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Malliou A, Mitsiou C, Kyritsis AP, Alexiou GA. Therapeutic Hypothermia in Treating Glioblastoma: A Review. Ther Hypothermia Temp Manag 2024; 14:2-9. [PMID: 37184912 DOI: 10.1089/ther.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Glioblastoma (GBM) is the most commonly occurring of all malignant central nervous system (CNS) tumors in adults. Considering the low median survival of only ∼15 months and poor prognosis in GBM patients, despite surgical resection with adjuvant radiation and chemotherapy, it is vital to seek brand new and innovative treatment in combination with already existing methods. Hypothermia participates in many metabolic pathways, inflammatory responses, and apoptotic processes, while also promoting the integrity of neurons. Following the successful application of therapeutic hypothermia across a spectrum of disorders such as traumatic CNS injury, cardiac arrest, and epilepsy, several clinical trials have set to evaluate the potency of hypothermia in treating a variety of cancers, including breast and ovaries cancer. In regard to primary neoplasms and more specifically, GBM, hypothermia has recently shown promising results as an auxiliary treatment, reinforcing chemotherapy's efficacy. In this review, we discuss the recent advances in utilizing hypothermia as treatment for GBM and other cancers.
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Affiliation(s)
- Athina Malliou
- Neurosurgical Institute, University of Ioannina, Ioannina, Greece
| | | | | | - George A Alexiou
- Neurosurgical Institute, University of Ioannina, Ioannina, Greece
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2
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Whitelaw A, Thoresen M. Therapeutic Hypothermia for Hypoxic-Ischemic Brain Injury Is More Effective in Newborn Infants than in Older Patients: Review and Hypotheses. Ther Hypothermia Temp Manag 2023; 13:170-174. [PMID: 37638830 DOI: 10.1089/ther.2023.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Posthypoxic therapeutic hypothermia has been tested in newborn infants, with seven randomized trials showing consistent evidence of reduction in death, cerebral palsy, and cognitive impairment at school age. In contrast, randomized trials of hypothermia after cardiac arrest in adults have not shown consistent evidence of lasting neurological protection. The apparently greater effectiveness of therapeutic hypothermia in newborns may be due to important biological and clinical differences. One such difference is that adults are heavily colonized with microbes, and many have active inflammatory processes at the time of arrest, but few newborns are heavily colonized or infected at the time of birth. Inflammation can interfere with hypothermia's neuroprotection. A second difference is that apoptosis is more commonly the pathway of neuronal death in newborns than in adults. Hypothermia inhibits apoptosis but not necrosis. Newborns have a larger endogenous supply of stem cells (which reduce apoptosis) than adults and this may favor regeneration and protection from hypothermia and regeneration. A third difference is that immature oligodendroglia are more sensitive to free radical attack then mature oligodendroglia. Hypothermia reduces free radical release. In addition, immature brain has increased N-methyl-D-aspartate receptor subunits compared with adults and hypothermia reduces excitotoxic amino acids. Adults suffering cardiac arrest often have comorbidities such as diabetes, hypertension, and atherosclerosis, which complicate recovery, but newborn infants rarely have comorbidities before asphyxia. Adult hypothermia treatment may have been too short as no trial has cooled for longer than 48 hours, some only 24 or 12 hours, but neonatal therapeutic hypothermia has routinely lasted 72 hours. We hypothesize that this combination of differences favors the effectiveness of therapeutic hypothermia in newborn infants compared with adults.
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Affiliation(s)
- Andrew Whitelaw
- Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Marianne Thoresen
- Translational Health Sciences, University of Bristol, Bristol, United Kingdom
- Department of Physiology, Institute of Basic Medical Research, University of Oslo, Oslo, Norway
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Andelius TCK, Bøgh N, Pedersen MV, Omann C, Andersen M, Andersen HB, Hjortdal VE, Pedersen M, Rasmussen MB, Kyng KJ, Henriksen TB. Early changes in cerebral metabolism after perinatal hypoxia-ischemia: a study in normothermic and hypothermic piglets. Front Pediatr 2023; 11:1167396. [PMID: 37325341 PMCID: PMC10264796 DOI: 10.3389/fped.2023.1167396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Hypoxic ischemic encephalopathy (HIE) after a perinatal insult is a dynamic process that evolves over time. Therapeutic hypothermia (TH) is standard treatment for severe to moderate HIE. There is a lack of evidence on the temporal change and interrelation of the underlying mechanisms that constitute HIE under normal and hypothermic conditions. We aimed to describe early changes in intracerebral metabolism after a hypoxic-ischemic insult in piglets treated with and without TH and in controls. Methods Three devices were installed into the left hemisphere of 24 piglets: a probe measuring intracranial pressure, a probe measuring blood flow and oxygen tension, and a microdialysis catheter measuring lactate, glucose, glycerol, and pyruvate. After a standardized hypoxic ischemic insult, the piglets were randomized to either TH or normothermia. Results Glycerol, a marker of cell lysis, increased immediately after the insult in both groups. There was a secondary increase in glycerol in normothermic piglets but not in piglets treated with TH. Intracerebral pressure, blood flow, oxygen tension, and extracellular lactate remained stable during the secondary increase in glycerol. Conclusion This exploratory study depicted the development of the pathophysiological mechanisms in the hours following a perinatal hypoxic-ischemic insult with and without TH and controls.
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Affiliation(s)
- Ted C. K. Andelius
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Nikolaj Bøgh
- The MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Mette V. Pedersen
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Camilla Omann
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mads Andersen
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Hannah B. Andersen
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Vibeke E. Hjortdal
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Pedersen
- Comparative Medicine Lab, Aarhus University Hospital, Aarhus, Denmark
| | - Martin B. Rasmussen
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Kasper J. Kyng
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Tine B. Henriksen
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Ferroptosis: A Promising Therapeutic Target for Neonatal Hypoxic-Ischemic Brain Injury. Int J Mol Sci 2022; 23:ijms23137420. [PMID: 35806425 PMCID: PMC9267109 DOI: 10.3390/ijms23137420] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 02/06/2023] Open
Abstract
Ferroptosis is a type of programmed cell death caused by phospholipid peroxidation that has been implicated as a mechanism in several diseases resulting from ischemic-reperfusion injury. Most recently, ferroptosis has been identified as a possible key injury mechanism in neonatal hypoxic-ischemic brain injury (HIBI). This review summarizes the current literature regarding the different ferroptotic pathways, how they may be activated after neonatal HIBI, and which current or investigative interventions may attenuate ferroptotic cell death associated with neonatal HIBI.
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Taiwo AB, Okeniyi JA, Ogundare OE, Fatunla OA, Babatola OA, Akibu Oyelami O. Blood Pressure Profile and Trends in the Neonatal Transitioning Period: A Comparative Study of Term Asphyxiated and Healthy Newborns. Glob Pediatr Health 2022; 9:2333794X221099263. [PMID: 35592790 PMCID: PMC9112315 DOI: 10.1177/2333794x221099263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Extra-uterine transition difficulties including BP abnormalities have been documented following perinatal asphyxia. Aim. The study aimed to determine the BP changes in the early neonatal transitioning period. Method. This comparative, cross-sectional study was conducted at the Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria. Result. A total of 246 term babies were analyzed. Their mean (standard deviation) systolic, diastolic and mean arterial blood pressures (SBP, DBP, and MBP) at birth were 68.2 (9.0), 39.9 (7.0), and 49.4 (6.9) mmHg and 67.4 (7.9), 37.1 (6.1), and 47.2 (5.8) mmHg, respectively. Asphyxiated neonates had significantly higher initial DBP (P < .001) and MAP (P = .008), lower SBP (P < .001) and MAP (P = .024) at 6 hours and lower SBP at 12 hours after birth, statistically. Conclusion. This study showed that while the BP of healthy neonates steadily increases in the first 48 hours after birth, it fluctuated markedly within the first 12 hours of birth among asphyxiated babies.
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Affiliation(s)
| | - John Akintunde Okeniyi
- Department of paediatrics, Obafemi Awolowo Teaching Hospital, Ile -Ife, Osun State, Nigeria
| | | | | | | | - Oyeku Akibu Oyelami
- Department of paediatrics, Obafemi Awolowo Teaching Hospital, Ile -Ife, Osun State, Nigeria
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Lespay-Rebolledo C, Tapia-Bustos A, Perez-Lobos R, Vio V, Casanova-Ortiz E, Farfan-Troncoso N, Zamorano-Cataldo M, Redel-Villarroel M, Ezquer F, Quintanilla ME, Israel Y, Morales P, Herrera-Marschitz M. Sustained Energy Deficit Following Perinatal Asphyxia: A Shift towards the Fructose-2,6-bisphosphatase (TIGAR)-Dependent Pentose Phosphate Pathway and Postnatal Development. Antioxidants (Basel) 2021; 11:74. [PMID: 35052577 PMCID: PMC8773255 DOI: 10.3390/antiox11010074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022] Open
Abstract
Labor and delivery entail a complex and sequential metabolic and physiologic cascade, culminating in most circumstances in successful childbirth, although delivery can be a risky episode if oxygen supply is interrupted, resulting in perinatal asphyxia (PA). PA causes an energy failure, leading to cell dysfunction and death if re-oxygenation is not promptly restored. PA is associated with long-term effects, challenging the ability of the brain to cope with stressors occurring along with life. We review here relevant targets responsible for metabolic cascades linked to neurodevelopmental impairments, that we have identified with a model of global PA in rats. Severe PA induces a sustained effect on redox homeostasis, increasing oxidative stress, decreasing metabolic and tissue antioxidant capacity in vulnerable brain regions, which remains weeks after the insult. Catalase activity is decreased in mesencephalon and hippocampus from PA-exposed (AS), compared to control neonates (CS), in parallel with increased cleaved caspase-3 levels, associated with decreased glutathione reductase and glutathione peroxidase activity, a shift towards the TIGAR-dependent pentose phosphate pathway, and delayed calpain-dependent cell death. The brain damage continues long after the re-oxygenation period, extending for weeks after PA, affecting neurons and glial cells, including myelination in grey and white matter. The resulting vulnerability was investigated with organotypic cultures built from AS and CS rat newborns, showing that substantia nigra TH-dopamine-positive cells from AS were more vulnerable to 1 mM of H2O2 than those from CS animals. Several therapeutic strategies are discussed, including hypothermia; N-acetylcysteine; memantine; nicotinamide, and intranasally administered mesenchymal stem cell secretomes, promising clinical translation.
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Affiliation(s)
- Carolyne Lespay-Rebolledo
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
| | - Andrea Tapia-Bustos
- School of Pharmacy, Faculty of Medicine, Universidad Andres Bello, Santiago 8370149, Chile;
| | - Ronald Perez-Lobos
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
| | - Valentina Vio
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
| | - Emmanuel Casanova-Ortiz
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
| | - Nancy Farfan-Troncoso
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
| | - Marta Zamorano-Cataldo
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
| | - Martina Redel-Villarroel
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
| | - Fernando Ezquer
- Center for Regenerative Medicine, Faculty of Medicine-Clínica Alemana, Universidad del Desarrollo, Santiago 7710162, Chile;
| | - Maria Elena Quintanilla
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
| | - Yedy Israel
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
- Center for Regenerative Medicine, Faculty of Medicine-Clínica Alemana, Universidad del Desarrollo, Santiago 7710162, Chile;
| | - Paola Morales
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
- Department of Neuroscience, Faculty of Medicine, University of Chile, Santiago 8380453, Chile
| | - Mario Herrera-Marschitz
- Molecular & Clinical Pharmacology Program, ICBM, Faculty of Medicine, University of Chile, Santiago 8380453, Chile; (C.L.-R.); (R.P.-L.); (V.V.); (E.C.-O.); (N.F.-T.); (M.Z.-C.); (M.R.-V.); (M.E.Q.); (Y.I.)
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Free Radicals and Neonatal Brain Injury: From Underlying Pathophysiology to Antioxidant Treatment Perspectives. Antioxidants (Basel) 2021; 10:antiox10122012. [PMID: 34943115 PMCID: PMC8698308 DOI: 10.3390/antiox10122012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 01/23/2023] Open
Abstract
Free radicals play a role of paramount importance in the development of neonatal brain injury. Depending on the pathophysiological mechanisms underlying free radical overproduction and upon specific neonatal characteristics, such as the GA-dependent maturation of antioxidant defenses and of cerebrovascular autoregulation, different profiles of injury have been identified. The growing evidence on the detrimental effects of free radicals on the brain tissue has led to discover not only potential biomarkers for oxidative damage, but also possible neuroprotective therapeutic approaches targeting oxidative stress. While a more extensive validation of free radical biomarkers is required before considering their use in routine neonatal practice, two important treatments endowed with antioxidant properties, such as therapeutic hypothermia and magnesium sulfate, have become part of the standard of care to reduce the risk of neonatal brain injury, and other promising therapeutic strategies are being tested in clinical trials. The implementation of currently available evidence is crucial to optimize neonatal neuroprotection and to develop individualized diagnostic and therapeutic approaches addressing oxidative brain injury, with the final aim of improving the neurological outcome of this population.
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Li J, Cheng X, Fu D, Liang Y, Chen C, Deng W, He L. Autophagy of Spinal Microglia Affects the Activation of Microglia through the PI3K/AKT/mTOR Signaling Pathway. Neuroscience 2021; 482:77-86. [PMID: 34902496 DOI: 10.1016/j.neuroscience.2021.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 12/28/2022]
Abstract
Delayed paralysis occurs within some patients suffered from ischemic spinal cord injury (ISCI) due to the aorta occlusion during the repair surgery of thoracic and thoracoabdominal aortic aneurysms. Although mild hypothermia has been reported to improve ISCI and prolong the tolerance of rats to ISCI without inducing immediate paralysis, the mechanism remains unclear. Herein, the study revealed that the mild hypothermia treatment indeed partially improved the ISCI in rats caused by cross-clamping at the descending aorta. ISCI induced the excessive activation of microglia and moderate autophagy in the spinal cord tissues of rats, while mild hypothermia significantly induced autophagy and reversed the excessive activation of microglia in the spinal cord tissues of rats. In OGD-stimulated mouse microglia BV-2 cells, the excessive activation of microglia and moderate autophagy were also observed; in the rapamycin-treated OGD model in BV-2 cells, autophagy was significantly enhanced whereas the excessive activation of microglia was reversed. In both in vivo ISCI model in rats and in vitro OGD model in BV-2 cells, the PI3K/AKT/mTOR pathway showed to be inhibited, whereas the PI3K/AKT/mTOR pathway was further inhibited by mild hypothermia in ISCI rats or rapamycin treatment in OGD-stimulated BV-2 cells. In conclusion, enhanced autophagy might be the mechanism of inhibited microglia activation by hypothermia treatment in ISCI rats and by rapamycin treatment in OGD-stimulated BV-2 cells. Autophagy could be enhanced through inhibiting the PI3K/AKT/mTOR pathway.
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Affiliation(s)
- Jingjuan Li
- Department of Anesthesiology, The Fifth Affiliated Hospital of Southern Medical University, Guangzhou 510900, China
| | - Xin Cheng
- Department of Nephrology, The Affiliated Hospital of Guilin Medical University, Guilin 541000, China
| | - Dan Fu
- Department of Pediatrics, The Fifth Affiliated Hospital of Southern Medical University, Guangzhou 510900, China
| | - Yi Liang
- Department of Anesthesiology, Graduate College, Guilin Medical University, Guilin, Guangxi 541001, China
| | - Cai Chen
- Department of Anesthesiology, The Fifth Affiliated Hospital of Southern Medical University, Guangzhou 510900, China
| | - Wei Deng
- Department of Anesthesiology, Graduate College, Guilin Medical University, Guilin, Guangxi 541001, China
| | - Liang He
- Department of Anesthesiology, The Fifth Affiliated Hospital of Southern Medical University, Guangzhou 510900, China.
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Adams M, Brotschi B, Birkenmaier A, Schwendener K, Rathke V, Kleber M, Hagmann C. Process variations between Swiss units treating neonates with hypoxic-ischemic encephalopathy and their effect on short-term outcome. J Perinatol 2021; 41:2804-2812. [PMID: 34290374 PMCID: PMC8752440 DOI: 10.1038/s41372-021-01156-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 05/28/2021] [Accepted: 07/09/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To compare therapeutic hypothermia (TH) treatment of term and near-term neonates with hypoxic-ischemic encephalopathy (HIE) between neonatal units. STUDY DESIGN Population-based, retrospective analysis of TH initiation and maintenance, and of diagnostic imaging. The comparison between units was based on crude data analysis, indirect standardization, and adjusted logistic regression. RESULTS TH was provided to 570 neonates with HIE between 2011 and 2018 in 10 Swiss units. We excluded 121 off-protocol cooled neonates to avoid selection bias. Of the remaining 449 neonates, the outcome was favorable to international benchmarks, but there were large unit-to-unit variations in baseline perinatal data and TH management. A total of 5% neonates did not reach target temperature within 7 h (3-10% between units), and 29% experienced over- or undercooling (0-38%). CONCLUSION Although the neonates had favorable short-term outcomes, areas for improvement remain for Swiss units in both process and outcome measures.
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Affiliation(s)
- Mark Adams
- Newborn Research, Department of Neonatology, University and University Hospital Zurich, Zurich, Switzerland.
| | - Barbara Brotschi
- Division of Neonatology and Pediatric Intensive Care, Children's University Hospital Zurich, Zurich, Switzerland
| | - André Birkenmaier
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital St. Gallen, Neonatal and Pediatric Intensive Care Unit, St. Gallen, Switzerland
| | - Katharina Schwendener
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, Spitalstrasse, Lucerne, Switzerland
| | - Verena Rathke
- Division of Neonatology and Pediatric Intensive Care, Children's University Hospital Zurich, Zurich, Switzerland
| | - Michael Kleber
- Clinic of Neonatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Cornelia Hagmann
- Division of Neonatology and Pediatric Intensive Care, Children's University Hospital Zurich, Zurich, Switzerland
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Kamash P, Ding Y. Hypothermia promotes synaptic plasticity and protective effects in neurological diseases. Brain Circ 2021; 7:294-297. [PMID: 35071849 PMCID: PMC8757500 DOI: 10.4103/bc.bc_28_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/13/2021] [Accepted: 08/07/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Peter Kamash
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
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11
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Nitric oxide and the brain. Part 2: Effects following neonatal brain injury-friend or foe? Pediatr Res 2021; 89:746-752. [PMID: 32563184 DOI: 10.1038/s41390-020-1021-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/30/2020] [Accepted: 06/02/2020] [Indexed: 12/30/2022]
Abstract
Nitric oxide (NO) has critical roles in a wide variety of key biologic functions and has intricate transport mechanisms for delivery to key distal tissues under normal conditions. However, NO also plays important roles during disease processes, such as hypoxia-ischemia, asphyxia, neuro-inflammation, and retinopathy of prematurity. The effects of exogenous NO on the developing neonatal brain remain controversial. Inhaled NO (iNO) can be neuroprotective or toxic depending on a variety of factors, including cellular redox state, underlying disease processes, duration of treatment, and dose. This review identifies key gaps in knowledge that should prompt further investigation into the possible role of iNO as a therapeutic agent after injury to the brain. IMPACT: NO is a key signal mediator in the neonatal brain with neuroprotective and neurotoxic properties. iNO, a commonly used medication, has significant effects on the neonatal brain. Dosing, duration, and timing of administration of iNO can affect the developing brain. This review article summarizes the roles of NO in association with various disease processes that impact neonates, such as brain hypoxia-ischemia, asphyxia, retinopathy of prematurity, and neuroinflammation. The impact of this review is that it clearly describes gaps in knowledge, and makes the case for further, targeted studies in each of the identified areas.
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Phadke A, Kumble A, Ravikumar K. Early clinical outcome and complications associated in neonates with hypoxic ischemic encephalopathy grade II/III who underwent treatment with servo controlled whole-body therapeutic hypothermia: A prospective observational study. J Clin Neonatol 2021. [DOI: 10.4103/jcn.jcn_119_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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When is a potential new neuroprotective treatment ready for translation? Pediatr Res 2020; 87:620-621. [PMID: 31706257 DOI: 10.1038/s41390-019-0673-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 01/28/2023]
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Liao R, Wood TR, Nance E. Nanotherapeutic modulation of excitotoxicity and oxidative stress in acute brain injury. Nanobiomedicine (Rij) 2020; 7:1849543520970819. [PMID: 35186151 PMCID: PMC8855450 DOI: 10.1177/1849543520970819] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 10/13/2020] [Indexed: 12/20/2022] Open
Abstract
Excitotoxicity is a primary pathological process that occurs during stroke, traumatic brain injury (TBI), and global brain ischemia such as perinatal asphyxia. Excitotoxicity is triggered by an overabundance of excitatory neurotransmitters within the synapse, causing a detrimental cascade of excessive sodium and calcium influx, generation of reactive oxygen species, mitochondrial damage, and ultimately cell death. There are multiple potential points of intervention to combat excitotoxicity and downstream oxidative stress, yet there are currently no therapeutics clinically approved for this specific purpose. For a therapeutic to be effective against excitotoxicity, the therapeutic must accumulate at the disease site at the appropriate concentration at the right time. Nanotechnology can provide benefits for therapeutic delivery, including overcoming physiological obstacles such as the blood–brain barrier, protect cargo from degradation, and provide controlled release of a drug. This review evaluates the use of nano-based therapeutics to combat excitotoxicity in stroke, TBI, and hypoxia–ischemia with an emphasis on mitigating oxidative stress, and consideration of the path forward toward clinical translation.
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Affiliation(s)
- Rick Liao
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA
| | - Thomas R Wood
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, WA, USA
| | - Elizabeth Nance
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA.,Department of Radiology, University of Washington, Seattle, WA, USA.,Center on Human Development and Disability, University of Washington, Seattle, WA, USA
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15
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Solevåg AL, Schmölzer GM, Cheung PY. Novel interventions to reduce oxidative-stress related brain injury in neonatal asphyxia. Free Radic Biol Med 2019; 142:113-122. [PMID: 31039399 DOI: 10.1016/j.freeradbiomed.2019.04.028] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 04/15/2019] [Accepted: 04/23/2019] [Indexed: 01/10/2023]
Abstract
Perinatal asphyxia-induced brain injury may present as hypoxic-ischemic encephalopathy in the neonatal period, and disability including cerebral palsy in the long term. The brain injury is secondary to both the hypoxic-ischemic event and the reoxygenation-reperfusion following resuscitation. Early events in the cascade of brain injury can be classified as either inflammation or oxidative stress through the generation of free radicals. The objective of this paper is to present efforts that have been made to limit the oxidative stress associated with hypoxic-ischemic encephalopathy. In the acute phase of ischemia/hypoxia and reperfusion/reoxygenation, the outcomes of asphyxiated infants can be improved by optimizing the initial delivery room stabilization. Interventions include limiting oxygen exposure, and shortening the time to return of spontaneous circulation through improved methods for supporting hemodynamics and ventilation. Allopurinol, melatonin, noble gases such as xenon and argon, and magnesium administration also target the acute injury phase. Therapeutic hypothermia, N-acetylcysteine2-iminobiotin, remote ischemic postconditioning, cannabinoids and doxycycline target the subacute phase. Erythropoietin, mesenchymal stem cells, topiramate and memantine could potentially limit injury in the repair phase after asphyxia. To limit the injurious biochemical processes during the different stages of brain injury, determination of the stage of injury in any particular infant remains essential. Currently, therapeutic hypothermia is the only established treatment in the subacute phase of asphyxia-induced brain injury. The effects and side effects of oxidative stress reducing/limiting medications may however be difficult to predict in infants during therapeutic hypothermia. Future neuroprotection in asphyxiated infants may indeed include a combination of therapies. Challenges include timing, dosing and administration route for each neuroprotectant.
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Affiliation(s)
- A L Solevåg
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - G M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - P-Y Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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16
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Koehler RC, Yang ZJ, Lee JK, Martin LJ. Perinatal hypoxic-ischemic brain injury in large animal models: Relevance to human neonatal encephalopathy. J Cereb Blood Flow Metab 2018; 38:2092-2111. [PMID: 30149778 PMCID: PMC6282216 DOI: 10.1177/0271678x18797328] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Perinatal hypoxia-ischemia resulting in death or lifelong disabilities remains a major clinical disorder. Neonatal models of hypoxia-ischemia in rodents have enhanced our understanding of cellular mechanisms of neural injury in developing brain, but have limitations in simulating the range, accuracy, and physiology of clinical hypoxia-ischemia and the relevant systems neuropathology that contribute to the human brain injury pattern. Large animal models of perinatal hypoxia-ischemia, such as partial or complete asphyxia at the time of delivery of fetal monkeys, umbilical cord occlusion and cerebral hypoperfusion at different stages of gestation in fetal sheep, and severe hypoxia and hypoperfusion in newborn piglets, have largely overcome these limitations. In monkey, complete asphyxia produces preferential injury to cerebellum and primary sensory nuclei in brainstem and thalamus, whereas partial asphyxia produces preferential injury to somatosensory and motor cortex, basal ganglia, and thalamus. Mid-gestational fetal sheep provide a valuable model for studying vulnerability of progenitor oligodendrocytes. Hypoxia followed by asphyxia in newborn piglets replicates the systems injury seen in term newborns. Efficacy of post-insult hypothermia in animal models led to the success of clinical trials in term human neonates. Large animal models are now being used to explore adjunct therapy to augment hypothermic neuroprotection.
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Affiliation(s)
- Raymond C Koehler
- 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Zeng-Jin Yang
- 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer K Lee
- 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.,2 The Pathobiology Graduate Training Program, Johns Hopkins University, Baltimore, MD, USA
| | - Lee J Martin
- 2 The Pathobiology Graduate Training Program, Johns Hopkins University, Baltimore, MD, USA.,3 Department of Pathology, Division of Neuropathology, Johns Hopkins University, Baltimore, MD, USA
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17
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Barata L, Arruza L, Rodríguez MJ, Aleo E, Vierge E, Criado E, Sobrino E, Vargas C, Ceprián M, Gutiérrez-Rodríguez A, Hind W, Martínez-Orgado J. Neuroprotection by cannabidiol and hypothermia in a piglet model of newborn hypoxic-ischemic brain damage. Neuropharmacology 2018; 146:1-11. [PMID: 30468796 DOI: 10.1016/j.neuropharm.2018.11.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/31/2018] [Accepted: 11/13/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Hypothermia, the gold standard after a hypoxic-ischemic insult, is not beneficial in all treated newborns. Cannabidiol is neuroprotective in animal models of newborn hypoxic-ischemic encephalopathy. This study compared the relative efficacies of cannabidiol and hypothermia in newborn hypoxic-ischemic piglets and assessed whether addition of cannabidiol augments hypothermic neuroprotection. METHODS One day-old HI (carotid clamp and FiO2 10% for 20 min) piglets were randomized to vehicle or cannabidiol 1 mg/kg i.v. u.i.d. for three doses after being submitted to normothermia or 48 h-long hypothermia with a subsequent rewarming period of 6 h. Non-manipulated piglets (naïve) served as controls. Hemodynamic or respiratory parameters as well as brain activity (aEEG amplitude) were monitored throughout the experiment. Following termination, brains were obtained for histological (TUNEL staining, apoptosis; immunohistochemistry for Iba-1, microglia), biochemical (protein carbonylation, oxidative stress; and TNFα concentration, neuroinflammation) or proton magnetic resonance spectroscopy (Lac/NAA: metabolic derangement; Glu/NAA: excitotoxicity). RESULTS HI led to sustained depressed brain activity and increased microglial activation, which was significantly improved by cannabidiol alone or with hypothermia but not by hypothermia alone. Hypoxic-ischemic-induced increases in Lac/NAA, Glu/NAA, TNFα or apoptosis were not reversed by either hypothermia or cannabidiol alone, but combination of the therapies did. No treatment modified the effects of HI on oxidative stress or astroglial activation. Cannabidiol treatment was well tolerated. CONCLUSIONS cannabidiol administration after hypoxia-ischemia in piglets offers some neuroprotective effects but the combination of cannabidiol and hypothermia shows some additive effect leading to more complete neuroprotection than cannabidiol or hypothermia alone.
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Affiliation(s)
- Lorena Barata
- Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain; Instituto de Investigación Puerta de Hierro Majadahonda, Spain
| | - Luis Arruza
- Servicio de Neonatología, Hospital Clínico San Carlos - IdISSC, Madrid, Spain
| | | | - Esther Aleo
- Servicio de Neonatología, Hospital Clínico San Carlos - IdISSC, Madrid, Spain
| | - Eva Vierge
- Servicio de Neonatología, Hospital Clínico San Carlos - IdISSC, Madrid, Spain
| | - Enrique Criado
- Servicio de Neonatología, Hospital Clínico San Carlos - IdISSC, Madrid, Spain
| | - Elena Sobrino
- Instituto de Investigación Puerta de Hierro Majadahonda, Spain
| | - Carlos Vargas
- Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - María Ceprián
- Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain; Departamento de Bioquímica y Biología Molecular, CIBERNED, IRICYS. Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | | | | | - José Martínez-Orgado
- Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain; Servicio de Neonatología, Hospital Clínico San Carlos - IdISSC, Madrid, Spain.
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18
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Abstract
Xenon is an inert, highly polarizable noble gas with demonstrated safety and application in general anesthesia for over 50 years. A potent inhibitor of the N-methyl-D-aspartate subtype of glutamate receptors, xenon has a well-documented ameliorating effect on excitotoxic neuronal injury in numerous cellular and animal models of hypoxic-ischemic brain injury. The most important determinant of overall survival and morbidity in out-of-hospital cardiac arrest is the severity of neurological injury. The only approved neuroprotective strategy in this setting is mild therapeutic hypothermia, which has demonstrated significant, albeit modest, improvements in mortality. The combination therapy of therapeutic hypothermia and xenon in porcine models of cardiac arrest has shown a greater improvement in functional outcomes than either intervention alone, thereby prompting the study of combination therapy in randomized clinical trials. The treatment of postarrest patients with xenon and mild hypothermia is safe and demonstrates favorable cardiovascular features, including a reduced heart rate, a reduction in troponin elevations, and a decreased need for vasopressors. Combination therapy is superior in protecting white matter integrity than hypothermia alone, but did not significantly impact neurological outcomes at 6-month follow-up. Despite an abundance of preclinical evidence supporting xenon's neuroprotective properties, its translational potential in postcardiac arrest care is indeterminate due to a lack of adequately-powered studies.
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19
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Davidson JO, Dhillon SK, Wassink G, Zhou KQ, Bennet L, Gunn AJ. Endogenous neuroprotection after perinatal hypoxia-ischaemia: the resilient developing brain. J R Soc N Z 2018. [DOI: 10.1080/03036758.2018.1529685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Joanne O. Davidson
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Simerdeep K. Dhillon
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Guido Wassink
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Kelly Q. Zhou
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Alistair J. Gunn
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
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20
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Rocha-Ferreira E, Poupon L, Zelco A, Leverin AL, Nair S, Jonsdotter A, Carlsson Y, Thornton C, Hagberg H, Rahim AA. Neuroprotective exendin-4 enhances hypothermia therapy in a model of hypoxic-ischaemic encephalopathy. Brain 2018; 141:2925-2942. [PMID: 30165597 PMCID: PMC6158761 DOI: 10.1093/brain/awy220] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/20/2018] [Accepted: 07/12/2018] [Indexed: 12/29/2022] Open
Abstract
Hypoxic-ischaemic encephalopathy remains a global health burden. Despite medical advances and treatment with therapeutic hypothermia, over 50% of cooled infants are not protected and still develop lifelong neurodisabilities, including cerebral palsy. Furthermore, hypothermia is not used in preterm cases or low resource settings. Alternatives or adjunct therapies are urgently needed. Exendin-4 is a drug used to treat type 2 diabetes mellitus that has also demonstrated neuroprotective properties, and is currently being tested in clinical trials for Alzheimer's and Parkinson's diseases. Therefore, we hypothesized a neuroprotective effect for exendin-4 in neonatal neurodisorders, particularly in the treatment of neonatal hypoxic-ischaemic encephalopathy. Initially, we confirmed that the glucagon like peptide 1 receptor (GLP1R) was expressed in the human neonatal brain and in murine neurons at postnatal Day 7 (human equivalent late preterm) and postnatal Day 10 (term). Using a well characterized mouse model of neonatal hypoxic-ischaemic brain injury, we investigated the potential neuroprotective effect of exendin-4 in both postnatal Day 7 and 10 mice. An optimal exendin-4 treatment dosing regimen was identified, where four high doses (0.5 µg/g) starting at 0 h, then at 12 h, 24 h and 36 h after postnatal Day 7 hypoxic-ischaemic insult resulted in significant brain neuroprotection. Furthermore, neuroprotection was sustained even when treatment using exendin-4 was delayed by 2 h post hypoxic-ischaemic brain injury. This protective effect was observed in various histopathological markers: tissue infarction, cell death, astrogliosis, microglial and endothelial activation. Blood glucose levels were not altered by high dose exendin-4 administration when compared to controls. Exendin-4 administration did not result in adverse organ histopathology (haematoxylin and eosin) or inflammation (CD68). Despite initial reduced weight gain, animals restored weight gain following end of treatment. Overall high dose exendin-4 administration was well tolerated. To mimic the clinical scenario, postnatal Day 10 mice underwent exendin-4 and therapeutic hypothermia treatment, either alone or in combination, and brain tissue loss was assessed after 1 week. Exendin-4 treatment resulted in significant neuroprotection alone, and enhanced the cerebroprotective effect of therapeutic hypothermia. In summary, the safety and tolerance of high dose exendin-4 administrations, combined with its neuroprotective effect alone or in conjunction with clinically relevant hypothermia make the repurposing of exendin-4 for the treatment of neonatal hypoxic-ischaemic encephalopathy particularly promising.
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Affiliation(s)
- Eridan Rocha-Ferreira
- Centre of Perinatal Medicine and Health, Institute of Clinical Sciences, Department of Obstetrics and Gynecology & Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
- EGA Institute for Women’s Health, University College London, UK
| | - Laura Poupon
- UCL School of Pharmacy, University College London, UK
| | - Aura Zelco
- UCL School of Pharmacy, University College London, UK
| | - Anna-Lena Leverin
- Centre of Perinatal Medicine and Health, Institute of Clinical Sciences, Department of Obstetrics and Gynecology & Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Syam Nair
- Centre of Perinatal Medicine and Health, Institute of Clinical Sciences, Department of Obstetrics and Gynecology & Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Andrea Jonsdotter
- Centre of Perinatal Medicine and Health, Institute of Clinical Sciences, Department of Obstetrics and Gynecology & Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ylva Carlsson
- Centre of Perinatal Medicine and Health, Institute of Clinical Sciences, Department of Obstetrics and Gynecology & Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Claire Thornton
- Department of Women and Children’s Health, Centre for the Developing Brain, School of Life Course Sciences, King’s College London, UK
| | - Henrik Hagberg
- Centre of Perinatal Medicine and Health, Institute of Clinical Sciences, Department of Obstetrics and Gynecology & Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
- Department of Perinatal Imaging and Health, Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King s College London, UK
| | - Ahad A Rahim
- UCL School of Pharmacy, University College London, UK
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21
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Huun MU, Garberg H, Løberg EM, Escobar J, Martinez-Orgado J, Saugstad OD, Solberg R. DHA and therapeutic hypothermia in a short-term follow-up piglet model of hypoxia-ischemia: Effects on H+MRS biomarkers. PLoS One 2018; 13:e0201895. [PMID: 30086156 PMCID: PMC6080779 DOI: 10.1371/journal.pone.0201895] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/24/2018] [Indexed: 12/22/2022] Open
Abstract
Background Therapeutic hypothermia has become the standard of care for newborns with hypoxic-ischemic encephalopathy in high and middle income countries. Docosahexaenoic acid (DHA) has neuroprotective properties of reducing excitotoxicity, neuroinflammation and apoptosis in rodent models. We aim to study whether post hypoxic administration of i.v. DHA will reduce H+MRS biomarkers and gene expression of inflammation and apoptosis both with and without hypothermia in a large animal model. Methods Fifty-five piglets were randomized to severe global hypoxia (N = 48) or not (Sham, N = 7). Hypoxic piglets were further randomized by factorial design: Vehicle (VEH), DHA, VEH + Hypothermia (HT), or DHA + HT. 5 mg/kg DHA was given intravenously 210 min after end of hypoxia. Two-way ANOVA analyses were performed with DHA and hypothermia as main effects. Results Cortical lactate/N-acetylaspartate (Lac/NAA) was significantly reduced in DHA + HT compared to HT. DHA had significant main effects on increasing N-acetylaspartate and glutathione in hippocampus. Therapeutic hypothermia significantly reduced the Lac/NAA ratio and protein expression of IL-1β and TNFα in hippocampus and reduced Troponin T in serum. Neuropathology showed significant differences between sham and hypoxia, but no differences between intervention groups. Conclusion DHA and therapeutic hypothermia significantly improve specific H+MRS biomarkers in this short-term follow up model of hypoxia-ischemia. Longer recovery periods are needed to evaluate whether DHA can offer translational neuroprotection.
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Affiliation(s)
- Marianne Ullestad Huun
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
- * E-mail:
| | - Håvard Garberg
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Else Marit Løberg
- Department of Pathology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Javier Escobar
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Neonatal Research Unit, Health Research Institute Hospital La Fe, Valencia, Spain
| | | | - Ola Didrik Saugstad
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Rønnaug Solberg
- Department of Pediatric Research, Women and Children's Division and Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Department of Pediatrics, Vestfold Hospital Trust, Tønsberg, Norway
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22
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Amer AR, Oorschot DE. Xenon Combined With Hypothermia in Perinatal Hypoxic-Ischemic Encephalopathy: A Noble Gas, a Noble Mission. Pediatr Neurol 2018; 84:5-10. [PMID: 29887039 DOI: 10.1016/j.pediatrneurol.2018.02.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 02/21/2018] [Indexed: 12/14/2022]
Abstract
Perinatal hypoxia-ischemia is a major cause of neonatal morbidity. It generates primary neuronal damage of the neonatal brain and later secondary damage when reperfusion of the ischemic brain tissue causes a surge of oxygen free radicals and inflammation. This post-hypoxic-ischemic brain damage is a leading cause of motor and intellectual disabilities in survivors. Research worldwide has focused on mitigating this injury. Mild or moderate hypothermia is the standard treatment in many centers. However, its benefit is modest and the search for combinatorial effective neuroprotectants continues. This review focuses on xenon as one such agent. The use of mild to moderate hypothermia is reviewed first. Then promising results on the use of xenon to potentiate the effect of hypothermia in in vitro and in vivo animal experiments are discussed. In the first feasibility study on human neonates, researchers found a significant benefit of using 50% xenon for 18 hours in addition to 72 hours of hypothermia. Yet, this additional benefit of xenon was lacking in a larger cohort study, potentially because xenon was used beyond six hours of birth. The future of using xenon is promising, but further clinical studies are awaited to confirm the feasibility of its routine use and its optimal timing, concentration, and duration, for human neonatal hypoxia-ischemia.
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Affiliation(s)
- Ashraf R Amer
- Department of Anatomy, School of Biomedical Sciences and the Brain Health Research Center, University of Otago, Dunedin, New Zealand
| | - Dorothy E Oorschot
- Department of Anatomy, School of Biomedical Sciences and the Brain Health Research Center, University of Otago, Dunedin, New Zealand.
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23
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Zhang Z, Zhang L, Ding Y, Han Z, Ji X. Effects of Therapeutic Hypothermia Combined with Other Neuroprotective Strategies on Ischemic Stroke: Review of Evidence. Aging Dis 2018; 9:507-522. [PMID: 29896438 PMCID: PMC5988605 DOI: 10.14336/ad.2017.0628] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 06/28/2017] [Indexed: 12/19/2022] Open
Abstract
Ischemic stroke is a major cause of death and disability globally, and its incidence is increasing. The only treatment approved by the US Food and Drug Administration for acute ischemic stroke is thrombolytic treatment with recombinant tissue plasminogen activator. As an alternative, therapeutic hypothermia has shown excellent potential in preclinical and small clinical studies, but it has largely failed in large clinical studies. This has led clinicians to explore the combination of therapeutic hypothermia with other neuroprotective strategies. This review examines preclinical and clinical progress towards developing highly effective combination therapy involving hypothermia for stroke patients.
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Affiliation(s)
- Zheng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurology, the First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Linlei Zhang
- Department of Neurology, the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Yuchuan Ding
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Zhao Han
- Department of Neurology, the Second Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
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24
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Wassink G, Davidson JO, Lear CA, Juul SE, Northington F, Bennet L, Gunn AJ. A working model for hypothermic neuroprotection. J Physiol 2018; 596:5641-5654. [PMID: 29660115 DOI: 10.1113/jp274928] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/28/2018] [Indexed: 01/04/2023] Open
Abstract
Therapeutic hypothermia significantly improves survival without disability in near-term and full-term newborns with moderate to severe hypoxic-ischaemic encephalopathy. However, hypothermic neuroprotection is incomplete. The challenge now is to find ways to further improve outcomes. One major limitation to progress is that the specific mechanisms of hypothermia are only partly understood. Evidence supports the concept that therapeutic cooling suppresses multiple extracellular death signals, including intracellular pathways of apoptotic and necrotic cell death and inappropriate microglial activation. Thus, the optimal depth of induced hypothermia is that which effectively suppresses the cell death pathways after hypoxia-ischaemia, but without inhibiting recovery of the cellular environment. Thus mild hypothermia needs to be continued until the cell environment has recovered until it can actively support cell survival. This review highlights that key survival cues likely include the inter-related restoration of neuronal activity and growth factor release. This working model suggests that interventions that target overlapping mechanisms, such as anticonvulsants, are unlikely to materially augment hypothermic neuroprotection. We suggest that further improvements are most likely to be achieved with late interventions that maximise restoration of the normal cell environment after therapeutic hypothermia, such as recombinant human erythropoietin or stem cell therapy.
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Affiliation(s)
- Guido Wassink
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | | | - Sandra E Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Frances Northington
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Laura Bennet
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, University of Auckland, Auckland, New Zealand
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25
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Ahn SY, Chang YS, Sung DK, Sung SI, Park WS. Hypothermia broadens the therapeutic time window of mesenchymal stem cell transplantation for severe neonatal hypoxic ischemic encephalopathy. Sci Rep 2018; 8:7665. [PMID: 29769612 PMCID: PMC5955959 DOI: 10.1038/s41598-018-25902-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/26/2018] [Indexed: 01/06/2023] Open
Abstract
Recently, we have demonstrated that concurrent hypothermia and mesenchymal stem cells (MSCs) transplantation synergistically improved severe neonatal hypoxic ischemic encephalopathy (HIE). The current study was designed to determine whether hypothermia could extend the therapeutic time window of MSC transplantation for severe neonatal HIE. To induce HIE, newborn rat pups were exposed to 8% oxygen for 2 h following unilateral carotid artery ligation on postnatal day (P) 7. After approving severe HIE involving >50% of the ipsilateral hemisphere volume, hypothermia (32 °C) for 2 days was started. MSCs were transplanted 2 days after HIE modeling. Follow-up brain MRI, sensorimotor function tests, assessment of inflammatory cytokines in the cerebrospinal fluid (CSF), and histological evaluation of peri-infarction area were performed. HIE induced progressively increasing brain infarction area over time, increased cell death, reactive gliosis and brain inflammation, and impaired sensorimotor function. All these damages observed in severe HIE showed better, robust improvement with a combination treatment of hypothermia and delayed MSC transplantation than with either stand-alone therapy. Hypothermia itself did not significantly reduce brain injury, but broadened the therapeutic time window of MSC transplantation for severe newborn HIE.
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Affiliation(s)
- So Yoon Ahn
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, South Korea
| | - Yun Sil Chang
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea.,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, South Korea
| | - Dong Kyung Sung
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, South Korea
| | - Se In Sung
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, South Korea
| | - Won Soon Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea. .,Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea. .,Stem Cell and Regenerative Medicine Institute, Samsung Medical Center, Seoul, South Korea.
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26
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Herrera-Marschitz M, Perez-Lobos R, Lespay-Rebolledo C, Tapia-Bustos A, Casanova-Ortiz E, Morales P, Valdes JL, Bustamante D, Cassels BK. Targeting Sentinel Proteins and Extrasynaptic Glutamate Receptors: a Therapeutic Strategy for Preventing the Effects Elicited by Perinatal Asphyxia? Neurotox Res 2018; 33:461-473. [PMID: 28844085 PMCID: PMC5766721 DOI: 10.1007/s12640-017-9795-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 12/29/2022]
Abstract
Perinatal asphyxia (PA) is a relevant cause of death at the time of labour, and when survival is stabilised, associated with short- and long-term developmental disabilities, requiring inordinate care by health systems and families. Its prevalence is high (1 to 10/1000 live births) worldwide. At present, there are few therapeutic options, apart from hypothermia, that regrettably provides only limited protection if applied shortly after the insult.PA implies a primary and a secondary insult. The primary insult relates to the lack of oxygen, and the secondary one to the oxidative stress triggered by re-oxygenation, formation of reactive oxygen (ROS) and reactive nitrogen (RNS) species, and overactivation of glutamate receptors and mitochondrial deficiencies. PA induces overactivation of a number of sentinel proteins, including hypoxia-induced factor-1α (HIF-1α) and the genome-protecting poly(ADP-ribose) polymerase-1 (PARP-1). Upon activation, PARP-1 consumes high amounts of ATP at a time when this metabolite is scarce, worsening in turn the energy crisis elicited by asphyxia. The energy crisis also impairs ATP-dependent transport, including glutamate re-uptake by astroglia. Nicotinamide, a PARP-1 inhibitor, protects against the metabolic cascade elicited by the primary stage, avoiding NAD+ exhaustion and the energetic crisis. Upon re-oxygenation, however, oxidative stress leads to nuclear translocation of the NF-κB subunit p65, overexpression of the pro-inflammatory cytokines IL-1β and TNF-α, and glutamate-excitotoxicity, due to impairment of glial-glutamate transport, extracellular glutamate overflow, and overactivation of NMDA receptors, mainly of the extrasynaptic type. This leads to calcium influx, mitochondrial impairment, and inactivation of antioxidant enzymes, increasing further the activity of pro-oxidant enzymes, thereby making the surviving neonate vulnerable to recurrent metabolic insults whenever oxidative stress is involved. Here, we discuss evidence showing that (i) inhibition of PARP-1 overactivation by nicotinamide and (ii) inhibition of extrasynaptic NMDA receptor overactivation by memantine can prevent the short- and long-term consequences of PA. These hypotheses have been evaluated in a rat preclinical model of PA, aiming to identify the metabolic cascades responsible for the long-term consequences induced by the insult, also assessing postnatal vulnerability to recurrent oxidative insults. Thus, we present and discuss evidence demonstrating that PA induces long-term changes in metabolic pathways related to energy and oxidative stress, priming vulnerability of cells with both the neuronal and the glial phenotype. The effects induced by PA are region dependent, the substantia nigra being particularly prone to cell death. The issue of short- and long-term consequences of PA provides a framework for addressing a fundamental issue referred to plasticity of the CNS, since the perinatal insult triggers a domino-like sequence of events making the developing individual vulnerable to recurrent adverse conditions, decreasing his/her coping repertoire because of a relevant insult occurring at birth.
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Affiliation(s)
- Mario Herrera-Marschitz
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
| | - Ronald Perez-Lobos
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
- Escuela de Tecnologia Medica, Facultad de Medicina, Universidad Andres Bello, PO Box 8370146, Santiago, Chile
| | - Carolyne Lespay-Rebolledo
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
| | - Andrea Tapia-Bustos
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
| | - Emmanuel Casanova-Ortiz
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
| | - Paola Morales
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
- Faculty of Sciences, University of Chile, Santiago, Chile
| | | | - Diego Bustamante
- Programme of Molecular & Clinical Pharmacology, ICBM, Faculty of Medicine, University of Chile, Av. Independencia, PO Box 8389100, 1027 Santiago, Chile
| | - Bruce K. Cassels
- Department of Neuroscience, Faculty of Medicine, University of Chile, Santiago, Chile
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Therapeutic hypothermia translates from ancient history in to practice. Pediatr Res 2017; 81:202-209. [PMID: 27673420 PMCID: PMC5233584 DOI: 10.1038/pr.2016.198] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/28/2016] [Indexed: 12/16/2022]
Abstract
Acute postasphyxial encephalopathy around the time of birth remains a major cause of death and disability. The possibility that hypothermia may be able to prevent or lessen asphyxial brain injury is a "dream revisited". In this review, a historical perspective is provided from the first reported use of therapeutic hypothermia for brain injuries in antiquity, to the present day. The first uncontrolled trials of cooling for resuscitation were reported more than 50 y ago. The seminal insight that led to the modern revival of studies of neuroprotection was that after profound asphyxia, many brain cells show initial recovery from the insult during a short "latent" phase, typically lasting ~6 h, only to die hours to days later during a "secondary" deterioration phase characterized by seizures, cytotoxic edema, and progressive failure of cerebral oxidative metabolism. Studies designed around this conceptual framework showed that mild hypothermia initiated as early as possible before the onset of secondary deterioration, and continued for a sufficient duration to allow the secondary deterioration to resolve, is associated with potent, long-lasting neuroprotection. There is now compelling evidence from randomized controlled trials that mild induced hypothermia significantly improves intact survival and neurodevelopmental outcomes to midchildhood.
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Giesinger RE, Bailey LJ, Deshpande P, McNamara PJ. Hypoxic-Ischemic Encephalopathy and Therapeutic Hypothermia: The Hemodynamic Perspective. J Pediatr 2017; 180:22-30.e2. [PMID: 27742125 DOI: 10.1016/j.jpeds.2016.09.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/13/2016] [Accepted: 09/07/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Regan E Giesinger
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Liane J Bailey
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Poorva Deshpande
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Patrick J McNamara
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada.
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Glucose and Intermediary Metabolism and Astrocyte–Neuron Interactions Following Neonatal Hypoxia–Ischemia in Rat. Neurochem Res 2016; 42:115-132. [DOI: 10.1007/s11064-016-2149-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 12/09/2016] [Accepted: 12/10/2016] [Indexed: 11/27/2022]
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Lee YK, Penn A, Patel M, Pandit R, Song D, Ha BY. Hypothermia-treated neonates with hypoxic-ischemic encephalopathy: Optimal timing of quantitative ADC measurement to predict disease severity. Neuroradiol J 2016; 30:28-35. [PMID: 27881816 DOI: 10.1177/1971400916678229] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
To determine the optimal time window for MR imaging with quantitative ADC measurement in neonatal HIE after hypothermia treatment, a retrospective review was performed on consecutive hypothermia-treated term neonates with HIE, with an initial and follow-up MR imaging within the first two weeks of life. Three neuroradiologists categorized each set of MR imaging as normal, mild, moderate or severe HIE based on a consensus review of the serial imaging. The lowest ADC values from the white matter, corpus callosum, and basal ganglia/thalamus were measured. The ADC values between mild-moderate and severe HIE were compared using a Student's t-test over a range of different time windows. A total of 33 MR imaging examinations were performed on 16 neonates that included three normal, four mild, five moderate, and four severe HIE. The time window of 3-10 days showed a statistically significant decrease in ADC value in severe HIE compared to mild-moderate HIE in all three locations, respectively: white matter 0.5 ± 0.22 versus 0.83 ± 0.27 ( p value 0.01), corpus callosum 0.69 ± 0.19 versus 0.91 ± 0.17 ( p value 0.01), and basal ganglia/thalamus 0.63 ± 0.16 versus 0.98 ± 0.06 ( p value <0.01). The range of 3-10 days is the optimal time window for MR imaging with quantitative ADC after hypothermia treatment.
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Affiliation(s)
- Yauk K Lee
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Alex Penn
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Mahesh Patel
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Rajul Pandit
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
| | - Dongli Song
- 2 Department of Pediatrics, Santa Clara Valley Medical Center, USA
| | - Bo Yoon Ha
- 1 Department of Radiology, Santa Clara Valley Medical Center, USA
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Lingam I, Avdic-Belltheus A, Robertson NJ. Using animal models to improve care of neonatal encephalopathy. Arch Dis Child Educ Pract Ed 2016; 101:271-6. [PMID: 27147551 DOI: 10.1136/archdischild-2015-309927] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 04/13/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Ingran Lingam
- Institute for Women's Health, University College London, London, UK
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Lafuente H, Pazos MR, Alvarez A, Mohammed N, Santos M, Arizti M, Alvarez FJ, Martinez-Orgado JA. Effects of Cannabidiol and Hypothermia on Short-Term Brain Damage in New-Born Piglets after Acute Hypoxia-Ischemia. Front Neurosci 2016; 10:323. [PMID: 27462203 PMCID: PMC4940392 DOI: 10.3389/fnins.2016.00323] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/27/2016] [Indexed: 12/12/2022] Open
Abstract
Hypothermia is a standard treatment for neonatal encephalopathy, but nearly 50% of treated infants have adverse outcomes. Pharmacological therapies can act through complementary mechanisms with hypothermia improving neuroprotection. Cannabidiol could be a good candidate. Our aim was to test whether immediate treatment with cannabidiol and hypothermia act through complementary brain pathways in hypoxic-ischemic newborn piglets. Hypoxic-ischemic animals were randomly divided into four groups receiving 30 min after the insult: (1) normothermia and vehicle administration; (2) normothermia and cannabidiol administration; (3) hypothermia and vehicle administration; and (4) hypothermia and cannabidiol administration. Six hours after treatment, brains were processed to quantify the number of damaged neurons by Nissl staining. Proton nuclear magnetic resonance spectra were obtained and analyzed for lactate, N-acetyl-aspartate and glutamate. Metabolite ratios were calculated to assess neuronal damage (lactate/N-acetyl-aspartate) and excitotoxicity (glutamate/Nacetyl-aspartate). Western blot studies were performed to quantify protein nitrosylation (oxidative stress), content of caspase-3 (apoptosis) and TNFα (inflammation). Individually, the hypothermia and the cannabidiol treatments reduced the glutamate/Nacetyl-aspartate ratio, as well as TNFα and oxidized protein levels in newborn piglets subjected to hypoxic-ischemic insult. Also, both therapies reduced the number of necrotic neurons and prevented an increase in lactate/N-acetyl-aspartate ratio. The combined effect of hypothermia and cannabidiol on excitotoxicity, inflammation and oxidative stress, and on cell damage, was greater than either hypothermia or cannabidiol alone. The present study demonstrated that cannabidiol and hypothermia act complementarily and show additive effects on the main factors leading to hypoxic-ischemic brain damage if applied shortly after the insult.
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Affiliation(s)
- Hector Lafuente
- Neonatology Research Group, Biocruces Health Research InstituteBizkaia, Spain
| | - Maria R. Pazos
- Group of Cannabinoids Research on Neonatal Pathologies, Research Institute Puerta de Hierro MajadahondaMadrid, Spain
| | - Antonia Alvarez
- Department of Cell Biology, University of the Basque CountryLeioa, Spain
| | - Nagat Mohammed
- Group of Cannabinoids Research on Neonatal Pathologies, Research Institute Puerta de Hierro MajadahondaMadrid, Spain
| | - Martín Santos
- Group of Cannabinoids Research on Neonatal Pathologies, Research Institute Puerta de Hierro MajadahondaMadrid, Spain
| | - Maialen Arizti
- Neonatology Research Group, Biocruces Health Research InstituteBizkaia, Spain
| | | | - Jose A. Martinez-Orgado
- Group of Cannabinoids Research on Neonatal Pathologies, Research Institute Puerta de Hierro MajadahondaMadrid, Spain
- Department of Neonatology, Hospital Clínico San Carlos–Instituto de Investigación Sanitaria San Carlos (IdISSC)Madrid, Spain
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Burd I, Welling J, Kannan G, Johnston MV. Excitotoxicity as a Common Mechanism for Fetal Neuronal Injury with Hypoxia and Intrauterine Inflammation. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2016; 76:85-101. [PMID: 27288075 DOI: 10.1016/bs.apha.2016.02.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Excitotoxicity is a mechanism of neuronal injury, implicated in the pathogenesis of many acute and chronic neurologic disorders, including perinatal brain injury associated with hypoxia-ischemia and exposure to intrauterine inflammation. Glutamate, the primary excitatory neurotransmitter, signals through N-methyl-d-aspartic acid (NMDA)/α-amino-3-hydroxy-5-methylisoxazole-4-propionate (AMPA) receptors. Proper functioning of both of these receptors, in conjunction with glutamate signaling, is crucial for normal development. However, even a small imbalance can result in perinatal neuronal injury. Therefore, a mechanistic understanding of the role of excitotoxicity and the NMDA/AMPA receptor functions is critical to establishing the pathogenesis of hypoxic-ischemic encephalopathy (HIE) and perinatal brain injury due to exposure to intrauterine inflammation. Evidence from experimental animal models and clinical studies indicates that both oxygen and glucose deficiencies play a major role in fetal neuronal injury. However, the connection between these deficiencies, excitotoxicity, and HIE is not well established. The excitotoxic mechanisms in animal models and humans have many parallels, suggesting that detailed animal studies can elicit clinically relevant discoveries. While current therapies for HIE include hypothermia and other neuroprotective measures, emphasizing prevention of acute injuries, increase of therapeutic time window, and increased neural repair, there are no effective widely used treatment modalities for fetuses and neonates exposed to intrauterine inflammation. Further studies of HIE and intrauterine inflammation (as in cases of preterm birth and chorioamnionitis) will provide a better insight into development of effective therapeutic interventions for these conditions.
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Affiliation(s)
- I Burd
- Integrated Research Center for Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - J Welling
- Integrated Research Center for Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - G Kannan
- Integrated Research Center for Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - M V Johnston
- Kennedy Krieger Institute for Disabilities, Baltimore, MD, United States.
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Picchi A, Valente S, Gensini G. Therapeutic hypothermia in the intensive cardiac care unit. J Cardiovasc Med (Hagerstown) 2016; 16:363-71. [PMID: 25022927 DOI: 10.2459/jcm.0000000000000108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Therapeutic hypothermia has demonstrated to improve both survival and neurological outcome in patients who experienced an out-of-hospital cardiac arrest. Nevertheless, many aspects of its clinical application are still controversial. Current guidelines recommend to cool patients who survive a cardiac arrest due to either ventricular fibrillation or ventricular tachycardia, whereas the beneficial effect of lowering body temperature in nonshockable rhythms is still questionable due to the lack of randomized controlled trial involving this subgroup of patients. Although therapeutic hypothermia is often begun before hospital arrival, the optimal time to start cooling is still a matter of debate. Furthermore, different methods are available to low body temperature, but no direct comparisons are available to establish which device performs better than others, and a combination of external and endovascular cooling is usually preferred. The present review is aimed at summarizing the available evidence supporting the use in clinical practice of mild hypothermia in comatose survivors from cardiac arrest and at evaluating its adverse events and their treatment.
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Affiliation(s)
- Andrea Picchi
- aDepartment of Cardiology, Misericordia Hospital, Grosseto bDepartment of Medical and Surgical Critical Care, University of Florence, Florence, Italy
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Johnston MV. Evidence for a mechanism to lower glutamate levels in fetal hypoxia-ischemia caused by asphyxia. Dev Med Child Neurol 2016; 58:9-10. [PMID: 26333719 DOI: 10.1111/dmcn.12878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Michael V Johnston
- Kennedy Krieger Institute and Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Perinatal brain damage: The term infant. Neurobiol Dis 2015; 92:102-12. [PMID: 26409031 PMCID: PMC4915441 DOI: 10.1016/j.nbd.2015.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/27/2015] [Accepted: 09/22/2015] [Indexed: 12/21/2022] Open
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Sayouri H, Boudier A, Vigneron C, Leroy P, Le Tacon S. [Hydrogen sulfide: A promising therapy in neuroprotection following cardiac arrest?]. ANNALES PHARMACEUTIQUES FRANÇAISES 2015; 73:401-10. [PMID: 26033567 DOI: 10.1016/j.pharma.2015.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 04/13/2015] [Accepted: 04/15/2015] [Indexed: 01/17/2023]
Abstract
Each year, in France, the number of cardiac arrests is evaluated between 30,000 to 50,000. When a patient survives, he undergoes a post-resuscitation syndrome which can aggravate the injuries and for which nowadays, no medication is available. In some kinds of cardiac arrest, a hypothermia protocol can be applied with a need for monitoring because of the appearance of side effects. In this context, hydrogen sulfide, which is a gasotransmitter with numerous physiological and pharmacological properties, may be interesting. Indeed, its use could protect against oxidative, inflammatory and apoptotic troubles induced by the post-resuscitation syndrome. The implied biochemical mechanisms are adenosine triphosphate potassium channels activation and cytochrome c oxidase inhibition. This molecule can also induce a suspended animation state characterized by a metabolism decrease, which could give a delay for physicians to start a therapeutic monitoring. Thus, in spite of a modest and sometimes contradictory literature, this compound could become the first neuroprotective molecule in cardiac arrest.
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Affiliation(s)
- H Sayouri
- EA 3452 CITHEFOR, faculté de pharmacie, université de Lorraine, 5, rue A.-Lebrun, BP 80403, 54001 Nancy cedex, France; Service de réanimation pédiatrique, hôpital d'enfants, centre hospitalo-universitaire de Nancy, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - A Boudier
- EA 3452 CITHEFOR, faculté de pharmacie, université de Lorraine, 5, rue A.-Lebrun, BP 80403, 54001 Nancy cedex, France.
| | - C Vigneron
- EA 3452 CITHEFOR, faculté de pharmacie, université de Lorraine, 5, rue A.-Lebrun, BP 80403, 54001 Nancy cedex, France
| | - P Leroy
- EA 3452 CITHEFOR, faculté de pharmacie, université de Lorraine, 5, rue A.-Lebrun, BP 80403, 54001 Nancy cedex, France
| | - S Le Tacon
- Service de réanimation pédiatrique, hôpital d'enfants, centre hospitalo-universitaire de Nancy, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
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Abstract
BACKGROUND Patients undergoing neurosurgery are at risk of cerebral ischaemia with resultant cerebral hypoxia and neuronal cell death. This can increase both the risk of mortality and long term neurological disability. Induced hypothermia has been shown to reduce the risk of cerebral ischaemic damage in both animal studies and in humans who have been resuscitated following cardiac arrest. This had lead to an increasing interest in its neuroprotective potential in neurosurgical patients. This review was originally published in 2011 and did not find any evidence of either effectiveness or harm in these patients. This updated review was designed to capture current evidence to readdress these issues. OBJECTIVES To evaluate the effectiveness and safety profile of induced hypothermia versus normothermia for neuroprotection in patients undergoing brain surgery. Effectiveness was to be measured in terms of short and long term mortality and functional neurological outcomes. Safety was to be assessed in terms of the rate of the adverse events infection, myocardial infarction, ischaemic stroke, congestive cardiac failure and any other adverse events reported by the authors of the included studies. SEARCH METHODS For the original review, the authors searched the databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), EMBASE (OvidSP) and LILACS to November 2010. For the updated review all these databases were re-searched from November 2010 to May 2014.For both the original and updated versions, grey literature was sought by searching reference lists of identified studies and relevant review articles, and conference proceedings. No language restrictions were applied. SELECTION CRITERIA As in the original review, we included randomized controlled trials (RCTs) of induced hypothermia versus normothermia for neuroprotection in patients of any age and gender undergoing brain surgery, which addressed mortality, neurological morbidity or adverse event outcomes. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data and two independently assessed the risk of bias of the included studies. Any discrepancies were resolved by discussion between authors. MAIN RESULTS In this updated review, one new ongoing study was found but no new eligible completed studies were identified. This update was therefore conducted using the same four studies included in the original review. These studies included a total of 1219 participants, mean age 40 to 54 years. All included studies were reported as RCTs. Two were multicentred, together including a total of 1114 patients who underwent cerebral aneurysm clipping, and were judged to have an overall low risk of bias. The other two studies were single centred. One included 80 patients who had a craniotomy following severe traumatic brain injury and was judged to have an unclear or low risk of bias. The other study included 25 patients who underwent hemicranicectomy to relieve oedema following cerebral infarction and was judged to have an unclear or high risk of bias. All studies assessed hypothermia versus normothermia. Overall 608 participants received hypothermia with target temperatures ranging from 32.5 °C to 35 °C, and 611 were assigned to normothermia with the actual temperatures recorded in this group ranging form 36.5 °C to 38 °C. For those who were cooled, 556 had cooling commenced immediately after induction of anaesthesia that was continued until the surgical objective of aneurysm clipping was achieved, and 52 had cooling commenced immediately after surgery and continued for 48 to 96 hours.Pooled estimates of effect were calculated for the outcomes mortality during treatment or follow-up (ranging from in-hospital to one year); neurological outcome measured in terms of the Glasgow Outcome Score (GOS) of 3 or less; and adverse events of infections, myocardial infarction, ischaemic stroke and congestive cardiac failure. With regards to mortality, the risk of dying if allocated to hypothermia compared to normothermia was not statistically significantly different (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.59 to 1.27, P = 0.47). There was no indication that the time at which cooling was started affected the risk of dying (RR with intraoperative cooling 0.95, 95% CI 0.60 to 1.51, P = 0.83; RR for cooling postoperatively 0.67, 95% CI 0.34 to 1.35, P = 0.26). For the neurological outcome, the risk of having a poor outcome with a GOS of 3 or less was not statistically different in those who received hypothermia versus normothermia (RR 0.80, 95% CI 0.61 to 1.04, P = 0.09). Again there was no indication that the time at which cooling was started affected this result. Regarding adverse events, there was no statistically significant difference in the incidence in those allocated to hypothermia versus normothermia for risk of surgical infection (RR 1.20, 95% CI 0.73 to 1.97, P = 0.48), myocardial infarction (RR 1.86, 95% CI 0.69 to 4.98, P = 0.22), ischaemic stroke (RR 0.93, 95% CI 0.82 to 1.05, P = 0.24) or congestive heart failure (RR 0.85, 95% CI 0.60 to 1.21, P = 0.38). In contrast to other outcomes, where time of application of cooling did not change the statistical significance of the effect estimates, there was a weak statistically significant increased risk of infection in those who were cooled postoperatively versus those who were not cooled (RR 1.77, 95% CI 1.05 to 2.98, P = 0.03). Overall, as in the original review, no evidence was found that the use of induced hypothermia was either beneficial or harmful in patients undergoing neurosurgery. AUTHORS' CONCLUSIONS We found no evidence that the use of induced hypothermia was associated with a significant reduction in mortality or severe neurological disability, or an increase in harm in patients undergoing neurosurgery.
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Affiliation(s)
| | - Ron Levy
- Kingston General HospitalDepartment of NeurosurgeryDept of Surgery, Room 304 , Victory 3 ,76 Stuart StreetKingstonONCanadaK7L 2V7
| | - J. Gordon Boyd
- Kingston General HospitalDepartment of Medicine (Neurology) and Critical CareDept of Medicine , Davies 276 Stuart StreetKingstonONCanadaK7L 2V7
| | - Andrew G Day
- Kingston General HospitalClinical Research CentreAngada 4, Room 5‐42176 Stuart StreetKingstonONCanadaK7L 2V7
| | - Micheal C Wallace
- Kingston General HospitalDepartment of NeurosurgeryDept of Surgery, Room 304 , Victory 3 ,76 Stuart StreetKingstonONCanadaK7L 2V7
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Shah DK, Wusthoff CJ, Clarke P, Wyatt JS, Ramaiah SM, Dias RJ, Becher JC, Kapellou O, Boardman JP. Electrographic seizures are associated with brain injury in newborns undergoing therapeutic hypothermia. Arch Dis Child Fetal Neonatal Ed 2014; 99:F219-24. [PMID: 24443407 DOI: 10.1136/archdischild-2013-305206] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Seizures are common among newborns with hypoxic-ischaemic encephalopathy (HIE) but the relationship between seizure burden and severity of brain injury among neonates receiving therapeutic hypothermia (TH) for HIE is unclear. We tested the hypothesis that seizure burden is associated with cerebral tissue injury independent of amplitude-integrated EEG (aEEG) background activity. STUDY DESIGN Term neonates undergoing 72 h of TH at four centres were selected for study if they had continuous aEEG and MRI. The aEEG with corresponding 2-channel raw EEG (aEEG/EEG), was classified by severity of background and seizure burden; MR images were classified by the severity of tissue injury. RESULTS Of 85 neonates, 52% had seizures on aEEG/EEG. Overall, 35% had high seizure burden, 49% had abnormal aEEG background in the first 24 h and 36% had severe injury on MRI. Seizures were most common on the first day, with significant recurrence during and after rewarming. Factors associated with severe injury on MRI were high seizure burden, poor aEEG background, 10 min Apgar and the need for more than one anticonvulsant. In multivariate logistic regression, high seizure burden was independently associated with greater injury on MRI (OR 5.00, 95% CI 1.47 to 17.05 p=0.01). Neither aEEG background, nor 10 min Apgar score were significant. CONCLUSIONS Electrographic seizure burden is associated with severity of brain injury on MRI in newborns with HIE undergoing TH, independent of degree of abnormality on aEEG background. Seizures are common during cooling, particularly on day 1, with a significant rebound on day 4.
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Barrett RD, Bennet L, Blood AB, Wassink G, Gunn AJ. Asphyxia and therapeutic hypothermia modulate plasma nitrite concentrations and carotid vascular resistance in preterm fetal sheep. Reprod Sci 2014; 21:1483-91. [PMID: 24740991 DOI: 10.1177/1933719114530187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In this study, we tested the hypothesis that cerebral hypoperfusion after asphyxia and induced hypothermia is associated with reduced circulating nitrite levels as an index of nitric oxide synthase (NOS) activity. The preterm fetal sheep at 0.7 gestation (103-104 days, term = 147 days) received 25-minute umbilical cord occlusion, followed by mild whole-body cooling from 30 minutes to 72 hours after occlusion. Occlusion and induced hypothermia were independently associated with reduced carotid vascular conductance (CaVC) from 2 to 72 hours, and with transiently suppressed plasma nitrite levels at 6 hours. There was a significant within-subjects correlation (r(2) = 0.33, P = .002) between CaVC and plasma nitrite values in the first 24 hours after occlusion but not after sham occlusion. These findings suggest that in preterm fetal sheep, changes in NOS activity are an important mediator of changes in carotid vascular tone in the early recovery phase after asphyxia and may help mediate some of the vascular effects of induced hypothermia.
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Affiliation(s)
- Robert D Barrett
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Arlin B Blood
- Department of Pediatrics and Center for Perinatal Biology, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Guido Wassink
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, University of Auckland, Auckland, New Zealand
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Drury PP, Davidson JO, Mathai S, van den Heuij LG, Ji H, Bennet L, Tan S, Silverman RB, Gunn AJ. nNOS inhibition during profound asphyxia reduces seizure burden and improves survival of striatal phenotypic neurons in preterm fetal sheep. Neuropharmacology 2014; 83:62-70. [PMID: 24726307 DOI: 10.1016/j.neuropharm.2014.03.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 03/17/2014] [Accepted: 03/31/2014] [Indexed: 12/01/2022]
Abstract
Basal ganglia injury after hypoxia-ischemia remains common in preterm infants, and is closely associated with later cerebral palsy. In the present study we tested the hypothesis that a highly selective neuronal nitric oxide synthase (nNOS) inhibitor, JI-10, would improve survival of striatal phenotypic neurons after profound asphyxia, and that the subsequent seizure burden and recovery of EEG are associated with neural outcome. 24 chronically instrumented preterm fetal sheep were randomized to either JI-10 (3 ml of 0.022 mg/ml, n = 8) or saline (n = 8) infusion 15 min before 25 min complete umbilical cord occlusion, or saline plus sham-occlusion (n = 8). Umbilical cord occlusion was associated with reduced numbers of calbindin-28k-, GAD-, NPY-, PV-, Calretinin- and nNOS-positive striatal neurons (p < 0.05 vs. sham occlusion) but not ChAT-positive neurons. JI-10 was associated with increased numbers of calbindin-28k-, GAD-, nNOS-, NPY-, PV-, Calretinin- and ChAT-positive striatal neurons (p < 0.05 vs. saline + occlusion). Seizure burden was strongly associated with loss of calbindin-positive cells (p < 0.05), greater seizure amplitude was associated with loss of GAD-positive cells (p < 0.05), and with more activated microglia in the white matter tracts (p < 0.05). There was no relationship between EEG power after 7 days recovery and total striatal cell loss, but better survival of NPY-positive neurons was associated with lower EEG power. In summary, these findings suggest that selective nNOS inhibition during asphyxia is associated with protection of phenotypic striatal projection neurons and has potential to help reduce basal ganglia injury in some premature babies.
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Affiliation(s)
- Paul P Drury
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Sam Mathai
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | | | - Haitao Ji
- Department of Chemistry, Department of Molecular Biosciences, Chemistry of Life Processes Institute, Center for Molecular Innovation and Drug Discovery, Northwestern University, Evanston, IL 60208-3113, USA; Department of Chemistry, University of Utah, Salt Lake City, UT, USA
| | - Laura Bennet
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Sidhartha Tan
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, IL, USA
| | - Richard B Silverman
- Department of Chemistry, Department of Molecular Biosciences, Chemistry of Life Processes Institute, Center for Molecular Innovation and Drug Discovery, Northwestern University, Evanston, IL 60208-3113, USA
| | - Alistair J Gunn
- Department of Physiology, University of Auckland, Auckland, New Zealand.
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Abstract
Prolonged, moderate cerebral hypothermia initiated within a few hours after severe hypoxia-ischemia and continued until resolution of the acute phase of delayed cell death can reduce acute brain injury and improve long-term behavioral recovery in term infants and in adults after cardiac arrest. The specific mechanisms of hypothermic neuroprotection remain unclear, in part because hypothermia suppresses a broad range of potential injurious factors. This article examines proposed mechanisms in relation to the known window of opportunity for effective protection with hypothermia. Knowledge of the mechanisms of hypothermia will help guide the rational development of future combination treatments to augment neuroprotection with hypothermia and identify those most likely to benefit.
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Wassink G, Gunn ER, Drury PP, Bennet L, Gunn AJ. The mechanisms and treatment of asphyxial encephalopathy. Front Neurosci 2014; 8:40. [PMID: 24578682 PMCID: PMC3936504 DOI: 10.3389/fnins.2014.00040] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 02/12/2014] [Indexed: 11/13/2022] Open
Abstract
Acute post-asphyxial encephalopathy occurring around the time of birth remains a major cause of death and disability. The recent seminal insight that allows active neuroprotective treatment is that even after profound asphyxia (the “primary” phase), many brain cells show initial recovery from the insult during a short “latent” phase, typically lasting approximately 6 h, only to die hours to days later after a “secondary” deterioration characterized by seizures, cytotoxic edema, and progressive failure of cerebral oxidative metabolism. Although many of these secondary processes are potentially injurious, they appear to be primarily epiphenomena of the “execution” phase of cell death. Animal and human studies designed around this conceptual framework have shown that moderate cerebral hypothermia initiated as early as possible but before the onset of secondary deterioration, and continued for a sufficient duration to allow the secondary deterioration to resolve, has been associated with potent, long-lasting neuroprotection. Recent clinical trials show that while therapeutic hypothermia significantly reduces morbidity and mortality, many babies still die or survive with disabilities. The challenge for the future is to find ways of improving the effectiveness of treatment. In this review, we will dissect the known mechanisms of hypoxic-ischemic brain injury in relation to the known effects of hypothermic neuroprotection.
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Affiliation(s)
- Guido Wassink
- Fetal Physiology and Neuroscience Team, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand
| | - Eleanor R Gunn
- Fetal Physiology and Neuroscience Team, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand
| | - Paul P Drury
- Fetal Physiology and Neuroscience Team, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand
| | - Laura Bennet
- Fetal Physiology and Neuroscience Team, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand
| | - Alistair J Gunn
- Fetal Physiology and Neuroscience Team, Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland Auckland, New Zealand
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Dassios T, Austin T. Respiratory function parameters in ventilated newborn infants undergoing whole body hypothermia. Acta Paediatr 2014; 103:157-61. [PMID: 24147974 DOI: 10.1111/apa.12476] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 10/17/2013] [Indexed: 11/29/2022]
Abstract
AIM Whole body hypothermia (WBH) exerts proven neuroprotective effects in infants with hypoxic-ischaemic encephalopathy (HIE). Our aim was to describe how WBH could impact on respiratory function in mechanically ventilated newborn infants, by recording primary and composite indices of oxygenation and ventilation before, during and after WBH. METHODS The medical notes of 31 mechanically ventilated full-term newborn infants who underwent WBH for HIE were retrospectively reviewed. Fraction of inspired oxygen (FiO2), tidal volume (TV), mean airway Pressure (MAP), minute ventilation (MV), static compliance of the respiratory system (C(statRS)), ventilation efficiency index (VEI), alveolar-arterial gradient (A-a gradient) and oxygenation index (OI) were documented before and during hypothermic treatment, as well as during and after rewarming. RESULTS Fraction of inspired oxygen, MAP, OI and A-a gradient decreased during induction of hypothermia and tended to increase during rewarming. C(statRS), VEI and TV increased during induction of hypothermia and tended to decrease during rewarming. None of the changes achieved statistical significance. CONCLUSION These results suggest that WBH might affect respiratory function in mechanically ventilated infants with HIE. Oxygenation might be enhanced by hypothermia, probably as a result of decreased metabolism, while ventilation might also be facilitated as a result of the effect of hypothermia on lung mechanics.
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Affiliation(s)
- Theodore Dassios
- Neonatal Intensive Care Unit; Rosie Maternity Hospital; Cambridge University Hospitals NHS Foundation Trust; Hills Road Cambridge UK
| | - Topun Austin
- Neonatal Intensive Care Unit; Rosie Maternity Hospital; Cambridge University Hospitals NHS Foundation Trust; Hills Road Cambridge UK
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Cotten CM, Shankaran S. Hypothermia for hypoxic-ischemic encephalopathy. ACTA ACUST UNITED AC 2014; 5:227-239. [PMID: 20625441 DOI: 10.1586/eog.10.7] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Moderate to severe hypoxic-ischemic injury in newborn infants, manifested as encephalopathy immediately or within hours after birth, is associated with a high risk of either death or a lifetime with disability. In recent multicenter clinical trials, hypothermia initiated within the first 6 postnatal hours has emerged as a therapy that reduces the risk of death or impairment among infants with hypoxic-ischemic encephalopathy. Prior to hypothermia, no therapies directly targeting neonatal encephalopathy secondary to hypoxic-ischemic injury had convincing evidence of efficacy. Hypothermia therapy is now becoming increasingly available at tertiary centers. Despite the deserved enthusiasm for hypothermia, obstetric and neonatology caregivers, as well as society at large, must be reminded that in the clinical trials more than 40% of cooled infants died or survived with impairment. Although hypothermia is an evidence-based therapy, additional discoveries are needed to further improve outcome after HIE. In this article, we briefly present the epidemiology of neonatal encephalopathy due to hypoxic-ischemic injury, describe the rationale for the use of hypothermia therapy for hypoxic-ischemic encephalopathy, and present results of the clinical trials that have demonstrated the efficacy of hypothermia. We also present findings noted during and after these trials that will guide care and direct research for this devastating problem.
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Affiliation(s)
- C Michael Cotten
- Associate Professor of Pediatrics, Duke University Medical Center, Box 2739 DUMC, Durham, NC 27710, USA, Tel.: +1 919 681 4844, ,
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Joy R, Pournami F, Bethou A, Bhat VB, Bobby Z. Effect of therapeutic hypothermia on oxidative stress and outcome in term neonates with perinatal asphyxia: a randomized controlled trial. J Trop Pediatr 2013; 59:17-22. [PMID: 22907998 DOI: 10.1093/tropej/fms036] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate in term babies with perinatal asphyxia, the effect of therapeutic hypothermia (TH) on oxidative stress and neurological outcome at discharge. METHODS Babies who satisfied inclusion criteria were randomized to TH, with cooling gel packs to a target temperature of 33-34°C for 72 h or normothermia. Blood sample was collected before and after TH for oxidative stress assessment: total antioxidant status (TAS) and malondialdehyde (MDA). RESULTS Of 116 babies randomized, there was no statistically significant difference in the baseline TAS and MDA. After 72 h of TH, TAS was significantly higher (p = <0.001) (761.69 ± 114.01 vs. 684.16 ± 88.86) and MDA was significantly lower (p = <0.001) in TH group (1.73 ± 0.66 vs. 5.2 ± 1.06). Risk of developing deficit was lower (p < 0.001) in TH group with relative risk of 0.49 and 95 % confidence interval: 0.29-0.68. CONCLUSION TH reduces oxidative stress and improves neurological outcome in perinatal asphyxia. TRIAL REGISTRATION NUMBER CTRI/2011/12/002196.
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Affiliation(s)
- Rojo Joy
- Department of Pediatrics Neonatology Division, Jawaharlal Institute of Postgraduate Medical Education and Research JIPMER, Puducherry 605 006, India
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Rescuing the neonatal brain from hypoxic injury with autologous cord blood. Bone Marrow Transplant 2012; 48:890-900. [PMID: 22964590 DOI: 10.1038/bmt.2012.169] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 08/02/2012] [Accepted: 08/03/2012] [Indexed: 12/28/2022]
Abstract
Brain injury resulting from perinatal hypoxic-ischemic encephalopathy (HIE) is a major cause of acute mortality in infants and chronic neurologic disability in surviving children. Recent multicenter clinical trials demonstrated the effectiveness of hypothermia initiated within the first 6 postnatal hours to reduce the risk of death or major neurological disabilities among neonates with HIE. However, in these trials, approximately 40% of cooled infants died or survived with significant impairments. Therefore, adjunct therapies are required to improve the outcome in neonates with HIE. Cord blood (CB) is a rich source of stem cells. Administration of human CB cells in animal models of HIE has generally resulted in improved outcomes and multiple mechanisms have been suggested including anti-inflammation, release of neurotrophic factors and stimulation of endogenous neurogenesis. Investigators at Duke are conducting studies of autologous CB infusion in neonates with HIE and in children with cerebral palsy. These pilot studies indicate no added risk from the regimens used, but results of ongoing placebo-controlled trials are needed to assess efficacy. Meanwhile, further investigations are warranted to determine the best strategies, that is, timing, dosing, route of delivery, choice of stem cells and ex vivo modulations, to attain long-term benefits of CB stem cell therapy.
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Filippi L, Fiorini P, Daniotti M, Catarzi S, Savelli S, Fonda C, Bartalena L, Boldrini A, Giampietri M, Scaramuzzo R, Papoff P, Del Balzo F, Spalice A, la Marca G, Malvagia S, Della Bona ML, Donzelli G, Tinelli F, Cioni G, Pisano T, Falchi M, Guerrini R. Safety and efficacy of topiramate in neonates with hypoxic ischemic encephalopathy treated with hypothermia (NeoNATI). BMC Pediatr 2012; 12:144. [PMID: 22950861 PMCID: PMC3478965 DOI: 10.1186/1471-2431-12-144] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 08/31/2012] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Despite progresses in neonatal care, the mortality and the incidence of neuro-motor disability after perinatal asphyxia have failed to show substantial improvements. In countries with a high level of perinatal care, the incidence of asphyxia responsible for moderate or severe encephalopathy is still 2-3 per 1000 term newborns. Recent trials have demonstrated that moderate hypothermia, started within 6 hours after birth and protracted for 72 hours, can significantly improve survival and reduce neurologic impairment in neonates with hypoxic-ischemic encephalopathy. It is not currently known whether neuroprotective drugs can further improve the beneficial effects of hypothermia. Topiramate has been proven to reduce brain injury in animal models of neonatal hypoxic ischemic encephalopathy. However, the association of mild hypothermia and topiramate treatment has never been studied in human newborns. The objective of this research project is to evaluate, through a multicenter randomized controlled trial, whether the efficacy of moderate hypothermia can be increased by concomitant topiramate treatment. METHODS/DESIGN Term newborns (gestational age ≥ 36 weeks and birth weight ≥ 1800 g) with precocious metabolic, clinical and electroencephalographic (EEG) signs of hypoxic-ischemic encephalopathy will be randomized, according to their EEG pattern, to receive topiramate added to standard treatment with moderate hypothermia or standard treatment alone. Topiramate will be administered at 10 mg/kg once a day for the first 3 days of life. Topiramate concentrations will be measured on serial dried blood spots. 64 participants will be recruited in the study. To evaluate the safety of topiramate administration, cardiac and respiratory parameters will be continuously monitored. Blood samplings will be performed to check renal, liver and metabolic balance. To evaluate the efficacy of topiramate, the neurologic outcome of enrolled newborns will be evaluated by serial neurologic and neuroradiologic examinations. Visual function will be evaluated by means of behavioural standardized tests. DISCUSSION This pilot study will explore the possible therapeutic role of topiramate in combination with moderate hypothermia. Any favourable results of this research might open new perspectives about the reduction of cerebral damage in asphyxiated newborns.
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Affiliation(s)
- Luca Filippi
- Neonatal Intensive Care Unit, Medical Surgical Feto-Neonatal Department, A. Meyer University Children's Hospital, Viale Pieraccini, 24, I-50139, Florence, Italy.
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Kendall GS, Mathieson S, Meek J, Rennie JM. Recooling for rebound seizures after rewarming in neonatal encephalopathy. Pediatrics 2012; 130:e451-5. [PMID: 22753564 DOI: 10.1542/peds.2011-3496] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Infants undergoing therapeutic hypothermia for hypoxic ischemic encephalopathy are at risk for rebound seizures during and after the rewarming phase. We report a term male infant who was cooled for hypoxic ischemic encephalopathy. He developed electrographic seizures for the first time during the warming phase, which continued in the hours after rewarming. The seizures stopped within 30 minutes of recooling to 33.5°C without anticonvulsant medication. He was uneventfully cooled for an additional 24 hours and then rewarmed with no recurrence of seizures. Hypothermia appeared to have an antiepileptic effect in this case and may be worthy of additional investigation as an adjunct to antiepileptic drug therapy in newborns.
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Affiliation(s)
- Giles S Kendall
- Division of Academic Neonatology, Institute of Women’s Health, University College London, London, United Kingdom.
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Bednarek N, Mathur A, Inder T, Wilkinson J, Neil J, Shimony J. Impact of therapeutic hypothermia on MRI diffusion changes in neonatal encephalopathy. Neurology 2012; 78:1420-7. [PMID: 22517107 DOI: 10.1212/wnl.0b013e318253d589] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The objective of this work was to determine the impact of therapeutic hypothermia (TH) on the magnitude and time course of mean diffusivity (MD) changes following hypoxic-ischemic encephalopathy (HIE) in newborns. METHODS Cerebral MRI scans of infants undergoing whole body TH for HIE from 2007 to 2010 were retrospectively reviewed. The data were analyzed identically to a control group of newborns with HIE previously published, prior to the development of TH. Anatomic injury was defined on T1- and T2-weighted ("late") MRI obtained after the fifth day of life. Since MD values vary regionally, the ratios of MD values for injured and normal tissue were calculated for areas of injury. Normal values were obtained from corresponding brain regions of 12 infants undergoing TH who had no injury on MRI studies. RESULTS Twenty-three of 59 infants who underwent TH and MRI displayed cerebral injury on late MRI and were included in the study. MD ratios were decreased in all injured infants within the first 7 days of life. The return of MD to normal (pseudonormalization) occurred after the tenth day as compared to 6-8 days in the control group. Infants with severest injury demonstrated greater reduction in MD, but no difference in time to pseudonormalization. CONCLUSION TH slows the evolution of diffusion abnormalities on MRI following HIE in term infants.
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Affiliation(s)
- N Bednarek
- Neonatology Unit, Alix de Champagne, Reims, France
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