Calcium ions and calcium antagonists in ischaemia

Voltage-gated calcium channel antagonists and traumatic brain injury

Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Despite more than 30 years of research, no pharmacological agents have been identified that improve neurological function following TBI. However, several lines of research described in this review provide support for further development of voltage gated calcium channel (VGCC) antagonists as potential therapeutic agents. Following TBI, neurons and astrocytes experience a rapid and sometimes enduring increase in intracellular calcium ([Ca²⁺]_i). These fluxes in [Ca²⁺]_i drive not only apoptotic and necrotic cell death, but also can lead to long-term cell dysfunction in surviving cells. In a limited number of in vitro experiments, both L-type and N-type VGCC antagonists successfully reduced calcium loads as well as neuronal and astrocytic cell death following mechanical injury. In rodent models of TBI, administration of VGCC antagonists reduced cell death and improved cognitive function. It is clear that there is a critical need to find effective therapeutics and rational drug delivery strategies for the management and treatment of TBI, and we believe that further investigation of VGCC antagonists should be pursued before ruling out the possibility of successful translation to the clinic.

Lack of effect of PN 200-110 on neuronal injury and neurological outcome in middle cerebral artery-occluded rats

We evaluated the influence of a continuous intravenous infusion of 0.24 mg/kg PN 200-110 started 20 minutes before the induction of ischemia and continued for 2 hours on infarct size, histopathology, and neurological outcome in middle cerebral artery-occluded rats treated with PN 200-110 (n = 8), placebo (n = 7), or saline (n = 8). Neurological examination was performed 24 hours after occlusion. We quantified infarct size by 2,3,5-triphenyl-tetrazolium chloride, hematoxylin and eosin, and Nissl staining and by computerized analysis of tracings of the infarcted areas and evaluated neuronal injury at the infarct periphery. The different types of ischemic cell damage were quantified by direct visual counting. We found no differences among saline-, placebo-, and PN 200-110-treated rats regarding infarct size, amount of neuronal alteration, and neurological outcome. Our results indicate the lack of a significant protective effect of this drug in experimental focal ischemia.

Brain protection: physiological and pharmacological considerations. Part II: The pharmacology of brain protection

Neuroprotective agents may exert their effect by reducing cerebral oxygen demand (CMRO2), increasing cerebral oxygen delivery, or by altering ongoing pathological processes. Barbiturates provide neuroprotection by reducing the CMRO2 necessary for synaptic transmission while leaving the component necessary for cellular metabolism intact. Isoflurane may exert a neuroprotective effect by a similar mechanism but its efficacy is likely less than that of barbiturates due to adverse effects on cerebral blood flow. Lidocaine reduces CMRO2 by affecting both cellular metabolic processes and synaptic transmission and thus resembles hypothermia in its mechanism of action. Benzodiazepines reduce CMRO2 by reducing synaptic transmission and their use as neuroprotectants produces less haemodynamic compromise than barbiturates. The mechanism of protection by calcium entry blocking agents appears to be due to improved blood flow as opposed to altering abnormal Ca++ fluxes. In contrast, agents such as ketamine and MK-801 may prevent abnormal Ca++ fluxes through their competitive interaction with N-methyl-D-aspartate receptors. Phenytoin prevents K(+)-mediated ischaemic events from progressing. Agents worthy of further investigation include corticosteroids, free radical scavengers, prostaglandin inhibitors and iron chelators.

Transvenous perfusion of the brain with verapamil during focal cerebral ischemia in rats

We report on the effect of calcium channel blocker verapamil administered into the inferior cerebral vein in rats 1 hour after occlusion of the middle cerebral artery. Twenty-four rats were divided into four groups of six rats each. Group A rats received no medication. The other three groups received 0.1 mg verapamil/kg/2 hr. Group B rats received verapamil intravenously. Group C and D rats received verapamil and autologous arterial blood by transvenous perfusion of the brain, Group C rats at 100 mm Hg perfusion pressure and Group D rats at 150 mm Hg perfusion pressure. The administration of verapamil started 1 hour after middle cerebral artery occlusion and lasted for 2 hours. Three hours after occlusion, we used double- or single-tracer autoradiography with 4-[18F]fluoroantipyrine or [14C]iodoantipyrine and [14C]alpha-aminoisobutyric acid as tracers to study the brains for local cerebral blood flow and blood-brain barrier permeability changes. Group C showed a significant increase of local cerebral blood flow in the parietal cortex (89%, p less than 0.01) and sensorimotor cortex (64%, p less than 0.05) compared with Group A. Group D showed an extensive and striking increase in local cerebral blood flow of the ischemic cortical and subcortical areas (57-100%, p less than 0.05). Group B showed no significant changes but exhibited further reduction of local cerebral blood flow in the ischemic cerebral hemisphere associated with slightly increased local cerebral blood flow in the nonischemic cerebral hemisphere compared with Group A. There was no change of blood-brain barrier permeability in any group.(ABSTRACT TRUNCATED AT 250 WORDS)

An experimental study of the effect of nimodipine in primate subarachnoid haemorrhage

Acute subarachnoid haemorrhage was produced in baboons by a transorbital vessel avulsion technique. Half the animals were pretreated with an intravenous infusion of the calcium antagonistic nimodipine, in a dosage comparable with clinical levels. The severity of the haemorrhage, as measured by changes in intracranial pressure, cerebral perfusion pressure, cerebral blood flow and reactivity, and evoked potentials, was not greater in the group receiving nimodipine. Changes in extracellular K+ and pH were much less marked in animals receiving nimodipine. It is suggested that nimodipine (a) has a protective effect at a cellular level against the ionic changes of ischaemia, (b) does not alter the mechanical severity of subarachnoid haemorrhage.

Effects of calcium channel blockers on neurologic outcome after focal ischemia in rabbits

To determine the efficacy of calcium channel blockers in preserving neurologic function after central nervous system ischemia, we studied three such agents in two animal models. We treated rabbits after inducing ischemia in the brain with intra-arterial microspheres and in the spinal cord using a removable aortic occluding device. We found no benefit, in terms of neurologic functional outcome, from lidoflazine, nimodipine, or nicardipine. All three agents elevated regional blood flow in the spinal cord. We conclude that calcium antagonists are not likely to prove beneficial if used alone in the treatment of focal central nervous system ischemia.

Cerebral resuscitation: pathophysiology and therapy

The interest in the possibility of cerebral resuscitation has been growing exponentially during the last decade. It became clear that pharmacotherapeutic interaction can possibly alter the outcome of cerebral hypoxia/ischemia. The present review is an attempt to provide an organizational framework for a systematic integration of studies specifically dealing with pharmacological treatment post-insult.

Effects of calcium antagonists on high-energy phosphates in ischemic rat brain measured by 31P NMR spectroscopy

The effects of various calcium antagonists on the ATP, PCr, and Pi levels as well as intracellular pH in normal and ischemic rat brain were examined by 31P NMR spectroscopy using a surface coil. None of the calcium antagonists tested showed any effect in the nonischemic rat brain. However, when global ischemia was induced by cardiac arrest, the ensuring rapid decrease of ATP and PCr and concomitant increase of Pi were significantly retarded by dihydropyridine calcium antagonists, but not by verapamil. The fall in pH caused by ischemia was not affected by either drug. Barbiturates showed effects similar to calcium antagonists, whereas calcium agonists showed the opposite. These results suggest that dihydropyridine calcium antagonists, similar to barbiturates, decrease the high-energy phosphate consumption of the brain, which might be beneficial in instances where their production is severely hampered, e.g., during ischemia.

Effects of nimodipine on acute focal cerebral ischemia

Nimodipine is a calcium slow channel blocker with several pharmacologic properties suggesting the potential to favorably modify outcome in focal cerebral ischemia. Thirty adult cats underwent unilateral middle cerebral artery (MCA) occlusion for 4 hours. Seventeen cats were treated with an ipsilateral intracarotid infusion of nimodipine (1 microgram kg-1 min -1) beginning 15 minutes before MCA occlusion and continuing throughout the occlusion period. Eight nimodipine treated cats maintaining MAP greater than 90 mmHg were assigned to a Higher Pressure Nimodipine (HPN) group. The remaining nine treated cats with MAP less than 90 mmHg were assigned to the Lower Pressure Nimodipine (LPN) group. Thirteen cats were untreated, receiving an isovolumetric amount of vehicle through the ipsilateral carotid artery. Local cerebral blood flow (ICBF) was continuously monitored using thermal diffusion probes. The brains, assessed for colloidal carbon perfusion, fluorescein and Evans blue staining, electroencephalographic activity (EEG), and histological changes, revealed no significant differences by any of these methods between the HPN and control animals with the exceptions of: HPN treated cats exhibited a preservation of EEG activity at 15 minutes post-occlusion compared to the untreated cats, and Post-ischemic surface colloidal carbon perfusion was better preserved in the treated cats than in the untreated cats. Mild hypotension, as demonstrated by the LPN group, negated these two positive effects. Prior to MCA occlusion, ICBF was bilaterally significantly increased after nimodipine infusion in the HPN group as compared to vehicle infusion. Intra-arterially infused nimodipine did not reduce infarct size.

Delayed treatment with nimodipine improves cerebral blood flow after complete cerebral ischemia in the dog

Ten minutes of complete cerebral ischemia was produced in 18 dogs by temporary ligation of the aorta and venae cavae. Dogs were randomly assigned to one of three groups. A bolus dose of 10 micrograms kg-1 nimodipine, a dihydropyridine calcium entry blocker, followed by a constant infusion of 1 microgram kg-1 min-1 was given at 15, 30, or 60 min post ischemia. Cerebral blood flow and metabolism were measured for 2 h postischemia. Delayed treatment with nimodipine ameliorated or reversed the cerebral hypoperfusion that routinely occurs after complete ischemia. In the groups treated at 15 and 30 min, CBF remained above 60 ml min-1 100 g-1. In the group treated at 60 min, there was a progressive decline in CBF to 37 ml min-1 100 g-1. Following treatment with nimodipine, CBF immediately increased and was maintained above 50 ml min-1 100 g-1 for the remainder of the study. Once treatment with nimodipine was begun, CBF was approximately double that of an untreated group. Changes in CBF reflected changes in cerebrovascular resistance. Nimodipine had no effect on cerebral metabolism. Since the postischemic hypoperfusion state is believed to contribute to the ultimate neurologic damage following complete ischemia, treatment with nimodipine, even if delayed up to 60 min, may improve the outcome.

Reversal of cerebral arterial spasm by intrathecal administration of a calcium antagonist (nimodipine)

Specific antagonists to the influx of calcium, necessary for the excitation-contraction coupling process in arterial smooth muscle, are potentially useful in the treatment of cerebral vasospasm but systemic hypotension might limit their clinical applicability. We studied the effect of the calcium antagonist nimodipine (BAY e 9736) on cerebral arterial spasm, intraventricular pressure and blood pressure (BP), when administered into the cerebral ventricles of the dog. Cerebral vasospasm was produced by the injection of autologous blood into the cisterna magna. In a group of 8 dogs, 100 micrograms of nimodipine was injected into the lateral ventricle. The effect of the drug on the basilar artery was monitored angiographically. Nimodipine always relieved spasm, and often the relaxation surpassed the resting vessel diameter. In a control group, the injection of placebo did not relax the spastic arteries. Determinations using gas chromatography of nimodipine in CSF and blood demonstrated that a concentration of 1 microgram/ml in cisternal CSF was sufficient to reduce spasm while concomitant plasma concentrations of 0.004 micrograms/ml did not result in significant BP reduction.

Intracarotid slow bolus injection of nimodipine during angiography for treatment of cerebral vasospasm after SAH. A preliminary report

Nimodipine was given as an intracarotid slow bolus injection in six patients with subarachnoid hemorrhage (SAH) due to rupture of a cerebral aneurysm, with angiographically demonstrated vasospasm. The patients were followed by serial angiograms for demonstration of the effect of nimodipine on vasospasm. After angiography, all patients were treated with a constant venous infusion of this new calcium antagonist. Although the therapeutic regimen was started only a few hours after onset of vasospasm, there was no change in cerebral vessel caliber detectable on angiograms following the intracarotid injection. Three patients died, two patients finally recovered with neurological deficits due to cerebral ischemia, and one patient with asymptomatic vasospasm remained symptom-free. Although nimodipine may act to prevent cerebral vasospasm after SAH, the authors believe that the intracarotid application is not effective after vasospasm has occurred.

Balloon catheter technique for dilatation of constricted cerebral arteries after aneurysmal SAH

The authors describe the technique and explain the reason for the use of an intravascular balloon catheter technique in the treatment of vasospasm in cases of subarachnoid haemorrhage due to rupture of a cerebral aneurysm. In 33 patients with SAH 105 major cerebral arteries were dilated (in the system of internal carotid and basilar arteries). Only in one case vasodilatation could not be accomplished. The effect of dilatation of vasospastic arteries was stable and the functional state of the brain was ameliorated, local and general cerebral dysfunctional signs and symptoms due to vasospasm regressed. The authors discuss indications and contraindications for intravascular balloon dilatation of spastic arteries, the time for the operation, the length of arteries to be dilated, and the possible mechanism of amelioration of cerebral blood flow to the brain stem.

Human pial vascular reactions to intravenous Nimodipine-infusion during EC-IC bypass surgery

In previous experimental work, the Ca-antagonist Nimodipine had shown a predominantly cerebroarterial dilatory effect. In the present double-blind study of 16 patients, pial arterial and venous reaction was investigated during EC-IC bypass surgery, infusing 1 microgram kg-1min-1 of Nimodipine intravenously. In pial arteries with resting diameters between 25 and 70 micrometers, a significant 18% dilatation was observed. Results are considered promising for future trials in the treatment and prevention of cerebral ischemia caused by vasoconstriction or vasospasm, especially vasospasm following subarachnoid hemorrhage.