Temporal changes in sensitivity of rats to cerebral ischemic insult

Ruscogenin timing administration mitigates cerebral ischemia-reperfusion injury through regulating circadian genes and activating Nrf2 pathway

BACKGROUND

Ruscogenin (Rus), a steroidal sapogenin extracted from Ophiopogon japonicus (L. f.) Ker-Gawl., has the effect of alleviating cerebral ischemia-reperfusion injury (IRI), acute lung injury. At present, the chronopharmacological effects of Rus are still unknown.

PURPOSE

This study explored the alleviating effect and mechanism of Rus timing administration on mice cerebral IRI.

METHODS

The animals in different groups were administrated Rus (10 mg/kg) by gavage at four time points (23:00-01:00, 05:00-07:00, 11:00-13:00, 17:00-19:00) respectively for 3 days. On the 4th day, middle cerebral artery occlusion (MCAO) surgery was operated during 5:00-7:00. Behavioral tests were executed and the brain was collected for infarct volume, qPCR and immunoblot detection. The levels of tumor necrosis factor-α (TNF-α), interleukin 6 (IL-6), interleukin-1beta (IL-1β) and inducible nitric oxide synthase (iNOS) were detected by qPCR. Glutathione (GSH), superoxide dismutase (SOD) activity and malondialdehyde (MDA) content in serum and cerebral cortex were detected. The clock genes were tested by western blot. Based on these results, 17:00-19:00 was selected to administrate Rus for further mechanism study and Nrf2 blocker group was administrated all-trans-retinoic acid (ATRA) at 14:00 for 3 days.

RESULTS

Administration of Rus reduced cerebral infarcted volume, ameliorated the behavior score and upregulated the mRNA and protein expression of Per1, Bmal1, Clock, Rev-erbα, transcription factor nuclear factor erythroid 2-related factor 2 (Nrf2), heme oxygenase-1 (HO-1), quinone oxidoreductase 1 (NQO1). Administration of Rus during 17:00-19:00 had better preventive effect than other three time points. Combined administration of ATRA blunted the preventive effect of Rus.

CONCLUSION

The preventive effect of Rus is affected by the time of administration, which was regulated by Nrf2 pathway. Taken together, we provide solid evidence to suggest that different administration time point affect the effectiveness of Rus in alleviating IRI.

Rev-erbα agonist SR9009 protects against cerebral ischemic injury through mechanisms involving Nrf2 pathway

Backgrounds: The circadian clock protein Rev-erbα is a crucial regulator of circadian rhythms that affects multiple molecular, cellular, and physiology pathways that control susceptibility, injury, and recovery in the neurological disorders. Emerging evidence suggest that Rev-erbα plays a key role in the inflammation and oxidative stress, two pivotal mechanisms in the pathogenesis, progression, and recovery process of ischemic stroke. However, it remains inconclusive whether Rev-erbα activation is protective against ischemic brain damage. Nuclear factor erythroid 2-related factor 2 (Nrf2) pathway, a master regulator of inflammatory and oxidative responses. Our study aimed to determine whether pharmacological activation of Rev-erbα by SR9009 protects against acute ischemic brain damage partly via Nrf2 pathway.

Methods: Adult mice were pretreated with SR9009 or Nrf2 inhibitor all-trans-retinoic acid (ATRA) for 3 days prior to Sham or middle cerebral artery occlusion (MCAO) operation. After ischemia for 1 h and reperfusion for 24 h, the neurological function and cerebral infarction volume were determined, superoxide dismutase (SOD) activity, malondialdehyde (MDA) content and glutathione peroxidase (GSH-PX) activity in serum were detected by kit. The mRNA and/or protein level of tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), inducible nitric oxide synthase (iNOS), Period (Per)1, Brain and muscle arnt-like1 (Bmal1), Circadian locomotor output cycles kaput (Clock), Rev-erbα, Nrf2, heme oxygenase-1 (HO-1) and quinone oxidoreductase 1 (NQO1) in cerebral cortex were detected by q-PCR and Western blot.

Results: We confirmed that SR9009 activated Rev-erbα gene in the cerebral cortex under basal condition. At 24 h after reperfusion, SR9009 ameliorated acute neurological deficits, reduced infarct volume. Meanwhile, the inflammatory TNF-α, IL-1β, iNOS and MDA content levels were significant decreased, SOD and GSH-PX activity were obviously increased, which were markedly blunted (or abolished) by ATRA. SR9009 enhanced the induction of Nrf2 and its downstream target genes HO-1 and NQO1 after ischemic insult. In addition, we found that SR9009 restored Rev-erbα, Bmal1, Clock, Per1 genes expression in the cerebral cortex under ischemic condition.

Conclusion: Taken together, Rev-erbα activation by SR9009 protects against ischemic stroke damage, at least, partly through Nrf2 pathway.

Association between the time of day at stroke onset and functional outcome of acute ischemic stroke patients treated with endovascular therapy

To investigate the association between time-of-day of stroke onset and functional outcome in patients with acute ischemic stroke(AIS) treated with endovascular thrombectomy(EVT). AIS patients treated with EVT between January 2013 and December 2018 were recruited and divided them into four 6-h interval groups according to the time-of-day of stroke onset. A total of 438 patients were enrolled, 3-month favorable outcome were achieved in 58.6%, 43.7%, 36.6%, and 30.5% of patients in the 00:00-06:00, 06:00-12:00, 12:00-18:00, and 18:00-24:00 groups, respectively (adjusted OR 0.61, 95% CI 0.40-0.93; p = 0.020). Compared with the 18:00-24:00 interval, patients in the 00:00-06:00 interval (adjusted OR 4.01, 95%CI 1.02-15.80, p = 0.047) and the 06:00-12:00 interval (adjusted OR 3.24, 95% CI 1.09-9.64, p = 0.034) were more likely to achieve favorable outcome. The time-of-day of stroke onset was not associated with 3-month mortality (adjusted p = 0.829), symptomatic intracerebral hemorrhage (sICH, adjusted p = 0.296), or early successful recanalization (adjusted p = 0.074). In conclusion, in AIS patients treated with EVT, those onsets either between 00:00 and 06:00 or between 06:00 and 12:00 appeared to be associated with a higher proportion of favorable outcomes at 3 months, but the time-of-day at stroke onset was not associated with the incidence of sICH, rate of early successful recanalization, or 3-month mortality.

Aging Is Associated With Lower Neuroactive Steroids and Worsened Outcomes Following Cerebral Ischemia in Male Mice

Ischemic stroke is a leading cause of disability and death, and aging is the main nonmodifiable risk factor. Following ischemia, neuroactive steroids have been shown to play a key role in cerebroprotection. Thus, brain steroid concentrations at the time of injury as well as their regulation after stroke are key factors to consider. Here, we investigated the effects of age and cerebral ischemia on steroid levels, behavioral outcomes, and neuronal degeneration in 3- and 18-month-old C57BL/6JRj male mice. Ischemia was induced by middle cerebral artery occlusion for 1 hour followed by reperfusion (MCAO/R) and analyses were performed at 6 hours after MCAO. Extended steroid profiles established by gas chromatography coupled with tandem mass spectrometry revealed that (1) brain and plasma concentrations of the main 5α-reduced metabolites of progesterone, 11-deoxycorticosterone, and corticosterone were lower in old than in young mice; (2) after MCAO/R, brain concentrations of progesterone, 5α-dihydroprogesterone, and corticosterone increased in young mice; and (3) after MCAO/R, brain concentrations of 5α-reduced metabolites of progesterone, 3α5α-tetrahydrodeoxycorticosterone, and 3β5α-tetrahydrodeoxycorticosterone were lower in old than in young mice. After ischemia, old mice showed increased sensori-motor deficits and more degenerating neurons in the striatum than young mice. Altogether, these findings strongly suggest that the decreased capacity of old mice to metabolize steroids toward the 5α-reduction pathway comparatively to young mice may contribute to the worsening of their stroke outcomes.

Limited changes in locomotor recovery and unaffected white matter sparing after spinal cord contusion at different times of day

The circadian gene expression rhythmicity drives diurnal oscillations of physiological processes that may determine the injury response. While outcomes of various acute injuries are affected by the time of day at which the original insult occurred, such influences on recovery after spinal cord injury (SCI) are unknown. We report that mice receiving moderate, T9 contusive SCI at ZT0 (zeitgeber time 0, time of lights on) and ZT12 (time of lights off) showed similar hindlimb function recovery in the Basso mouse scale (BMS) over a 6 week post-injury period. In an independent study, no significant differences in BMS were observed after SCI at ZT18 vs. ZT6. However, the ladder walking test revealed modestly improved performance for ZT18 vs. ZT6 mice at week 6 after injury. Consistent with those minor effects on functional recovery, terminal histological analysis revealed no significant differences in white matter sparing at the injury epicenter. Likewise, blood-spinal cord barrier disruption and neuroinflammation appeared similar when analyzed at 1 week post injury at ZT6 or ZT18. Therefore, locomotor recovery after thoracic contusive SCI is not substantively modulated by the time of day at which the neurotrauma occurred.

Effects of time-of-day on the concentration of defined excitatory and inhibitory amino acids in the cerebrospinal fluid of rats: a microdialysis study

Amino acid neurotransmitters are responsible for many physiological and pathological processes, and their cerebral concentrations respond to external influences such as the light-dark cycle and to the synthesis, release, and recapture rhythms and form part of the biochemical relationships derived from excitatory-inhibitory (E/I), glutamine-glutamate sum (GLX), glutamatergic processing (glutamine-glutamate ratio) and excitotoxic indexes. The changes in these variables during a 24-h period (1 day) are important because they allow organisms to adapt to external stimuli and form part of physiological processes. Under pathological conditions, the damage produced by acute events may depend on diurnal variations. Therefore, it is important to analyze the extracellular levels of amino acids as well as the above-mentioned indexes over a 24-h period. We focused on determining the cerebrospinal fluid levels of different amino acid neurotransmitters, and the E/I, GLX, glutamatergic processing and excitotoxic indexes, determined by microdialysis over a 24-h cycle. Our results showed significant changes during the 24-h light/dark cycle. Specifically, we found increments in the levels of glutamate (325%), GABA (550%), glutamine (300%), glycine (194%), alanine (304%) and the GLX index (263%) throughout the day, and the maximum levels of glutamate, glutamine, glycine, and alanine were obtained during the last period of the light period. In conclusion, the concentration of some amino acid neurotransmitters and the GLX index show variations depending on the light-dark cycle.

Diurnal Variation Induces Neurobehavioral and Neuropathological Differences in a Rat Model of Traumatic Brain Injury

Traumatic brain injury (TBI) induces two types of brain damage: primary and secondary. Damage initiates a series of pathophysiological processes, such as metabolic crisis, excitotoxicity with oxidative stress-induced damage, and neuroinflammation. The long-term perpetuation of these processes has deleterious consequences for neuronal function. However, it remains to be elucidated further whether physiological variation in the brain microenvironment, depending on diurnal variations, influences the damage, and consequently, exerts a neuroprotective effect. Here, we established an experimental rat model of TBI and evaluated the effects of TBI induced at two different time points of the light–dark cycle. Behavioral responses were assessed using a 21-point neurobehavioral scale and the cylinder test. Morphological damage was assessed in different regions of the central nervous system. We found that rats that experienced a TBI during the dark hours had better behavioral performance than those injured during the light hours. Differences in behavioral performance correlated with less morphological damage in the perilesional zone. Moreover, certain brain areas (CA1 and dentate gyrus subregions of the hippocampus) were less prone to damage in rats that experienced a TBI during the dark hours. Our results suggest that diurnal variation is a crucial determinant of TBI outcome, and the hour of the day at which an injury occurs should be considered for future research.

Potential circadian effects on translational failure for neuroprotection

Neuroprotectant strategies that have worked in rodent models of stroke have failed to provide protection in clinical trials. Here we show that the opposite circadian cycles in nocturnal rodents versus diurnal humans^1,2 may contribute to this failure in translation. We tested three independent neuroprotective approaches-normobaric hyperoxia, the free radical scavenger α-phenyl-butyl-tert-nitrone (αPBN), and the N-methyl-D-aspartic acid (NMDA) antagonist MK801-in mouse and rat models of focal cerebral ischaemia. All three treatments reduced infarction in day-time (inactive phase) rodent models of stroke, but not in night-time (active phase) rodent models of stroke, which match the phase (active, day-time) during which most strokes occur in clinical trials. Laser-speckle imaging showed that the penumbra of cerebral ischaemia was narrower in the active-phase mouse model than in the inactive-phase model. The smaller penumbra was associated with a lower density of terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL)-positive dying cells and reduced infarct growth from 12 to 72 h. When we induced circadian-like cycles in primary mouse neurons, deprivation of oxygen and glucose triggered a smaller release of glutamate and reactive oxygen species, as well as lower activation of apoptotic and necroptotic mediators, in 'active-phase' than in 'inactive-phase' rodent neurons. αPBN and MK801 reduced neuronal death only in 'inactive-phase' neurons. These findings suggest that the influence of circadian rhythm on neuroprotection must be considered for translational studies in stroke and central nervous system diseases.

Time-of-Day Dependent Neuronal Injury After Ischemic Stroke: Implication of Circadian Clock Transcriptional Factor Bmal1 and Survival Kinase AKT

Occurrence of stroke cases displays a time-of-day variation in human. However, the mechanism linking circadian rhythm to the internal response mechanisms against pathophysiological events after ischemic stroke remained largely unknown. To this end, temporal changes in the susceptibility to ischemia/reperfusion (I/R) injury were investigated in mice in which the ischemic stroke induced at four different Zeitgeber time points with 6-h intervals (ZT0, ZT6, ZT12, and ZT18). Besides infarct volume and brain swelling, neuronal survival, apoptosis, ischemia, and circadian rhythm related proteins were examined using immunohistochemistry, Western blot, planar surface immune assay, and liquid chromatography-mass spectrometry tools. Here, we present evidence that midnight (ZT18; 24:00) I/R injury in mice resulted in significantly improved infarct volume, brain swelling, neurological deficit score, neuronal survival, and decreased apoptotic cell death compared with ischemia induced at other time points, which were associated with increased expressions of circadian proteins Bmal1, PerI, and Clock proteins and survival kinases AKT and Erk-1/2. Moreover, ribosomal protein S6, mTOR, and Bad were also significantly increased, while the levels of PRAS40, negative regulator of AKT and mTOR, and phosphorylated p53 were decreased at this time point compared to ZT0 (06:00). Furthermore, detailed proteomic analysis revealed significantly decreased CSKP, HBB-1/2, and HBA levels, while increased GNAZ, NEGR1, IMPCT, and PDE1B at midnight as compared with early morning. Our results indicate that nighttime I/R injury results in less severe neuronal damage, with increased neuronal survival, increased levels of survival kinases and circadian clock proteins, and also alters the circadian-related proteins.

Pretreatment ADC Values Predict Response to Radiosurgery in Vestibular Schwannomas

BACKGROUND AND PURPOSE

The response rate of vestibular schwannomas to radiation therapy is variable, and there are surgical options available in the event of treatment failure. The aim of this study was to determine whether pre- and posttreatment ADC values can predict the tumor response to radiation therapy.

MATERIALS AND METHODS

From a data base of 162 patients with vestibular schwannomas who underwent radiation therapy with gamma knife, CyberKnife, or fractionated stereotactic radiation therapy as the first-line therapy between January 2003 and December 2013, we found 20 patients who had pretreatment ADC values. There were 108 patients (including these 20) had serial MR images that included DWI allowing calculated ADC values from 2-132 months after radiation therapy. Two reviewers measured the mean, minimum, and maximum ADC values from elliptical ROIs that included tumor tissue only. Treatment responders were defined as those with a tumor total volume shrinkage of 20% or more after radiation therapy.

RESULTS

The pretreatment mean minimum ADC for nonresponders was 986.7 × 10^-6 mm²/s (range, 844-1230 × 10^-6 mm²/s) and it was 669.2 × 10^-6 mm²/s (range, 345-883 × 10^-6 mm²/s) for responders. This difference was statistically significant (P < .001). Using a minimum ADC value of 800 × 10^-6 mm²/s led to the correct classification of 18/20 patients based on pretreatment ADC values. The intraclass correlation between reviewers was 0.61. No posttreatment ADC values predicted response.

CONCLUSIONS

Pretreatment ADC values of vestibular schwannomas are lower in responders than nonresponders. Using a minimum ADC value of 800 × 10^-6 mm²/s correctly classified 90% of cases.

3D quantitative assessment of response to fractionated stereotactic radiotherapy and single-session stereotactic radiosurgery of vestibular schwannoma

OBJECTIVES

To determine clinical outcome of patients with vestibular schwannoma (VS) after treatment with fractionated stereotactic radiotherapy (FSRT) and single-session stereotactic radiosurgery (SRS) by using 3D quantitative response assessment on MRI.

MATERIALS

This retrospective analysis included 162 patients who underwent radiation therapy for sporadic VS. Measurements on T1-weighted contrast-enhanced MRI (in 2-year post-therapy intervals: 0-2, 2-4, 4-6, 6-8, 8-10, 10-12 years) were taken for total tumour volume (TTV) and enhancing tumour volume (ETV) based on a semi-automated technique. Patients were considered non-responders (NRs) if they required subsequent microsurgical resection or developed radiological progression and tumour-related symptoms.

RESULTS

Median follow-up was 4.1 years (range: 0.4-12.0). TTV and ETV decreased for both the FSRT and SRS groups. However, only the FSRT group achieved significant tumour shrinkage (p < 0.015 for TTV, p < 0.005 for ETV over time). The 11 NRs showed proportionally greater TTV (median TTV pre-treatment: 0.61 cm(3), 8-10 years after: 1.77 cm(3)) and ETV despite radiation therapy compared to responders (median TTV pre-treatment: 1.06 cm(3); 10-12 years after: 0.81 cm(3); p = 0.001).

CONCLUSION

3D quantification of VS showed a significant decrease in TTV and ETV on FSRT-treated patients only. NR had significantly greater TTV and ETV over time.

KEY POINTS

Only FSRT not GK-treated patients showed significant tumour shrinkage over time. Clinical non-responders showed significantly less tumour shrinkage when compared to responders. 3D volumetric assessment of vestibular schwannoma shows advantages over unidimensional techniques.

Does the neuroprotective role of anandamide display diurnal variations?

The endocannabinoid system is a component of the neuroprotective mechanisms that an organism displays after traumatic brain injury (TBI). A diurnal variation in several components of this system has been reported. This variation may influence the recovery and survival rate after TBI. We have previously reported that the recovery and survival rate of rats is higher if TBI occurs at 1:00 than at 13:00. This could be explained by a diurnal variation of the endocannabinoid system. Here, we describe the effects of anandamide administration in rats prior to the induction of TBI at two different times of the day: 1:00 and 13:00. We found that anandamide reduced the neurological damage at both times. Nevertheless, its effects on bleeding, survival, food intake, and body weight were dependent on the time of TBI. In addition, we analyzed the diurnal variation of the expression of the cannabinoid receptors CB1R and CB2R in the cerebral cortex of both control rats and rats subjected to TBI. We found that CB1R protein was expressed more during the day, whereas its mRNA level was higher during the night. We did not find a diurnal variation for the CB2R. In addition, we also found that TBI increased CB1R and CB2R in the contralateral hemisphere and disrupted the CB1R diurnal cycle.

Lesion size and behavioral deficits after endothelin-1-induced ischemia are not dependent on time of day

BACKGROUND

The occurrence of stroke exhibits a strong circadian pattern with a peak in the morning hours after waking. The factors that influence this pattern of stroke prevalence may confer varying degrees of neuroprotection and therefore influence stroke severity. This question is difficult to address in clinical cases because of the variability in the location and duration of the ischemic event.

METHODS

The purpose of this study was to determine if time of day affected the severity of stroke targeting the motor cortex in rats. Strokes were produced using topical application of the vasoconstrictor endothelin-1 to motor cortex of unanesthetized animals at 2 time points: early day and early night. Behavioral deficits were measured using reaching, cylinder, and horizontal ladder tasks, and the volume of the lesion was quantified.

RESULTS

Behavior on reaching and horizontal ladder tasks were both severely impaired by endothelin-1 treatment compared to vehicle-treated animals, but deficits did not differ according to time of treatment. Similarly, while endothelin-1 produced larger lesions of the motor cortex than did vehicle treatment, the size of the lesion did not differ according to time of treatment.

CONCLUSIONS

These results suggest that while many factors under circadian control can influence the prevalence of stroke, the magnitude of lesion and behavioral deficit resulting from an ischemic event may not be influenced by time of day.

Tumor pseudoprogression following radiosurgery for vestibular schwannoma

We sought to characterize vestibular schwannoma (VS) pseudoprogression after radiosurgery to assess its incidence, causative factors, and association with radiation-induced adverse effects. We performed a retrospective study of VS treated with Gamma Knife radiosurgery during 2005-2009. Seventy-five patients had at least 24 months of clinical and radiographic follow-up (median, 29 months) and were included. Tumor response was calculated volumetrically using Gamma plan software on consecutive MRIs. All treatment plans were reviewed for dosimetry characteristics. Forty-nine VS (65%) were stable or regressed after treatment. Seventeen (23%) underwent pseudoprogression, with onset of enlargement at 6 months. Seven (9%) remained larger than initial treatment volume at last follow-up. Nine (12%) had persistent growth. Three patients underwent subsequent microsurgery. One patient required intervention at 3 months for cystic enlargement; otherwise, all patients with progressive enlargement had stable VS until at least 24 months. Twenty-six patients (34.7%) developed nonauditory adverse radiation effects after treatment, including cranial neuropathy, ataxia, and hydrocephalus. There was no statistical association between onset of clinical deterioration and tumor response. Volume changes in the first 24 months after radiosurgery rarely herald treatment failure. Any volume change after 24 months is indicative of treatment failure. Pseudoprogression does not appear to be independently linked to radiation-induced morbidity, and there are no patient-related or radiosurgical parameters that predict tumor response.

Different strokes for different folks: the rich diversity of animal models of focal cerebral ischemia

No single animal model is able to encompass all of the variables known to affect human ischemic stroke. This review highlights the major strengths and weaknesses of the most commonly used animal models of acute ischemic stroke in the context of matching model and experimental aim. Particular emphasis is placed on the relationships between outcome and underlying vascular variability, physiologic control, and use of models of comorbidity. The aim is to provide, for novice and expert alike, an overview of the key controllable determinants of experimental stroke outcome to help ensure the most effective application of animal models to translational research.

Dosing time-dependent actions of psychostimulants

The concept of the dosing time-dependent (DTD) actions of drugs has been used to describe the effects of diurnal rhythms on pharmacological responsiveness. Notwithstanding the importance of diurnal variability in drug pharmacokinetics and bioavailability, it appears that in the central nervous system (CNS), the DTD actions of psychotropic drugs involve diurnal changes in the CNS-specific expression of genes encoding for psychotropic drug targets and transcription factors known as clock genes. In this review, we focused our discussion on the DTD effects of the psychostimulants cocaine and amphetamines. Both cocaine and amphetamines produce differential lasting behavioral alterations, that is, locomotor sensitization, depending on the time of the day they are administered. This exemplifies a DTD action of these drugs. The DTD effects of these psychostimulants correlate with diurnal changes in the system of transcription factors termed clock genes, for example, Period 1, and with changes in the availability of certain subtypes of dopamine receptors, for example, D2 and D3. Diurnal synthesis and release of the pineal hormone melatonin influence the DTD behavioral actions of cocaine and amphetamines. The molecular mechanism of melatonin's effects on the responsiveness of CNS to psychostimulants appears to involve melatonin receptors and clock genes. It is proposed that the DTD characteristics of psychostimulant action and the contributions of the melatonergic system may have clinical implications that include treatments for the attention deficit hyperactivity disorder and possibly neurotoxicity/neuroprotection.

Abrupt shift of the pattern of diurnal variation in stroke onset with daylight saving time transitions

BACKGROUND

Stroke onset shows a pattern of diurnal variation, with a peak in morning hours. Rhythmic changes in blood pressure, hormones, and other parameters have been suggested as underlying mechanisms, but exogenous factors such as increasing physical activity after awakening may also be of relevance. To characterize the impact of external clock changes on the rhythmic variation in stroke onset, this parameter was recorded in patients during transition periods into and out of Daylight Saving Time (DST).

METHODS AND RESULTS

The present study was based on a prospective stroke registry in Germany that contains time points of stroke onset from 44 251 patients admitted between 2000 and 2005. To achieve a uniform timeline, time points of stroke onset were set back from Central European Summer Time (CEST) to Central European Time (CET) for patients admitted during DST periods. Compared with the last week before the clock change, transition to or from DST resulted in an immediate shift of stroke onset time points within the first week after the clock change in reference to the uniform timeline (transition from CET to CEST -60 minutes for the time points in both the 25th and 50th percentiles of the diurnal pattern, P<0.001; transition from CEST to CET +60 minutes for the time points in both the 25th and 50th percentiles, P<0.001; patients pooled on a weekly basis). A significant shift was already present the first and second day after the transitions (ie, Monday and Tuesday).

CONCLUSIONS

Transition to or from DST is coupled with an immediate shift in the time pattern of stroke onset. This strengthens the idea that exogenous factors associated with awakening are important determinants of the pattern of diurnal variation of stroke onset, because entrainment of the human circadian clock within hours is unlikely.

Tumor-volume changes after radiosurgery for vestibular schwannoma: implications for follow-up MR imaging protocol

BACKGROUND AND PURPOSE

The outcome of radiosurgery for vestibular schwannoma (VS) is assessed by posttreatment measurement of tumor size and could be influenced by the timing and quality of the assessment. This study evaluates the volumetric changes of VS after radiosurgery and proposes a radiologic follow-up program.

MATERIALS AND METHODS

Of 142 patients with VS treated with radiosurgery, we selected patients who were followed at least 3 times during a minimum of 32 months with a T1-weighted gadolinium-enhanced high-resolution 3D MR imaging examination identical to the pretreatment MR imaging. Forty-five patients were identified with a mean follow-up of 50 months (range, 32-78 months). Pre- and posttreatment tumor volumes were calculated by using BrainSCAN software by manually contouring tumors on each MR imaging study. Volume changes of >13% were defined as events.

RESULTS

At last follow-up MR imaging, volumes were smaller in 37 (82.2%) of the 45 patients. Eleven (29.7%) of these 37 tumors showed transient swelling preceding regression, with a median time to regression of 34 months (range, 20-55 months). Seven (15.6%) of the 45 tumors had volume progression compared with the tumor on pretreatment MR imaging studies. Of these 7 tumors, 3, however, had volume regression compared with the preceding MR imaging study, and in 4, volume progression was ongoing. One tumor remained the same.

CONCLUSIONS

Tumor-volume measurements by standardized T1-weighted gadolinium-enhanced high-resolution 3D MR imaging follow-up protocols revealed good local control of VS after radiosurgery. The first-follow-up MR imaging at 2 years and the second at 5 years postradiosurgery differentiated transient progression from ongoing progression and may prevent unnecessary therapeutic interventions.

Recovery after a traumatic brain injury depends on diurnal variations

Many studies indicate that the hour of the day at which the onset of stroke occurs is very important in patient recovery. Furthermore, multiple studies have been conducted which show that ischemia in rats produces different magnitudes of injury depending on the hour of the day at which it was induced. Using a traumatic brain injury (TBI) model, we analyzed the effect of the time of day on the recovery of rats and obtained a higher survival rate if TBI was induced at 01:00 h as compared with TBI induced at 13:00 h. We also analyzed the effect of the protease inhibitor cystatin C (CC) on the recovery of rats from TBI and found that it increased mortality and bleeding, and that these effects were more pronounced at 13:00 h.

Management of Vestibular Schwannomas that Enlarge after Stereotactic Radiosurgery: Treatment Recommendations Based on a 15 Year Experience

OBJECTIVE

Stereotactic radiosurgery is an effective alternative to surgical resection for the majority of patients with vestibular schwannomas (VS). However, after radiosurgery, the imaging characteristics of VSs are variable, and correct interpretation is critical to prevent unnecessary surgery for these patients.

METHODS

A retrospective study of 208 consecutive patients with unilateral VS having radiosurgery between March 1990 and December 2001. Thirty (14%) patients had tumors that enlarged at least 2 mm after radiosurgery. The median follow-up after radiosurgery was 56 months (range 24-132 mo).

RESULTS

The median time to tumor enlargement was 9 months (5-60 mo). The median volume increase was 75%. A loss of central enhancement was noted in 28 (93%) patients. Six (20%) patients had new symptoms noted at the time of tumor enlargement including hemifacial spasm (n = 2), ataxia (n = 2), trigeminal neuralgia (n = 1), and facial numbness (n = 1). Additional treatment was performed at the time of initial enlargement in 3 patients (resection, n = 2; ventriculoperitoneal shunt, n = 1). In the 28 patients who did not undergo resection at the time of initial enlargement, three patterns were identified on later imaging. Sixteen (57%) patients showed eventual tumor regression (type 1), and eight (29%) patients had tumors that increased and remained larger but did not show progressive enlargement (type 2). Four (14%) patients showed progressive enlargement on serial imaging (type 3) and underwent additional treatment (resection, n = 3; stereotactic radiation therapy, n = 1).

CONCLUSION

Tumor expansion after VS radiosurgery rarely denotes a failed procedure, and the majority of patients only require further imaging. Approximately one third of tumors that enlarge will remain increased in size compared with the time of radiosurgery but will not show sequential growth. Additional tumor treatment should be reserved only for patients who demonstrate progressive tumor enlargement on serial imaging (2% in this series).

Linear accelerator radiosurgery for vestibular schwannoma: measuring tumor volume changes on serial three-dimensional spoiled gradient-echo magnetic resonance images

OBJECT

The authors report on a series of 46 patients harboring vestibular schwannomas (VSs) treated using linear accelerator (LINAC) radiosurgery and an analysis of serial magnetic resonance (MR) imaging data, specifically the changes in tumor volume.

METHODS

Fifty-three consecutive patients underwent LINAC radiosurgery for VS between 1993 and 2002. Seven of these patients were lost to follow up. Three-dimensional (3D) spoiled gradient-echo (SPGR) MR imaging was performed at 3- to 4-month intervals after radiosurgery. Tumor volume was measured on Gd-enhanced MR images of each slice. The median duration of follow-up MR imaging studies was 56.5 months (range 12-120 months). Follow-up imaging studies were conducted for longer than 1 year in 42 of 53 patients. Tumor volume changes were categorized into four types: enlargement (eight lesions [19%]), no change (two lesions [4.8%]), transient enlargement followed by shrinkage (19 lesions [45.2%]), and direct shrinkage (13 lesions [31%]). Two cases (4.8%) with twice the initial tumor volume required repeated radiosurgery. All cases of transient enlargement had subsequent shrinkage within 2 years after radiosurgery. Nine (21.4%) of 42 patients demonstrated ventricular enlargement on MR images obtained after radiosurgery. Three patients (7.1%) required placement of a ventriculoperitoneal shunt because of symptomatic hydrocephalus, and another four cases (9.5%) spontaneously resolved.

CONCLUSIONS

Volume measurement on 3D-SPGR MR imaging was a suitable method to assess tumor changes. Volume changes beyond twofold or continuous enlargement for longer than 2 years after radiosurgery are key criteria in rating the effects of radiation. Some cases of hydrocephalus after radiosurgery resolved spontaneously and their rates of occurrence were similar to the typical incidence of hydrocephalus associated with VS.

Peripheral clocks and the regulation of cardiovascular and metabolic function

Circadian rhythms generated by cell autonomous biological clocks allow for the appropriate temporal synchronization of physiology and behavior, optimizing the efficiency of biological systems. Circadian oscillators and functions have been uncovered in both central and peripheral tissues. This article describes methodology, experimental design, and technical challenges pertaining to studies of circadian rhythms in the periphery. Experimental approaches are focused upon revealing the role of peripheral clocks in cardiovascular and metabolic function using in vitro and in vivo techniques.

Outpatient gamma knife surgery for vestibular schwannoma: definition of the therapeutic profile based on a 10-year experience

Object.The purpose of the study was to define the therapeutic profile of outpatient gamma knife surgery (GKS) for vestibular schwannoma (VS) by using sequential tumor volumetry to quantify changes following treatment.

Methods.A total of 111 patients met the inclusion criteria. The median follow-up duration was 7 years (range 5–9.6 years). Thirty-seven patients (33%) had undergone surgery before GKS and 10 (9%) had neurofibromatosis Type 2 (NF2). The median VS volume was 1.6 cm3(range 0.08–8.7 cm3).

The actuarial 6-year tumor control rate after a single GKS treatment was 95%. Tumor swelling was observed in 43 patients (38.7%). Recurrence was significantly associated with NF2 (p < 0.003) and the reduced dose (p < 0.03) delivered to these tumors. The incidence of facial nerve neuropathy was mainly determined by surgery prior to GKS (p < 0.0001). Facial nerve radiation toxicity was mild and transient. No permanent facial nerve toxicity was observed. Trigeminal neuropathy occurred in 13 patients, and this was correlated with the VS volume (p < 0.02). The median hearing loss was −10 dB (range + 20 dB to −70 dB). The risk of hearing loss was correlated with age and transient tumor swelling (p < 0.05) but not with dose parameters or NF2.

Conclusions.Outpatient GKS is feasible, effective, and safe. Its therapeutic profile compares favorably with that of microsurgery.

Hypothermic protection in rat focal ischemia models: strain differences and relevance to "reperfusion injury"

Hypothermic protection was compared in Long-Evans and spontaneously hypertensive rat (SHR) strains using transient focal ischemia, and in Wistar and SHR strains using permanent focal ischemia. Focal ischemia was produced by distal surgical occlusion of the middle cerebral artery and tandem occlusion of the ipsilateral common carotid artery (MCA/CCAO). Moderate hypothermia of 2 hours' duration was produced by systemic cooling to 32 degrees C, with further cooling of the brain achieved by reducing to 30 degrees C the temperature of the saline drip superfusing the exposed occlusion site. Infarct volume was determined from serial hematoxylin and eosin-stained frozen sections obtained routinely at 24 hours, or in some cases after 3 days' survival. In the SHR, moderate hypothermia was only effective when initiated before recirculation after a 90-minute occlusion period. In contrast, the same intervention was strikingly effective in the Long-Evans rat even when initiated after as long as 30-minute reperfusion after a 3-hour occlusion. This magnitude and duration of cooling was not protective in permanent MCA/CCAO in the SHR, but such transient hypothermia did effectively reduce infarct volume after permanent occlusions in Wistar rats. These results show striking differences in the temporal window for hypothermic protection among rat focal ischemia models. As expected, "reperfusion injury" in the Long-Evans strain is particularly responsive to delayed cooling. The finding that the SHR can be protected by hypothermia initiated immediately before recirculation suggests a rapidly evolving component of injury occurs subsequent to reperfusion in this model as well. Hypothermic protection after permanent occlusion in Wistar rats identifies a transient, temperature-sensitive phase of infarct evolution that is not evident in the unreperfused SHR. These observations confirm that distinct mechanisms can underlie the temporal progression of injury in rat stroke models, and emphasize the critical importance of considering model and strain differences in extrapolating results of hypothermic protection studies in animals to the design of interventions in clinical stroke.

Checkpoints and pitfalls in the experimental neuropathology of circulatory disturbance

In neural tissue injury many pathological processes are common to different neurological disorders, including cerebral ischemia. Because ischemia has a fundamentally simple impact on neural tissue, good laboratory modeling can help improve the general understanding of the neuropathological processes involved. Summarized here are some basic principles that should be followed to ensure that cerebral ischemia studies are reproducible and informative: (i) selection of an appropriate model of cerebral ischemia in an appropriate species (although rodents are widely used for genomic studies, the use of larger animals, with brain structures macroscopically similar to those of humans, is appropriate for many studies, e.g. of white matter lesions or the pathophysiology of cerebral edema); (ii) correct maintenance of physiological parameters, including body temperature, systemic blood pressure, and blood gas tensions, under appropriate general anesthesia; (iii) selection of an appropriate method of cerebral blood flow (CBF) monitoring (decisions include whether or not the experiment requires real-time monitoring, in vivo measurement, and CBF mapping); (iv) appropriate timing of drug application in therapeutic studies (many drugs that are effective when given immediately after a short period of ischemia are ineffective in clinical trials, probably because of longer periods of ischemia and delayed drug delivery in clinical settings); and (v) multiparametric evaluation of therapeutic effect (with the recent increase in diagnosis of cases of mild stroke, measurement of mortality and infarct size have proven to be insufficient for the evaluation of therapeutic effect). Use of mild ischemia models and batteries of neurological tests for individual neurological functions, such as motor, somatosensory, and visual function, are becoming important in experimental ischemia research. In histological evaluation, assessment of the extent of both selective neuronal loss and the infarct will become mandatory. Regional analysis of each brain structure and coordination of the results with the apparent neurological dysfunction is a promising approach.

Examination of sensorimotor performance following middle cerebral artery occlusion in rats

Middle cerebral artery occlusion (MCAO) in rats is the most commonly used stroke model. Besides the infarct size, assessment of sensorimotor performance has become increasingly important in neuroprotective drug research. However, contradictions exist about procedures for testing functional outcome following MCAO. The aim of the present study was to evaluate a relatively simple set of neurological tests based on the most commonly used scoring systems, and to describe the functional recovery and correlation with the infarct size in rats sacrificed 2 or 14 days after permanent or transient MCAO. The smaller infarct size of rats with transient occlusion was reflected in the neurological scores only during the first 6h. By day 14, no recovery occurred in postural signs, lateral resistance and spontaneous activity, other signs showed different degrees of recovery. Correlation with the infarct size was found only on certain days in gait disturbance, placing reactions, daily body weight and spontaneous activity. According to our observations, the most commonly used sensorimotor tests provide a useful initial screening of functional deficits, but these tests most probably measure deficits caused by infarction of the core area. It is suggested that these tests should be completed by more refined tests when testing a neuroprotective drug which reduces the infarct size in penumbral areas.

Liposome-mediated transfer of the bcl-2 gene results in neuroprotection after in vivo transient focal cerebral ischemia in an animal model

Acute cerebral ischemia causes hypoxic neuronal cell death by necrosis and apoptosis. Expression of anti-apoptotic transgenes in ischemic brain may provide a useful therapeutic strategy for alleviation of postischemic damage. The present study investigates liposome-mediated transfer of the human bcl-2 protein in a rat model of focal transient ischemia due to middle cerebral artery (MCA) occlusion. Two different types of plasmid vectors were used for bcl-2 expression: one driven by the constitutive cytomegalovirus promoter (pCMV) and another based on the hypoxia-inducible human vascular endothelial growth factor promoter (pHRE). Cationic liposome/plasmid DNA complexes (lipoplexes) were injected directly into the cerebrospinal fluid (CSF) of rats immediately after MCA occlusion. The brains of treated and control animals were analyzed 48 h later. Infarct volumes and numbers of apoptotic cells were quantified. Occlusion of the MCA resulted in ipsilateral cerebral infarcts in all study animals. Transfer of the bcl-2 gene resulted in high level widespread protein expression in the case of the pCMV-bcl2 plasmid, while animals treated with the pHRE-bcl2 vector showed lower expression levels of bcl2 which were in addition limited to the ischemic area. Treatment with pCMV-bcl2, but not with pHRE-bcl2, was able to significantly reduce the infarct volume, which was 109 +/- 8 mm(3) for pCMV-bcl2, 152 +/- 29 mm(3) for pHRE-bcl2, and 155 +/- 18 mm(3) for control animals. Animals transfected with either vector showed a significant reduction in numbers of apoptotic cells in the infarct and penumbra area compared with controls. There were no short-term neurological side-effects of the CSF injection of lipoplexes or of bcl-2 expression. In conclusion, the hypoxia-inducible bcl-2 expression mediated by intrathecal lipoplexes may represent a novel, biologically safe and lesion-selective therapeutic approach for neuroprotection after acute cerebral ischemia. DOI: 10.1038/sj/gt/3301676