Understanding secondary injury

Secondary injury is a term applied to the destructive and self-propagating biological changes in cells and tissues that lead to their dysfunction or death over hours to weeks after the initial insult (the "primary injury"). In most contexts, the initial injury is usually mechanical. The more destructive phase of secondary injury is, however, more responsible for cell death and functional deficits. This subject is described and reviewed differently in the literature. To biomedical researchers, systemic and tissue-level changes such as hemorrhage, edema, and ischemia usually define this subject. To cell and molecular biologists, "secondary injury" refers to a series of predominately molecular events and an increasingly restricted set of aberrant biochemical pathways and products. These biochemical and ionic changes are seen to lead to death of the initially compromised cells and "healthy" cells nearby through necrosis or apoptosis. This latter process is called "bystander damage." These viewpoints have largely dominated the recent literature, especially in studies of the central nervous system (CNS), often without attempts to place the molecular events in the context of progressive systemic and tissue-level changes. Here we provide a more comprehensive and inclusive discussion of this topic.

Post-Traumatic Neural Depression and Neurobehavioral Recovery after Brain Injury

There are an estimated 2 million traumatic brain injuries (TBIs) each year in the United States, making the yearly incidence eight times greater than that of breast cancer and 34 times greater than HIV/AIDS. Still, it remains a "silent epidemic" because TBI results in persistent neurobehavioral impairment, without necessarily imparting a physical scar. The present review is a comparative analysis of TBI research, both basic and applied, outlining the evidence that at least one component of the brain's innate response to insult (e.g., post-traumatic neural depression) is sufficiently well understood to be the target of additional clinical studies and therapeutic strategy development.

Polyethylene glycol rapidly restores physiological functions in damaged sciatic nerves of guinea pigs

OBJECTIVE

We have studied the ability of the hydrophilic polymer polyethylene glycol (PEG) to anatomically and physiologically reconnect damaged axons of the adult guinea pig spinal cord. Here we have extended this approach to test whether completely severed guinea pig sciatic nerves in isolation could be fused and whether PEG was able to repair severe standardized crush injuries to sciatic nerves in vivo.

METHODS

The fusion test was performed with isolated sciatic nerves maintained in a double-sucrose gap recording chamber. For in vivo experiments, the sciatic nerve was surgically exposed in the hind leg of deeply anesthetized adult guinea pigs and was crushed proximal to its insertion in the gastrocnemius muscle. PEG was injected just beneath the epineurium with a 29-gauge needle, allowed to remain in the damaged axon region for 2 minutes, and removed. Sham-treated guinea pigs received an injection of water or Krebs' solution. Three indices of recovery were simultaneously monitored in response to electrical stimulation of the proximal nerve, i.e., 1) recovery of compound muscle action potentials (in millivolts), 2) contraction force of the muscle (in dynes), and 3) displacement of the muscle (in millimeters).

RESULTS

When isolated sciatic nerves were severed within the double-sucrose gap chamber, compound action potential propagation through the transection plane was eliminated. After abutment of the two segments and 2-minute PEG application to this site, variable compound action potential recovery was measured in all four cases. The crush injuries to the sciatic nerve in vivo eliminated the three functional responses to sciatic nerve stimulation in all animals. Within the first 30 minutes after treatment, only 1 of 12 control animals exhibited spontaneous recovery in any of these measures, compared with six of eight PEG-treated animals. By 45 minutes, two more sham-treated animals and one more PEG-treated animal had recovered at least one functional response. This difference in proportions between PEG-treated and sham-treated animals was statistically significant (P < or =0.02).

CONCLUSION

We conclude that these preliminary data suggest that PEG application may be a way to interfere with the steady dissolution of peripheral nerve fibers after mechanical damage and to even functionally fuse or reconnect severed proximal and distal segments.

Vigabatrin directed against kindled seizures following cortical insult: impact on epileptogenesis and somatosensory recovery

The anticonvulsant drug vigabatrin has not been found to be detrimental to the recovery process when administered following focal cortical insult. This finding is in contrast to the negative postinjury consequences of other anticonvulsant drugs (e.g., phenobarbital and diazepam) with more direct activation of the GABA/benzodiazepine receptor complex. Moreover, phenobarbital directed against kindled seizures affects functional recovery more adversely than either the drug or subconvulsive seizures alone. The purpose of the present study was to determine whether vigabatrin (150, 200, and 250 mg/kg) directed against kindled seizures would impact recovery from lesion-induced somatosensory deficits. Vigabatrin was coupled with daily electrical kindling of the amygdala during the first week after a unilateral anteromedial cortex (AMC) lesion. Somatosensory recovery was assessed using bilateral tactile stimulation tests. Animals receiving the highest dose of vigabatrin prior to electrical kindling (250 mg/kg vigabatrin/kindled) remained significantly impaired even after two months of testing relative to vehicle/kindled, kindled/250 mg/kg vigabatrin, which received vigabatrin after electrical kindling, and the 150, 200, and 250 mg/kg vigabatrin/nonkindled groups (p < 0.0001). In contrast, neither vigabatrin (at any of the doses tested) nor subconvulsive kindled seizures impacted the recovery process (p > 0.05) when administered alone (i.e., without the drug + seizure interaction). These data add to the accumulating experimental and clinical evidence suggesting that the neurobehavioral consequences of the interaction between anticonvulsant drugs and subclinical seizures after brain insult are detrimental to functional recovery.

Effects of sodium and chloride on neuronal survival after neurite transection

An in vitro investigation was undertaken to study the roles of Na+ and Cl- in mammalian spinal cord (SC) neuron deterioration and death after injury involving physical disruption of the plasma membrane. Individual SC neurons in monolayer cultures were subjected to UV laser microbeam transection of a primary dendrite. Neurons lesioned in modified ionic environments (MIEs) where 50%-75% of the NaCl was replaced with sucrose had higher survival (65%-75%) than neurons lesioned in medium with normal (125 mM) NaCl (28%; p < 0.001). Subsequent experiments found a comparable increase in lesioned neuron survival in MIEs in which only Na+ was replaced with specific ionic substitutes; however, replacement of Cl- was not protective. Electron microscope examinations of neurons fixed <16 min after lesioning showed a dramatic decrease in vesiculation of the smooth endoplasmic reticulum and Golgi apparatus in the low NaCl or low Na+ MIEs. It is hypothesized that Na+ entry after membrane disruption may stimulate elevation of [Ca+2]i leading to ultrastructural disruption and death of injured neurons. The results of these studies suggest that a low NaCl MIE may be useful as an irrigant to limit damage spread and cell death within CNS tissues during surgery or after trauma.

Phenobarbital administration directed against kindled seizures delays functional recovery following brain insult

Anti-convulsant drug administration or recurrent seizures can impact functional recovery following brain insult. The nature of that impact depends on a variety of factors, including timing of drug administration and drug mechanism of action, as well as seizure number, timing, and severity. The objective of this study was to determine the functional consequences of anti-convulsant administration directed against seizure activity in brain-damaged animals. To this end, phenobarbital was coupled with daily electrical kindling of the amygdala beginning 48 h after a unilateral anteromedial cortex lesion. Recovery from somatosensory deficits was assessed, as was regional atrophy and basic fibroblast growth factor (bFGF) expression. Animals receiving phenobarbital prior to daily kindling failed to recover within 2 months of testing. In contrast, animals receiving saline prior to kindling as well as phenobarbital-treated non-kindled animals recovered within 2 months after the lesion. Though the exact mechanisms underlying these behavioral phenomena remain uncertain, patterns of bFGF expression among the groups provide some insight. Taken together, results from the present study suggest that anti-convulsant drug administration directed against subclinical seizure activity can be more detrimental to functional recovery than seizures alone or anti-convulsant drug treatment after seizure activity has occurred.

In vitro central nervous system models of mechanically induced trauma: a review

Injury is one of the leading causes of death among all people below the age of 45 years. In the United States, traumatic brain injury (TBI) and spinal cord injury (SCI) together are responsible for an estimated 90,000 disabled persons annually. To improve treatment of the patient and thereby decrease the associated mortality, morbidity, and cost, several in vivo models of central nervous system (CNS) injury have been developed and characterized over the past two decades. To complement the ability of these in vivo models to reproduce the sequelae of human CNS injury, in vitro models of neuronal injury have also been developed. Despite the inherent simplifications of these in vitro systems, many aspects of the posttraumatic sequelae are faithfully reproduced in cultured cells, including ultrastructural changes, ionic derangements, alterations in electrophysiology, and free radical generation. This review presents a number of these in vitro systems, detailing the mechanical stimuli, the types of tissue injured, and the in vivo injury conditions most closely reproduced by the models. The data generated with these systems is then compared and contrasted with data from in vivo models of CNS injury. We believe that in vitro models of mechanical injury will continue to be a valuable tool to study the cellular consequences and evaluate the potential therapeutic strategies for the treatment of traumatic injury of the CNS.

Increased jun immunoreactivity in an in vitro model of mammalian spinal neuron physical injury

Dendrites were transected from murine spinal neurons. Unlesioned neurons showed dark nucleolar and patchy cytoplasmic jun immunostaining. By 0.5 and 2 h, most lesioned neurons stained intensely throughout the soma. However, at 24 h only dead neurons displayed intense somal staining, and 100% of the surviving cells stained like unlesioned controls. Correlation of immunostaining patterns with viability, injury, and death suggests jun gene expression may influence the survival of neurons after physical injury.