Cortical blood flow and cognition after extracranial-intracranial bypass in a patient with severe carotid occlusive lesions. A three-year follow-up study

The neuron-astrocyte-microglia triad in CA3 after chronic cerebral hypoperfusion in the rat: Protective effect of dipyridamole

We investigated the quantitative and morphofunctional alterations of neuron-astrocyte-microglia triads in CA3 hippocampus, in comparison to CA1, after 2 Vessel Occlusion (2VO) and the protective effect of dipyridamole. We evaluated 3 experimental groups: sham-operated rats (sham, n=15), 2VO-operated rats treated with vehicle (2VO-vehicle, n=15), and 2VO-operated rats treated with dipyridamole from day 0 to day 7 (2VO-dipyridamole, n=15), 90days after 2VO. We analyzed Stratum Pyramidalis (SP), Stratum Lucidum (SL) and Stratum Radiatum (SR) of CA3. 1) ectopic neurons increased in SL and SR of 2VO-vehicle, and 2VO-dipyridamole rats; 2) apoptotic neurons increased in SP of 2VO-vehicle rats and dipyridamole reverted this effect; 3) astrocytes increased in SP, SL and SR of 2VO-vehicle and 2VO-dipyridamole rats; 4) TNF-α expression increased in astrocytes, blocked by dipyridamole, and in dendrites in SR of 2VO-vehicle rats; 5) total microglia increased in SL and SR of 2VO-vehicle and 2VO-dipyridamole rats; 6) triads increased in SR of 2VO-vehicle rats and dipyridamole reverted this effect. Microglia cooperated with astrocytes to phagocytosis of apoptotic neurons and debris, and engulfed ectopic non-fragmented neurons in SL of 2VO-vehicle and 2VO-dipyridamole rats, through a new mechanism called phagoptosis. CA3 showed a better adaptive capacity than CA1 to the ischemic insult, possibly due to the different behaviour of astrocytes and microglial cells. Dipyridamole had neuroprotective effects.

The neuron-astrocyte-microglia triad in a rat model of chronic cerebral hypoperfusion: protective effect of dipyridamole

Chronic cerebral hypoperfusion during aging may cause progressive neurodegeneration as ischemic conditions persist. Proper functioning of the interplay between neurons and glia is fundamental for the functional organization of the brain. The aim of our research was to study the pathophysiological mechanisms, and particularly the derangement of the interplay between neurons and astrocytes-microglia with the formation of "triads," in a model of chronic cerebral hypoperfusion induced by the two-vessel occlusion (2VO) in adult Wistar rats (n = 15). The protective effect of dipyridamole given during the early phases after 2VO (4 mg/kg/day i.v., the first 7 days after 2VO) was verified (n = 15). Sham-operated rats (n = 15) were used as controls. Immunofluorescent triple staining of neurons (NeuN), astrocytes (GFAP), and microglia (IBA1) was performed 90 days after 2VO. We found significantly higher amount of "ectopic" neurons, neuronal debris and apoptotic neurons in CA1 Str. Radiatum and Str. Pyramidale of 2VO rats. In CA1 Str. Radiatum of 2VO rats the amount of astrocytes (cells/mm(2)) did not increase. In some instances several astrocytes surrounded ectopic neurons and formed a "micro scar" around them. Astrocyte branches could infiltrate the cell body of ectopic neurons, and, together with activated microglia cells formed the "triads." In the triad, significantly more numerous in CA1 Str. Radiatum of 2VO than in sham rats, astrocytes and microglia cooperated in the phagocytosis of ectopic neurons. These events might be common mechanisms underlying many neurodegenerative processes. The frequency to which they appear might depend upon, or might be the cause of, the burden and severity of neurodegeneration. Dypiridamole significantly reverted all the above described events. The protective effect of chronic administration of dipyridamole might be a consequence of its vasodilatory, antioxidant and anti-inflammatory role during the early phases after 2VO.

Chronic cerebrovascular hypoperfusion affects global DNA methylation and histone acetylation in rat brain

DNA methylation and histone acetylation can be modified by various pathological or physiological factors such as hypoxia, thus influencing gene expression. In this study, we investigated the changes of global DNA methylation and histone acetylation and the related enzymes in rat brain after chronic cerebrovascular hypoperfusion by bilateral common carotid occlusion (2-VO) surgery. Colorimetric and immunohistochemistry staining were used to evaluate the global DNA methylation and histone acetylation levels, respectively. The expressions of DNA methyltransferase 1/3a (DNMT1/3a), methyl-CpG binding domain protein 2 (MBD2), histone deacetylase 3 (HDAC3) and acetyltransferase (HAT) were assessed by Western blot. We found that the level of global DNA methylation was decreased to 31.7% (P <0.01) of the sham-operated group at 10 days and increased by 30% (P <0.01) compared with the sham group at 90 days after 2-VO surgery. DNMT3a expression was down-regulated to 75.7% of the sham group, while MBD2 expression was up-regulated by 95% compared with sham group at 90 days after 2-VO. The histone H3 acetylation level was markedly decreased to 75.3% of the sham group at 10 days and 73.5% at 90 days after 2-VO, while no significant change was found for histone H4 acetylation. HDAC3 expression was markedly down-regulated to 36% of the sham group, whereas cAMP-response element binding protein expression was up-regulated by 33.6% compared with the sham group at 90 days after 2-VO. These results suggest that chronic cerebrovascular hypoperfusion influences global DNA methylation and histone acetylation levels through the related enzymes, and therefore might contribute to several neurodegenerative diseases.

Cognitive dysfunction induced by chronic cerebral hypoperfusion in a rat model associated with arteriovenous malformations

The relationship between chronic cerebral hypoperfusion and cognitive function has not been completely delineated. In the present studies, we developed an experimental model associated with arteriovenous malformation to investigate the effects of chronic cerebral hypoperfusion on cognitive function and neuropathological changes. The rat model was established by creating a fistula through an end-to-side anastomosis between the right distal external jugular vein and the ipsilateral common carotid artery, followed by ligation of the left vein draining the transverse sinus and bilateral external carotid arteries. Age-matched rats comprised a control group. Three months after surgery, cognitive functions were evaluated by the Morris water maze and hippocampal long-term potentiation (LTP). Neuropathological changes were examined using light and electron microscopic techniques. We found that both learning capacity and spatial memory were significantly impaired in rats with chronic cerebral hypoperfusion concomitant with LTP inhibition and neurodegeneration in the hippocampal CA1 region of model rats compared with control rats. In addition, model rats showed a decrease at the protein level of cyclic AMP response element binding (CREB) phosphorylation in hippocampal tissues. Therefore, cognitive impairment caused by chronic cerebral hypoperfusion associated with arteriovenous malformations may be partially explained by the neurodegeneration and reduction of CREB phosphorylation in rat hippocampus.

Chronic ischemia and neurocognition

Cognitive impairment from a major stroke as a consequence of carotid disease is an acknowledged clinical outcome; however, cognitive impairment without major stroke is open to discussion. The three recognized mechanisms for cognitive dysfunction from internal carotid artery are microembolization, white-matter disease, and hypoperfusion. The last has been most difficult to characterize physiologically. In this article, the authors review evidence supporting the existence of chronic ischemia in the brain and its direct impact on cognitive functions. By incorporating the pathophysiology of chronic ischemia into the algorithm of the management of carotid artery disease, we may be able to extend the goals of carotid artery revascularization beyond merely preventing stroke to include preventing or reversing cognitive decline.

[Extra-intracranial arterial bypass for treatment of patient with clinical refractory cerebral ischemia]

The extra-intracranial bypass may be used in selected cases of brain vascular insufficiency refractory to clinical treatment. We report a case of encephalic ischemia in the territory of the right middle cerebral artery due to occlusion of the ipsilateral internal carotid artery, with consequent reduction of the perfusion and vascular reserve in the parietal and frontal regions. Despite the clinical treatment, motor deficit improvement was directly related to the maintenance of high systemic arterial tension levels due to the use of vasopressor agent. After lateral-terminal extra-intracranial bypass between the superficial temporal and right middle cerebral artery, there was significant improvement of cerebral perfusion with remission of the motor deficit.

Cerebral revascularization

During the last 10 years, there has been a revival of interest in cerebral revascularization procedures. Not only have significant progressions in surgical techniques been published, the use of more advanced diagnostic methods has led to a widening of the indications for cerebral bypass surgery. The purpose of this review is to outline the current techniques for extracranial-to-intracranial (EC/IC) and intracranial-to-intracranial (IC/IC) bypass surgery, as well as to identify the current indications for revascularization procedures based on the available literature. The excimer laser-assisted non-occlusive anastomosis (ELANA) technique is described in more detail because we think that this technique almost completely eliminates the risk of cerebral ischemia due to the temporary vessel occlusion which is currently used in conventional anastomosis techniques.

[Clinical impact of 18F-fluorodeoxyglucose positron emission tomography in the diagnosis of brain diseases]

In this review it will be discussed in which neurological disorders positron emission tomography can yield important diagnostic information. Because positron emission tomography is an expensive method indications have to be clearly defined. One important question concerns the differentiation of tumor recurrence and scar due to radiation therapy or an operation. The grading of brain tumors is another application. In HIV patients fluorodeoxyglucose positron emission tomography can separate lymphoma and toxoplasmosis. In the evaluation of dementia positron emission tomography can help to clarify the differential diagnosis. Another important area is the presurgical evaluation of epilepsy patients and patients with cerebrovascular disease in whom a surgical revascularisation procedure is planned. In extrapyramidal disorders, positron emission tomography can often help to establish the final diagnosis.

Cognitive impairment and chronic cerebral hypoperfusion: what can be learned from experimental models

The relation between chronic cerebral hypoperfusion and cognitive functions has not been completely clarified. The resolution of cerebral hypoperfusion states, such as those induced by arteriovenous malformations or carotid stenosis/occlusion, has been reported to improve mental decline in humans. Subcortical vascular dementia is another human condition supposed to be linked with chronic cerebral hypoxia/ischemia. The extent of this cause/effect relation is, however, difficult to be assessed in humans, where different factors, such as ageing or subtle degenerative processes, can coexist and interact influencing cognitive performances. Experimental studies can help to elucidate this relation because they can use models of pure chronic/moderate cerebral hypoperfusion. An experimental model of chronic ischemia is the bilateral common carotid artery occlusion in the rat. In this paper, we present a review of experimental studies that evaluated cognitive functions in the rat with bilateral common carotid artery occlusion. We then present an experimental model of bilateral common carotid artery occlusion in the rat modified with respect to previous papers regarding both the surgical procedure and the neurocognitive evaluation that is focused on cognitive domains depending on subcortical-frontal circuits. We propose this model to investigate subcortical vascular dementia.

Persistent impairment of gait performances and working memory after bilateral common carotid artery occlusion in the adult Wistar rat

BACKGROUND

The clinical and pathophysiological effects of a chronic reduction of cerebral blood flow in humans are not completely known. We investigated whether rats subjected to bilateral common carotid artery occlusion (bCCA-o) developed focal neurological deficits, gait dysfunction, and working memory alterations.

METHODS

Eighteen male Wistar rats were subjected to bCCA-o, 13 were sham-operated. We assessed sensorimotor functions, gait on a 60 cm-long elevated bridge, and working memory (object recognition and Y maze tests) before and 30, 60, and 90 days after surgery. Histological analysis was performed in a subgroup of 10 rats.

RESULTS

No rat showed sensorimotor alterations after surgery. Although gait performances of both bCCA-o and sham-operated rats declined over time, the differences reached statistical significance only for the bCCA-o group (mean+/-SE: 26.8+/-5.0; 22.4+/-4.9; 24.5+/-5.5 cm at 30, 60, and 90 days, respectively) in comparison with baseline (52.9+/-5.2 cm; P<0.05). At 60 and 90 days, bCCA-o rats in comparison with sham-operated rats showed decreased performances on object recognition (discrimination index: 0.15+/-0.03 vs. 0.29+/-0.05 at 60 days and 0.10+/-0.04 vs. 0.41+/-0.07 at 90 days; P<0.05) and on Y maze test (alternating rats: 9.9 vs. 85.7% at 60 days and 16.6 vs. 100% at 90 days; P<0.01). In none of the animals were cerebral infarcts detected. Selective neuronal necrosis was observed in the cortex and hippocampus of both bCCA-o and sham-operated rats without any obvious difference.

CONCLUSIONS

bCCA-o in the Wistar rat induces persistent and progressive gait and working memory impairment without producing sensorimotor deficit or cerebral infarcts. This model may help to elucidate some physiopathological aspects of neurological impairment associated with states of cerebral chronic ischemia.

Evaluating the effect of superficial temporal artery to middle cerebral artery bypass on pure motor function using motor activation single photon emission computed tomography

OBJECTIVE

We evaluated and analyzed the effect of superficial temporal artery to middle cerebral artery bypass for internal carotid artery occlusion on pure motor function using motor activation single photon emission computed tomography.

METHODS

Motor activation single photon emission computed tomographic (SPECT) images were obtained for nine patients who had undergone superficial temporal artery to middle cerebral artery anastomosis for symptomatic internal carotid artery occlusion. All motor activation SPECT images using the finger opposition task on the affected side were obtained before bypass surgery and at 1 week, 1 month, and 3 months after bypass surgery. The results of motor activation single photon emission computed tomography were expressed as negative or positive.

RESULTS

Before bypass surgery, the resting SPECT images revealed reduction of cerebral blood flow (CBF) on the affected side in all nine patients. The results of motor activation single photon emission computed tomography in three patients were positive. One week after bypass surgery, the results of the resting and motor activation CBF studies did not demonstrate any marked changes. One month after bypass surgery, the resting CBF increased in four patients. The results obtained for two of the patients revealed preoperative positive motor activation. The results of motor activation single photon emission computed tomography obtained for five patients were positive. Three months after bypass surgery, eight patients experienced improvement in the resting CBF, and the results of motor activation single photon emission computed tomography obtained for seven patients were positive. Among these, the results of preoperative motor activation single photon emission tomography obtained for four patients were negative.

CONCLUSION

Superficial temporal artery to middle cerebral artery bypass is useful not only for resting CBF but also for pure motor function based on motor activation SPECT images. From the preoperative motor activation study, it was concluded that patients with preoperative positive motor activation could attain the effect of bypass earlier than patients with preoperative negative motor activation.

Symptomatic carotid artery occlusion. A reappraisal of hemodynamic factors

BACKGROUND

Over the last several years evidence has accumulated that in addition to embolism, a compromised cerebral blood flow may play an important role in causing transient ischemic attacks and ischemic stroke in patients with occlusion of the internal carotid artery. This evidence is found in both clinical features and ancillary investigations, particularly measurements of cerebral blood flow.

SUMMARY OF REVIEW

On the basis of 20 follow-up studies in patients with transient ischemic attacks or minor ischemic stroke associated with an occluded carotid artery, the annual risk of stroke was 5.5% (95% confidence interval [CI], 5.0% to 6.0%), and that of ipsilateral stroke (distinguished in 11 of the 20 studies) was 2.1% (95% CI, 1.6% to 2.8%). Patients with a compromised cerebral blood flow as measured by positron emission tomography, single-photon emission CT, transcranial Doppler, or stable xenon CT (six studies) have an even higher annual risk of stroke (all strokes: 12.5%; 95% CI, 8.9% to 17.6%; ipsilateral stroke: 9.5%; 95% CI, 6.4% to 14.0%).

CONCLUSIONS

Because a compromised cerebral blood flow may be an important causal factor in patients with symptomatic carotid artery occlusion, medical and surgical options for treatment are reviewed in this light.