Ischemic postconditioning fails to protect against neonatal cerebral stroke

Roles of Nitric Oxide in Brain Ischemia and Reperfusion

Brain ischemia and reperfusion (I/R) is one of the most severe clinical manifestations of ischemic stroke, placing a significant burden on both individuals and society. The only FDA-approved clinical treatment for ischemic stroke is tissue plasminogen activator (t-PA), which rapidly restores cerebral blood flow but can have severe side effects. The complex pathological process of brain I/R has been well-established in the past few years, including energy metabolism disorders, cellular acidosis, doubling of the synthesis or release of excitotoxic amino acids, intracellular calcium homeostasis, free radical production, and activation of apoptotic genes. Recently, accumulating evidence has shown that NO may be strongly related to brain I/R and involved in complex pathological processes. This review focuses on the role of endogenous NO in pathological processes in brain I/R, including neuronal cell death and blood brain barrier disruption, to explore how NO impacts specific signaling cascades and contributes to brain I/R injury. Moreover, NO can rapidly react with superoxide to produce peroxynitrite, which may also mediate brain I/R injury, which is discussed here. Finally, we reveal several therapeutic approaches strongly associated with NO and discuss their potential as a clinical treatment for ischemic stroke.

Cerebral Vasodilator Property of Poly(ADP-Ribose) Polymerase Inhibitor (PJ34) in the Neonatal and Adult Mouse Is Mediated by the Nitric Oxide Pathway

The poly(ADP-ribose) polymerase (PARP) inhibitor PJ34 has been reported to improve endothelial dysfunction in the peripheral system. We addressed the role of PJ34 on the vascular tone and vasoreactivity during development in the mouse brain. Blood flows were measured in the basilar trunk using ultrasonography. Cerebral vasoreactivity or vasodilation reserve was estimated as a percentage increase in mean blood flow velocities (mBFV) recorded under normoxia-hypercapnia in control and after PJ34 administration. Non-selective and selective eNOS and nNOS inhibitors were used to evaluate the role of NO-pathway into the hemodynamic effects of PJ34. PJ34 increased mBFVs from 15.8 ± 1.6 to 19.1 ± 1.9 cm/s (p = 0.0043) in neonatal, from 14.6 ± 1.4 to 16.1 ± 0.9 cm/s (p = 0.0049) in adult, and from 15.7 ± 1.7 to 17.5 ± 2.0 cm/s (p = 0.0024) in aged mice 48 h after administration. These PJ34 values were similar to those measured in age-matched control mice under normoxia-hypercapnia. This recruitment was mediated through the activation of constitutive NO synthases in both the neonatal (38.2 ± 6.7 nmol/min/mg protein) and adult (31.5 ± 4.4 nmol/min/mg protein) brain, as compared to age-matched control brain (6.9 ± 0.4 and 6.3 ± 0.7 nmol/min/mg protein), respectively. In addition, quite selective eNOS inhibitor was able to inhibit the recruitment. PJ34 by itself is able to increase cerebral blood flow through the NO-pathway activation at least over 48 h after a single administration.

Positive and negative conditioning in the neonatal brain

Brain injury in the perinatal period occurs in many clinical settings, e.g. hypoxic-ischemic encephalopathy (HIE) in term infants, neonatal stroke, encephalopathy of prematurity, and infections. These insults often result in life-long disabilities including cerebral palsy, cognitive deficits, visual dysfunction, hearing impairments, and epilepsy. However, the success of clinical implementation of a broad array of potential neuroprotective strategies tested experimentally has been limited with the exception of therapeutic hypothermia (TH) used within hours of birth in term human babies with mild to moderate HIE. There is an extensive search for adjuvant therapeutic approaches to enhance the outcomes. One strategy is to modify susceptibility in the developing CNS by means of preconditioning or postconditioning using sublethal stress. The pre-clinical and clinical literature has shown that CNS immaturity at the time of ischemic insult plays a central role in the response to injury. Thus, better understanding of the molecular regulation of the endogenous vulnerability of the immature brain is needed. Further, the use of sublethal stressors of different origin may help shed light on mechanistic similarities and distinctions beween conditioning strategies. In this review we discuss the mechanisms of protection that are achieved by an interplay of changes on the systemic level and brain level, and via changes of intracellular and mitochondrial signaling. We also discuss the barriers to improving our understanding of how brain immaturity and the type of insult-hypoxic, ischemic or inflammatory-affect the efficacy of conditioning efforts in the immature brain.

A Model of Perinatal Ischemic Stroke in the Rat: 20 Years Already and What Lessons?

Neonatal hypoxia-ischemia (HI) and ischemia are a common cause of neonatal brain injury resulting in cerebral palsy with subsequent learning disabilities and epilepsy. Recent data suggest a higher incidence of focal ischemia-reperfusion located in the middle cerebral artery (MCA) territory in near-term and newborn babies. Pre-clinical studies in the field of cerebral palsy research used, and still today, the classical HI model in the P7 rat originally described by Rice et al. (1). At the end of the 90s, we designed a new model of focal ischemia in the P7 rat to explore the short and long-term pathophysiology of neonatal arterial ischemic stroke, particularly the phenomenon of reperfusion injury and its sequelae (reported in 1998). Cerebral blood-flow and cell death/damage correlates have been fully characterized. Pharmacologic manipulations have been applied to the model to test therapeutic targets. The model has proven useful for the study of seizure occurrence, a clinical hallmark for neonatal ischemia in babies. Main pre-clinical findings obtained within these 20 last years are discussed associated to clinical pattern of neonatal brain damage.

Controlled arterial reflow after ischemia induces better outcomes in the juvenile rat brain

Our objective was to determine whether controlled reflow on one side and/or the other side after bilateral carotid occlusion release could reduce cell death in focal ischemic P14 rats. Arterial blood flow was measured using ultrasonography. Cell death, inflammation and nitrotyrosine were measured using immunofluorescence. When reflow was first induced in the contralateral side, we observed improved outcome markers compared with those when reflow was first induced in the ipsilateral side and/or simultaneous reflow was induced in both sides. Our data suggest that progressive rerouting of arterial flow through the circle of Willis toward the ischemic site reduced cell death.

Ischemic postconditioning in cerebral ischemia: Differences between the immature and mature brain?

Ischemic postconditioning (postC), defined as serial mechanical interruptions of blood flow at reperfusion, effectively reduces myocardial infarct size in all species tested so far, including humans. In the brain, ischemic postC leads to controversial results regardless of variations in factors such as onset time of beginning, the duration of ischemia and/or reperfusion, and the number of cycles of occlusion/reperfusion. Thus, many major issues remain to be resolved regarding its protective effects. Future studies should aim to identify the parameters that yield the strongest protection, as well as to understand why the efficacy of ischemic postC differs between models. This review will focus on initial hemodynamic changes and their consequences, and on specific features such as NO-dependent vascular tone and/or prolonged acidosis in cerebral ischemia-reperfusion in order to better understand the dynamics of ischemic postC in the developing brain.

Preconditioning provides neuroprotection in models of CNS disease: paradigms and clinical significance

Preconditioning is a phenomenon in which brief episodes of a sublethal insult induce robust protection against subsequent lethal injuries. Preconditioning has been observed in multiple organisms and can occur in the brain as well as other tissues. Extensive animal studies suggest that the brain can be preconditioned to resist acute injuries, such as ischemic stroke, neonatal hypoxia/ischemia, surgical brain injury, trauma, and agents that are used in models of neurodegenerative diseases, such as Parkinson's disease and Alzheimer's disease. Effective preconditioning stimuli are numerous and diverse, ranging from transient ischemia, hypoxia, hyperbaric oxygen, hypothermia and hyperthermia, to exposure to neurotoxins and pharmacological agents. The phenomenon of "cross-tolerance," in which a sublethal stress protects against a different type of injury, suggests that different preconditioning stimuli may confer protection against a wide range of injuries. Research conducted over the past few decades indicates that brain preconditioning is complex, involving multiple effectors such as metabolic inhibition, activation of extra- and intracellular defense mechanisms, a shift in the neuronal excitatory/inhibitory balance, and reduction in inflammatory sequelae. An improved understanding of brain preconditioning should help us identify innovative therapeutic strategies that prevent or at least reduce neuronal damage in susceptible patients. In this review, we focus on the experimental evidence of preconditioning in the brain and systematically survey the models used to develop paradigms for neuroprotection, and then discuss the clinical potential of brain preconditioning.

Sildenafil mediates blood-flow redistribution and neuroprotection after neonatal hypoxia-ischemia

BACKGROUND AND PURPOSE

The best conceivable treatment for hypoxia-ischemia (HI) is the restoration of blood flow to the hypoxic-ischemic region(s). Our objective was to examine whether boosting NO-cGMP signaling using sildenafil citrate, a phosphodiesterase-type 5 inhibitor, could modify cerebral blood flow and reduce lesions in the developing brain.

METHODS

HI was induced in P7 Sprague-Dawley rats by unilateral carotid artery occlusion and hypoxia, and followed by either PBS or sildenafil. Blood-flow velocities were measured by ultrasound imaging with sequential Doppler recordings to evaluate collateral recruitment. Cell death, blood-brain barrier integrity, and glial activation were analyzed by immunohistochemistry. Motor behavior was evaluated using an open-field device adapted to neonatal animals.

RESULTS

Sildenafil citrate (10 mg/kg) induced collateral patency, reduced terminal dUTP nick-end labeling-positive cells, reactive astrogliosis, and macrophage/microglial activation at 72 hours and 7 days post-HI. Sildenafil also reduced the number of terminal dUTP nick-end labeling-positive endothelial cells within lesion site. Seven days after HI and sildenafil treatment, tissue loss was significantly reduced, and animals recovered motor coordination.

CONCLUSIONS

Our findings strongly indicate that sildenafil citrate treatment, associated with a significant increase in cerebral blood flow, reduces HI damage and improves motor locomotion in neonatal rats. Sildenafil may represent an interesting therapeutic strategy for neonatal neuroprotection.