and 6 or 10 (for 7 day survival-CA1 neuronal death measurements) min of transient forebrain ischemia. CA1 blood flow and electroencephalogram (EEG) were continuously recorded. During the ischemic insult there were intergroup differences in the magnitude of CBF decreases in the CA1 region. In both groups 1 and 2, CBF returned to preischemic values within 1 min of reperfusion but hypothermic rats had more sustained hyperemia. Hypothermic rats had a quicker recovery of EEG activity and less delayed CA1 neuronal death (group 2 versus 4). These data suggest ischemic blood flow to the CA1 sector was altered by intraischemic mild hypothermia which may contribute to the greater benefit of intraischemic hypothermic neuroprotection.

Impaired autoregulation of cerebral blood flow in an experimental model of traumatic brain injury

In order to study the pathophysiology and the intracranial hemodynamics of traumatic brain injury, we have developed a modified closed-head injury model of impact-acceleration that expresses several features of severe head injury in humans, including acute and long-lasting intracranial hypertension, diffuse axonal injury, neuronal necrosis, bleeding, and edema. In view of the clinical relevance of impaired autoregulation of cerebral blood flow after traumatic brain injury, and aiming at further characterization of the model, we investigated the autoregulation efficiency 24 h after experimental closed-head injury. Cortical blood flow was continuously monitored with a laser-Doppler flowmeter, and the mean arterial blood pressure was progressively decreased by controlled hemorrhage. Relative laser-Doppler flow was plotted against the corresponding mean arterial blood pressure, and a two-line segmented model was applied to determine the break point and slopes of the autoregulation curves. The slope of the curve at the right hand of the break point was significantly increased in the closed head injury group (0.751 +/- 0.966%/mm Hg versus -0.104 +/- 0.425%/mm Hg,p = 0.028). The break point tended towards higher values in the closed head injury group (62.2 +/- 20.8 mm Hg versus 46.9 +/- 12.7 mm Hg; mean +/- SD, p = 0.198). It is concluded that cerebral autoregulation in this modified closed head injury model is impaired 24 h after traumatic brain injury. This finding, in addition to other characteristic features of severe head injury established earlier in this model, significantly contributes to its clinical relevance.

Hypothermia attenuates the vasodilatory response of pial arterioles to hemorrhagic hypotension in the cat

We investigated the effect of hypothermia on the vasodilatory response of pial arterioles to hemorrhagic hypotension. The cranial window technique was combined with microscopic video recording in an experiment involving 20 cats anesthetized with pentobarbital. The animals were randomly assigned to either a normothermic or a hypothermic group (32 degrees C). Mean arterial pressure (MAP) was reduced in stepwise increments of 10 mm Hg (from 100 to 50 mm Hg) by blood withdrawal. The diameter of small (50-100 microm) and large (100-200 microm) pial arterioles was measured. In the normothermic group (n = 9), small and large arterioles dilated at a MAP of 60 and 50 mm Hg, and at a MAP of 70, 60, and 50 mm Hg, respectively, compared with baseline values obtained at a MAP of 100 mm Hg. In contrast, in the hypothermic group (n = 11), vasodilation of either small or large arterioles was absent. The percentage diameter of small and large arterioles (percentage of control) was significantly lower at a MAP of 70, 60, and 50 mm Hg in the hypothermic group than the normothermic group. Our in vivo study demonstrates that hypothermia impairs autoregulatory vasodilation of pial arterioles in response to hemorrhagic hypotension.

IMPLICATIONS

Deliberate mild hypothermia has been proposed as a means of providing cerebral protection during neurosurgical procedures. Our results suggest that cerebral blood flow autoregulation in response to hemorrhagic hypotension may be impaired during hypothermic conditions, indicating the importance of maintaining perfusion pressure during hypothermic therapy to prevent cerebral ischemia.

Influence of rewarming conditions after hypothermia in gerbils with transient forebrain ischemia

OBJECT

Recently, several studies have demonstrated that hypothermia has a beneficial effect on clinical outcome; however, it is difficult to determine the appropriate rewarming conditions in clinical use. The purpose of the present study was to examine the influence of rewarming conditions in gerbils with transient forebrain ischemia.

METHODS

Ischemia was induced in the gerbils by a 5-minute bilateral common carotid artery occlusion, after which the animals were immediately subjected to moderate or deep hypothermia. After moderate hypothermia (30.5 degrees C for 4 hours) the animals were rewarmed over standard, fast, or slow time periods. After deep hypothermia (24 degrees C for 2 hours) the animals were rewarmed in a standard, fast, slow, or stepwise manner. Cerebral blood flow (CBF), extracellular glutamate, and lactate were monitored. Hippocampal CA I cell damage was assessed 7 days after induction of ischemia. In animals treated with moderate hypothermia, the rewarming rate had no influence on the number of surviving neurons. However, fast rewarming from deep hypothermia (to 37 degrees C for 30 minutes) failed to provide the neuroprotective effect of hypothermia. Furthermore, this group showed a poor recovery of CBF (p < 0.01) and, consequently, an increase in extracellular glutamate (p < 0.01) and lactate (p < 0.01) in the hippocampus.

CONCLUSIONS

The results of this study indicate a transient uncoupling of CBF and cerebral metabolism during fast rewarming from deep hypothermia, whereas slow and stepwise rewarming periods were found to be useful for protection against uncoupling of CBF and cerebral metabolism during rewarming.

Cortical NOS inhibition raises the lower limit of cerebral blood flow-arterial pressure autoregulation

The maintenance of constant cerebral blood flow (CBF) as arterial blood pressure is reduced, commonly referred to as CBF-pressure autoregulation, is typically characterized by a plateau until the vasodilatory capacity is exhausted at the lower limit, after which flow falls linearly with pressure. We investigated the effect of cortical, as opposed to systemic, nitric oxide synthase (NOS) inhibition on the lower limit of CBF-pressure autoregulation. Forty-four Sprague-Dawley rats were anesthetized with halothane and N2O in O2. With a closed cranial window placed the previous day in a ventilated and physiologically stable preparation, we determined the CBF using laser-Doppler flowmetry. Animals with low reactivity to inhaled CO2 and suffused ADP or ACh were excluded. Five arterial pressures from 100 to 40 mmHg were obtained with controlled hemorrhagic hypotension under cortical suffusion with artificial cerebrospinal fluid (aCSF) and then again after suffusion for 35 (n = 5) and 105 min (n = 10) with aCSF, 10(-3) M Nomega-nitro-L-arginine (L-NNA; n = 12), or 10(-3) M Nomega-nitro-D-arginine (D-NNA; n = 5). An additional group (n = 7) was studied after a 105-min suffusion of L-NNA followed by a single blood withdrawal procedure. The lower limit of autoregulation was identified visually by four blinded reviewers as a change in the slope of the five-point plot of CBF vs. mean arterial blood pressure. The lower limit of 90 +/- 4.3 mmHg after 105 min of 1 mM L-NNA suffusion was increased compared with the value in the time-control group of 75 +/- 5.3 mmHg (P < 0.01; ANOVA) and the initial value of 67 +/- 3.7 mmHg (P < 0.001). The lower limit of 84 +/- 5.9 mmHg in seven animals with 105 min of suffusion of 1 mM L-NNA without previous blood withdrawal was significantly increased (P < 0.01) in comparison with 70 +/- 1.9 mmHg from those with just aCSF suffusion (n = 37). No changes in lower limit for the other agents or conditions, including 105 or 35 min of aCSF or 35 min of L-NNA suffusion, were detected. The lack of effect on the lower limit with D-NNA suffusion suggests an enzymatic mechanism, and the lengthy L-NNA exposure of 105 min, but not 35 min, suggests inhibition of a diffusionally distant NOS source that mediates autoregulation. Thus cortical suffusion of L-NNA raises the lower limit of autoregulation, strongly suggesting that nitric oxide is at least one of the vasodilators active during hypotension as arterial pressure is reduced from normal.

Mechanisms of brain injury during infant cardiac surgery

Neurological injury is a major and often debilitating complication of congenital heart disease and open-heart surgery. Paradoxically, the full impact of this complication has been underscored by the marked decrease in mortality and the rescue of infants with desperate and previously lethal heart conditions. Although recent focus has been on mechanisms of brain injury originating during open-heart surgery, this article also emphasizes the importance of mechanisms initiated or perpetuated during the preoperative and postoperative periods. In addition to the usually implicated mechanism of hypoxia-ischemia, recent genetic advances suggest an important role for genetic deletion syndromes. Inflammatory cascades have been implicated in the end-organ injury seen after cardiopulmonary bypass and might play a role in neurological dysfunction. These mechanisms are reviewed, with an emphasis on recent developments in our understanding of brain injury in this population.

Moderate hypothermia reduces hypotensive, but not hypercapnic vasodilation of pial arterioles in rats

Two types of acid-base strategies are available for the blood gas management of patients during hypothermia: alpha-stat and pH-stat management. However, the more suitable strategy for therapeutic hypothermia is unclear. We studied the effects of hypothermia (30 degrees C) and acid-base management on reactivity to hypercapnia and hypotension in rat pial arterioles, using a closed cranial window. The baseline diameter during hypothermia decreased in the alpha-stat (PaCO2 was maintained at 35 mm Hg when measured at 37 degrees C, n = 8), but not in the pH-stat (PaCO2 was maintained at 35 mm Hg when corrected to the animal's actual temperature, n = 7). Vasodilation induced by hypotension was significantly reduced in hypothermic groups compared with the normothermic group (n = 7), whereas responses to hypercapnia were preserved. Moreover, hypotensive vasodilation was more attenuated in the pH-stat, than the alpha-stat, management. These findings show that moderate hypothermia and acid-base management alter cerebrovascular autoregulation.

Mild hypothermia disturbs regional cerebrovascular autoregulation in awake rats

The effects of mild hypothermia on regional CBF (rCBF) and autoregulation were investigated in 60 awake and spontaneously breathing Wistar rats. They were divided into normothermic (rectal and brain temperatures: 37.0 +/- 0.5 degrees C) and mildly hypothermic (33.0 +/- 0.5 degrees C) groups the temperature of the latter group was controlled by cooling a lead cast around each rat with ice-cold water. rCBF was measured by means of an autoradiographic technique with 14C-iodoantipyrine. In normothermia, rCBF in most of the supratentorial cortical regions was maintained down to a mean arterial blood pressure (MABP) of 50 mmHg, produced by exsanguination, while rCBF in most of the brain stem regions showed a tendency to increase despite this reduction of MABP (predysautoregulatory overshoot of CBF). In the mildly hypothermic group, pre-exsanguination rCBF values were lower than those in normothermia, and rCBF in all brain regions declined significantly in proportion to decreasing MABP, produced by exsanguination. It is, therefore, concluded that mild hypothermia disturbs cerebrovascular autoregulation in awake rats.

Dissociation between volume blood flow and laser-Doppler signal from rat muscle during changes in vascular tone

Although the laser-Doppler flowmetry (LDF) signal from skeletal muscle has been shown to provide a good measure of blood flow under some conditions, its behavior during administration of vasoactive substances has never been addressed. The aims of this study were to compare 1) changes in LDF signal with those in total muscle blood flow measured with radioactive microspheres after ganglionic blockade (chlorisondamine) and during administration of angiotensin II (ANG II), phenylephrine (PE), and isoproterenol (Iso) and 2) changes in vascular resistance estimated by the two techniques. The LDF signal from the biceps femoris muscle was investigated in anesthetized male Wistar rats. Ganglionic blockade led to a significant (P < 0.05) fall in mean arterial pressure (MAP) [medians (lower, upper quartiles): 78 (72, 83) vs. 127 (114, 138) mmHg under basal conditions], muscle blood flow (MBF, microsphere technique; 61%), and the LDF signal (29%). Muscle vascular resistance (MVR = MAP/MBF) was increased (64%, P < 0.05), but vascular resistance estimated as MAP/LDF signal (MVRLDF) was unchanged. During ANG II and PE infusions, MAP rose (P < 0.05) to 178 (155, 194) and 127 (124, 142) mmHg, respectively; MBF did not change compared with the preinfusion (postganglionic blockade) level and remained significantly (P < 0.05) lower than baseline, whereas the LDF signal increased up to a level not different from baseline. MVR rose and was significantly (P < 0.05) higher than baseline, whereas MVRLDF did not differ significantly from baseline. During Iso infusion, MAP fell [58 (56, 60) vs. 94 (92, 102) mmHg, P < 0.05], the LDF signal was reduced (49%, P < 0.05) despite a large increase in MBF (139%, P < 0.05), and MVR fell (74%, P < 0.05), whereas MVRLDF did not change vs. preinfusion level. Our results suggest that 1) changes in the LDF signal from muscle may not correlate with changes in total muscle blood flow measured by the microsphere technique during infusion of vasoactive substances and 2) the use of LDF data for estimation of MVR during changes in vascular tone in rat skeletal muscle is probably not appropriate.

Mild hypothermia can attenuate nitroglycerin-induced vasodilation of pial arterioles in the cat

The purpose of the present study was to investigate the effect of mild hypothermia on nitroglycerin-induced vasodilation of cerebral vessels. The cranial window technique, combined with microscopic video recording, was used in an experiment involving 26 cats anesthetized with isoflurane. Animals were randomly assigned to either a normothermic or a mildly hypothermic group (33 degrees C). We administered three different concentrations of nitroglycerin (10[-6], 10[-5], 10[-4] M) under the window and measured the diameter of small (< 100 microm) and large (100-200 microm) pial arterioles. In the normothermic group (n = 13), nitroglycerin produced a significant dilation of both small and large arterioles in a dose-dependent manner. In the hypothermic group (n = 13), a significant dilation of arterioles was observed only after topical application of nitroglycerin at a concentration of 10(-4) M. The percent increase in diameter of small and large arterioles was less in the hypothermic group than the normothermic group. Our in vivo study demonstrates that topically applied nitroglycerin produces a dose-dependent dilation of pial arterioles in normothermic cats anesthetized with isoflurane, but the reduction of temperature to 33 degrees C significantly attenuates nitroglycerin-induced vasodilation of pial arterioles.

IMPLICATIONS

Although nitroglycerin may be used in hypothermic patients, the effect of mild hypothermia on nitroglycerin-induced vasodilation of cerebral vessels is unknown. In this study, we investigated the effects of nitroglycerin on pial arteriolar diameter in normothermic and hyperthermic cats. Hypothermia was found to attenuate nitroglycerin-induced vasodilation.

Cerebrovascular responses under controlled and monitored physiological conditions in the anesthetized mouse

Control of physiological parameters such as respiration, blood pressure, and arterial blood gases has been difficult in the mouse due to the lack of technology required to monitor these parameters in small animals. Here we report that anesthetized and artificially ventilated mice can be maintained under physiological control for several hours with apparently normal cerebrovascular reactivity to hypercapnia and mechanical vibrissal stimulation. SV-129 mice were anesthetized with urethane (750 mg/kg i.p.) and alpha-chloralose (50 mg/kg i.p.), intubated, paralyzed, and artificially ventilated. Respiratory control was maintained within physiological range by reducing the inspiratory phase of the respiratory cycle to < 0.1 s and by adjusting end-tidal CO2 to give a PCO2 of 35 +/- 3 mm Hg. In these mice, mean arterial pressure (95 +/- 9 mm Hg), heart rate (545 +/- 78 beats/min), and arterial pH (7.27 +/- 0.10) could be maintained for several hours. Body temperature was kept at 36.5-37.5 degrees C. We observed stable regional CBF (rCBF) measurements (as determined by laser-Doppler flowmetry) when systemic arterial blood pressure was varied between 40 and 130 mm Hg. Hypercapnia led to a 38 +/- 15% (5% CO2) and 77 +/- 34% (10% CO2) increase in rCBF. Mechanical stimulation of contralateral vibrissae for 1 min increased rCBF by 14 +/- 4%. Changes in rCBF compare favorably with those observed previously in another rodent species, the Sprague-Dawley rat. After placement of a closed cranial window, cerebrovascular reactivity to hypercapnia and whisker stimulation was intact and well maintained during 2-h superfusion with artificial CSF.

Intraischemic hypothermia decreases the release of glutamate in the cores of permanent focal cerebral infarcts

The cerebroprotective effects of hypothermia in focal models of ischemia are well established, but little is known about the underlying mechanisms of this form of brain protection. Cortical cooling in global transient ischemic models suggests that hypothermia limits glutamate excitotoxicity by decreasing the release of glutamate during ischemia. Few studies have examined glutamate release in the more physiological model of permanent focal ischemia. In this study, we used a rat model of middle cerebral artery occlusion (MCAO) of permanent focal ischemia. Extracellular glutamate concentration was analyzed bilaterally by microdialysis for 30 minutes before MCAO to 120 minutes after MCAO. Normothermic animals (n = 13) had a baseline glutamate concentration of 9.23 +/- 2.5 mumol/ml (mean +/- standard error of the mean) before MCAO. Extracellular glutamate rose quickly after vessel occlusion and peaked at 33.95 +/- 6.3 mumol/ml 30 minutes after MCAO. By 60 minutes after MCAO, this level had decreased to 25.14 +/- 6.3 mumol/ml; glutamate levels decreased slightly to 21.35 +/- 6.8 mumol/ml by 120 minutes. Hypothermic animals (n = 11) had an initial extracellular glutamate concentration of 5.22 +/- 1.3 mumol/ml before MCAO. This value rose gradually to a maximum of 10.69 +/- 3.3 microns/ml at 50 minutes after MCAO and then returned to a baseline value of 2.58 +/- 1.2 mumol/ml by 120 minutes. Contralateral control glutamate dialysates in the normothermic and hypothermic groups remained near baseline throughout the experimental period. The mean percentages of right hemispheric volumes occupied by infarcts were 11.96 +/- 1.68% in the hypothermic group and 19.77 +/- 2.03% in the normothermic animals.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mild hypothermia and cerebral protection]

To define the part played by mild-to-moderate hypothermia in neuroprotection, it is necessary to take into account the thermoregulatory responses that occur in the normal human as the change in central temperature exceeds 0.2 degrees C. The mechanisms induced by cold are cutaneous vasoconstriction and shivering. They must be suppressed before starting controlled hypothermia. In these conditions, controlled moderate hypothermia between 32 and 35 degrees C does not seem to have deleterious side-effects, especially on coagulation. Caution is needed with the analysis of the numerous papers reporting experiments concerning the effects of moderate hypothermia in animals with induced cerebral ischaemia because of significant differences in the study designs. These differences concern mainly the time of onset of hypothermia, viz before or after ischaemia, the fact that the ischaemia is either global or focal, that it is caused by vascular occlusion posttraumatic or initiated by hypo or hyperglycemia. Some differences are also existing in the criteria used to appreciate the neuronal damage, as well as in the level of temperature and the site where it is measured. The mechanism of neuroprotection from moderate hypothermia seems to be not only a decrease in cerebral metabolism, but also involves a specific action on some intra-cellular events such as the blocking of the release of glutamate and of lipid peroxydation in brain tissue. An indirect proof of the neuroprotective effect of moderate hypothermia is the increase in the neuronal damage induced by moderate hyperthermia. It is conceivable that moderate hypothermia could exert a better neuroprotective effect than the drugs having this reputation, such as barbiturates, isoflurane and propofol.(ABSTRACT TRUNCATED AT 250 WORDS)