Delayed treatment with 1,3-butanediol reduces loss of CA1 neurons in the hippocampus of rats following brief forebrain ischemia

The Alzheimer's Disease Brain, Its Microvasculature, and NADPH Oxidase

The deterioration of the brain's microvasculature, particularly in the hippocampus, appears to be a very early event in the development of Alzheimer's disease (AD), preceding even the deposition of amyloid-β. A damaged microvasculature reduces the supply of oxygen and glucose to this region and limits the production of energy, ATP. The damage may be a function of the rise with age in the expression and activity of NADPH oxidase (NOX) in these microvessels. This rise renders these vessels vulnerable to the effects of oxidative stress and inflammation. The rise in NOX activity with age is even more marked in the AD brain where an inverse correlation has been demonstrated between NOX activity and cognitive ability. Apocynin, a putative NOX inhibitor, has been shown to block the damaging effects of NOX activation. Apocynin acts as a strong scavenger of H2O2, and as a weak scavenger of superoxide. Like apocynin, sodium oxybate (SO) has also been shown to block the toxic effects of NOX activation. The application of SO generates NADPH and ATP. SO inhibits oxidative stress and maintains normal cerebral ATP levels under hypoxic conditions. Moreover, it acts epigenetically to attenuate the expression of NOX. SO may delay the onset and slow the progress of AD by suppling energy and maintaining an antioxidative environment in the brain throughout the night. The slow wave activity produced by SO may also activate the glymphatic system and promote the clearance of amyloid-β from the brain.

Systematic Review - Neuroprotection of ketosis in acute injury of the mammalian central nervous system: A meta-analysis

To evaluate the neuroprotection exerted by ketosis against acute damage of the mammalian central nervous system (CNS). Search engines were interrogated to identify experimental studies comparing the mitigating effect of ketosis (intervention) versus non-ketosis (control) on acute CNS damage. Primary endpoint was a reduction in mortality. Secondary endpoints were a reduction in neuronal damage and dysfunction, and an 'aggregated advantage' (composite of all primary and secondary endpoints). Hedges' g was the effect measure. Subgroup analyses evaluated the modulatory effect of age, insult type, and injury site. Meta-regression evaluated timing, type, and magnitude of intervention as predictors of neuroprotection. The selected publications were 49 experimental murine studies (period 1979-2020). The intervention reduced mortality (g 2.45, SE 0.48, p < .01), neuronal damage (g 1.96, SE 0.23, p < .01) and dysfunction (g 0.99, SE 0.10, p < .01). Reduction of mortality was particularly pronounced in the adult subgroup (g 2.71, SE 0.57, p < .01). The aggregated advantage of ketosis was stronger in the pediatric (g 3.98, SE 0.71, p < .01), brain (g 1.96, SE 0.18, p < .01), and ischemic insult (g 2.20, SE 0.23, p < .01) subgroups. Only the magnitude of intervention was a predictor of neuroprotection (g 0.07, SE 0.03, p 0.01 per every mmol/L increase in ketone levels). Ketosis exerts a potent neuroprotection against acute damage to the mammalian CNS in terms of reduction of mortality, of neuronal damage and dysfunction. Hematic levels of ketones are directly proportional to the effect size of neuroprotection.

Energy and the Alzheimer brain

The high energy demands of the poorly myelinated long axon hippocampal and cortical neurons render these neurons selectively vulnerable to degeneration in Alzheimer's disease. However, pathology engages all of the major elements of the neurovascular unit of the mature Alzheimer brain, the neurons, glia and blood vessels. Neurons present with retrograde degeneration of the axodendritic tree, capillaries with string vessels and markedly reduced densities and glia with signs of inflammatory activation. The neurons, capillaries and astrocytes of the mature Alzheimer brain harbor structurally defective mitochondria. Clinically, reduced glucose utilization, decades before cognitive deterioration, betrays ongoing energy insufficiency. β-hydroxybutyrate and γ-hydroxybutyrate can both provide energy to the brain when glucose utilization is blocked. Early work in mouse models of Alzheimer's disease demonstrate their ability to reverse the pathological changes in the Alzheimer brain and initial clinical trials reveal their ability to improve cognition and every day function. Supplying the brain with energy holds great promise for delaying the onset of Alzheimer's disease and slowing its progress.

Neuroprotection in diet-induced ketotic rat brain after focal ischemia

Neuroprotective properties of ketosis may be related to the upregulation of hypoxia inducible factor (HIF)-1alpha, a primary constituent associated with hypoxic angiogenesis and a regulator of neuroprotective responses. The rationale that the utilization of ketones by the brain results in elevation of intracellular succinate, a known inhibitor of prolyl hydroxylase (the enzyme responsible for the degradation of HIF-1alpha) was deemed as a potential mechanism of ketosis on the upregulation of HIF-1alpha. The neuroprotective effect of diet-induced ketosis (3 weeks of feeding a ketogenic diet), as pretreatment, on infarct volume, after reversible middle cerebral artery occlusion (MCAO), and the upregulation of HIF-1alpha were investigated. The effect of beta-hydroxybutyrate (BHB), as a pretreatment, via intraventricular infusion (4 days of infusion before stroke) was also investigated following MCAO. Levels of HIF-1alpha and Bcl-2 (anti-apoptotic protein) proteins and succinate content were measured. A 55% or 70% reduction in infarct volume was observed with BHB infusion or diet-induced ketosis, respectively. The levels of HIF-1alpha and Bcl-2 proteins increased threefold with diet-induced ketosis; BHB infusions also resulted in increases in these proteins. As hypothesized, succinate content increased by 55% with diet-induced ketosis and fourfold with BHB infusion. In conclusion, the biochemical link between ketosis and the stabilization of HIF-1alpha is through the elevation of succinate, and both HIF-1alpha stabilization and Bcl-2 upregulation play a role in ketone-induced neuroprotection in the brain.

Normoxic resuscitation after cardiac arrest protects against hippocampal oxidative stress, metabolic dysfunction, and neuronal death

Resuscitation and prolonged ventilation using 100% oxygen after cardiac arrest is standard clinical practice despite evidence from animal models indicating that neurologic outcome is improved using normoxic compared with hyperoxic resuscitation. This study tested the hypothesis that normoxic ventilation during the first hour after cardiac arrest in dogs protects against prelethal oxidative stress to proteins, loss of the critical metabolic enzyme pyruvate dehydrogenase complex (PDHC), and minimizes subsequent neuronal death in the hippocampus. Anesthetized beagles underwent 10 mins ventricular fibrillation cardiac arrest, followed by defibrillation and ventilation with either 21% or 100% O2. At 1 h after resuscitation, the ventilator was adjusted to maintain normal blood gas levels in both groups. Brains were perfusion-fixed at 2 h reperfusion and used for immunohistochemical measurements of hippocampal nitrotyrosine, a product of protein oxidation, and the E1alpha subunit of PDHC. In hyperoxic dogs, PDHC immunostaining diminished by approximately 90% compared with sham-operated dogs, while staining in normoxic animals was not significantly different from nonischemic dogs. Protein nitration in the hippocampal neurons of hyperoxic animals was 2-3 times greater than either sham-operated or normoxic resuscitated animals at 2 h reperfusion. Stereologic quantification of neuronal death at 24 h reperfusion showed a 40% reduction using normoxic compared with hyperoxic resuscitation. These results indicate that postischemic hyperoxic ventilation promotes oxidative stress that exacerbates prelethal loss of pyruvate dehydrogenase and delayed hippocampal neuronal cell death. Moreover, these findings indicate the need for clinical trials comparing the effects of different ventilatory oxygen levels on neurologic outcome after cardiac arrest.

Pyruvate dehydrogenase complex: metabolic link to ischemic brain injury and target of oxidative stress

The mammalian pyruvate dehydrogenase complex (PDHC) is a mitochondrial matrix enzyme complex (greater than 7 million Daltons) that catalyzes the oxidative decarboxylation of pyruvate to form acetyl CoA, nicotinamide adenine dinucleotide (the reduced form, NADH), and CO(2). This reaction constitutes the bridge between anaerobic and aerobic cerebral energy metabolism. PDHC enzyme activity and immunoreactivity are lost in selectively vulnerable neurons after cerebral ischemia and reperfusion. Evidence from experiments carried out in vitro suggests that reperfusion-dependent loss of activity is caused by oxidative protein modifications. Impaired enzyme activity may explain the reduced cerebral glucose and oxygen consumption that occurs after cerebral ischemia. This hypothesis is supported by the hyperoxidation of mitochondrial electron transport chain components and NAD(H) that occurs during reperfusion, indicating that NADH production, rather than utilization, is rate limiting. Additional support comes from the findings that immediate postischemic administration of acetyl-L-carnitine both reduces brain lactate/pyruvate ratios and improves neurologic outcome after cardiac arrest in animals. As acetyl-L-carnitine is converted to acetyl CoA, the product of the PDHC reaction, it follows that impaired production of NADH is due to reduced activity of either PDHC or one or more steps in glycolysis. Impaired cerebral energy metabolism and PDHC activity are associated also with neurodegenerative disorders including Alzheimer's disease and Wernicke-Korsakoff syndrome, suggesting that this enzyme is an important link in the pathophysiology of both acute brain injury and chronic neurodegeneration.

Acute ethanol administration and transient ischemia: a behavioral and neuropathological study

A pressing clinical question is how acute ethanol exposure might alter the outcome of a simultaneous transient ischemic attack (TIA), since ethanol is known to dysregulate key intermediary metabolites post-ischemia. Mongolian gerbils were administered ethanol (1 or 4 g/kg, s.c.) 1 hour before induction of transient ischemia, via bilateral carotid occlusions of 5 minutes duration. A control group was administered isotonic saline and rendered ischemic. All animals were maintained normothermic during the ischemic procedure. Subjects underwent behavioral assay of acquisition to the water maze 7 days after recovery from the surgery, and neuropathological examination 1-month after the ischemic brain insult. There were no behavioral or neuropathological between-group differences suggesting that mechanisms other than adverse ethanol-induced perturbations of ischemic processes predominate in mediating epidemiological findings of elevated stroke morbidity with high ethanol consumption.

The antioxidant defences of brain mitochondria during short-term forebrain ischemia and recirculation in the rat

This study evaluated changes in the antioxidant defences of mitochondria induced by 30 min of forebrain ischemia and recirculation up to 24 h in rats. Following treatment, mitochondria were isolated from two brain subregions: the dorsolateral striatum, an area in which there is loss of most neurons, and the paramedian cortex in which most neurons are resistant to damage. During ischemia and the first few hours of recirculation, the mitochondrial defences were largely preserved based on measurements of the activities of the enzymes, superoxide dismutase, glutathione peroxidase and glutathione reductase, as well as the response of the mitochondria to a subsequent exposure to H2O2 in vitro. However, some moderate changes were detected, particularly in the mitochondria from the dorsolateral striatum. A decrease of 30% in the activity of superoxide dismutase was seen at the conclusion of the ischemic period and a small increase in susceptibility to changes induced by H2O2 was detected during early recirculation. This latter change preceded and possibly contributed to the development of an impairment of respiratory function detected in mitochondria from the dorsolateral striatum at 3 h of recirculation. At 24 h of recirculation, larger changes were seen in the activities of all three of the enzymes in mitochondria from the dorsolateral striatum but not the paramedian cortex that was associated with progression to advanced neuronal damage in the former subregion.

Protective effects of the free radical scavengers, dimethyl sulfoxide and ethanol, in cerebral ischemia in gerbils

The effects of dimethyl sulfoxide (DMSO) and ethanol, which share an ability to scavenge free radicals, on ischemia/reperfusion-evoked injury to hippocampal CA1 pyramidal cells were evaluated in the Mongolian gerbil. Ischemia was induced by a 5 min period of bilateral common carotid artery occlusion followed by reperfusion for 5 days. Three groups of unanesthetized gerbils were injected intraperitoneally with either saline, DMSO (2.8 mmol/kg) or ethanol (2.0 mmol/kg) 30 min prior to ischemia. All three groups displayed significant increases in locomotor activity post-ischemia, with no differences between groups. The extent of CA1 pyramidal neuron loss was significantly reduced in the DMSO and ethanol treated gerbils. The results suggest that both agents may be useful as adjuvant therapies in the treatment of cerebral ischemia/reperfusion injury.

beta-Hydroxybutyrate fuels synaptic function during development. Histological and physiological evidence in rat hippocampal slices

To determine whether ketone bodies sustain neuronal function as energy substrates, we examined the effects of beta-hydroxybutyrate (betaHB) on synaptic transmission and morphological integrity during glucose deprivation in rat hippocampal slices. After the depression of excitatory postsynaptic potentials (EPSPs) by 60 min of glucose deprivation, administration of 0.5-10 mM D-betaHB restored EPSPs in slices from postnatal day (PND) 15 rats but not in slices from PND 30 or 120 rats. At PND 15, adding D-betaHB to the media allowed robust long-term potentiation of EPSPs triggered by high frequency stimulation, and prevented the EPSP-spike facilitation that suggests hyperexcitability of neurons. Even after PND 15,D-betaHB blocked morphological changes produced by either glucose deprivation or glycolytic inhibition. These results indicate that D-betaHB is not only able to substitute for glucose as an energy substrate but is also able to preserve neuronal integrity and stability, particularly during early development.

The effects of a butanediol treatment on acute focal cerebral ischemia assessed by quantitative diffusion and T2 MR imaging

Increased water T2 values indicates the presence of vasogenic edema. Decreased apparent diffusion coefficient (ADC) maps reveal ischemic areas displaying cytotoxic edema. ADC and T2 abnormalities spread through the middle cerebral artery (MCA) territory up to 24 h after middle cerebral artery occlusion (MCAO). Also, it was found that ADC and T2 contours closely match at 3.5 and 24 h. Since butanediol reduces vasogenic edema and improves energy status in various models of ischemia, we used these two techniques to investigate putative improvements in cytotoxic and vasogenic edema after permanent MCAO performed on rats. Rats were given no treatment (n = 8), or a treatment with 25 mmol/kg intraperitoneal (i.p.) butanediol (n = 5), 30 min before and 2.5 h after MCAO. Quantitative ADC and T2 maps of brain water were obtained, from which the volumes presenting abnormalities were calculated at various time points up to 24 h. Effects of butanediol on the ADC and T2 values in these areas were determined. Butanediol reduced neither the ADC volume nor the initial ADC decline. However, it reduced T2 volumes by 32% at 3.5 h and 15% at 24 h (p < 0.05), and reduced T2 increase in the striatum at 3.5 h post-MCAO. Therefore, our results show for the first time that a pharmacological agent such as butanediol can delay the development of vasogenic edema but does not limit the development of vasogenic edema but does not limit the development of cytotoxic edema. ADC imaging detects areas of severe metabolic disturbance but not moderately ischemic peripheral areas where butanediol is presumed to be more efficacious.

Calcium, energy metabolism and the development of selective neuronal loss following short-term cerebral ischemia

Short-term cerebral ischemia results in the delayed loss of specific neuronal subpopulations. This review discusses changes in energy metabolism and Ca2+ distribution during ischemia and recirculation and considers the possible contribution of these changes to the development of selective neuronal loss. Severe ischemia results in a rapid decline of ATP content and a subsequent large movement of Ca2+ from the extracellular to the intracellular space. Similar changes are seen in tissue subregions containing neurons destined to die and those areas largely resistant to short-term ischemia, although differences have been observed in Ca2+ uptake between individual neurons. The large accumulation of intracellular Ca2+ is widely considered as a critical initiating event in the development of of neuronal loss but, as yet, definitive evidence has not been obtained. the increased intracellular Ca2+ content activates a number of additional processes including lipolysis of phospholipids and degradation or inactivation of some specific proteins, all of which could contribute to altered function on restoration of blood flow to the brain. Reperfusion results in a rapid recovery of ATP production. Cytoplasmic Ca2+ concentration is also restored during early recirculation as a result of both removal to the extracellular space and uptake into mitochondria. Within a few hours of recirculation, subtle increases in intracellular Ca2+ and a reduced capacity for mitochondrial respiration have been detected in some ischemia-susceptible regions. Both of these changes could potentially contribute to the development of neuronal loss. More pronounced alterations in Ca2+ homeostasis, resulting in a second period of increased mitochondrial Ca2+, develop with further recirculation in ischemia-susceptible regions. The available evidence suggests that these increases in Ca2+, although developing late, are likely to precede the irreversible loss of neuronal function and may be a necessary contributor to the final stages of this process.

Biochemical changes associated with selective neuronal death following short-term cerebral ischaemia

A brief interruption of blood flow to the brain results in the selective loss of specific subpopulations of neurons. Important advances have been made in recent years in defining the biochemical changes associated with cerebral ischaemia and reperfusion and in identifying physical and chemical interventions capable of modifying the extent of neuronal loss. Neuronal death is not irreversibly determined by the ischaemic period but develops during recirculation over a period of hours or even days in different susceptible neuronal populations. The onset of ischaemia produces a rapid decline in ATP production and an associated major redistribution of ions across the plasma membrane including a large intracellular accumulation of Ca2+ in many neurons. Alterations subsequently develop in many other metabolites. These include a marked and progressive release of neurotransmitters and a rapid accumulation of free fatty acids. Most of these alterations are reversed within the first 20 min to 1 hr of recirculation. The changes essential for initiating damage in neurons destined to die have not been definitively identified although there is some evidence suggesting roles for the intracellular Ca2+ accumulation, the release of the neurotransmitter glutamate and a brief burst of free radical production which occurs during early recirculation. During further recirculation, there are reductions in oxidative glucose metabolism and protein synthesis in many brain regions. Few changes have been detected which distinguish tissue containing ischaemia-susceptible neurons from ischaemia-resistant regions until the development of advanced degeneration and neuronal loss. Subtle changes in cytoplasmic Ca2+ content and a decrease in the respiratory capacity of mitochondria are two changes apparently selectively affecting ischaemia-susceptible regions which could contribute to neuronal loss. The mitochondrial change may be one indicator of a slowly developing post-ischaemic increase in susceptibility to oxidative damage in some cells.