5-Hydroxytryptamine-induced vasoconstriction after cerebral hematoma in piglets

Inflammatory Pathways Following Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is an acute cerebrovascular emergency resulting from the rupture of a brain aneurysm. Despite only accounting for 5% of all strokes, SAH imposes a significant health burden on society due to its relatively young age at onset. Those who survive the initial bleed are often afflicted with severe disabilities thought to result from delayed cerebral ischemia (DCI). Consequently, elucidating the underlying mechanistic pathways implicated in DCI development following SAH remains a priority. Neuroinflammation has recently been implicated as a promising new theory for the development of SAH complications. However, despite this interest, clinical trials have failed to provide consistent evidence for the use of anti-inflammatory agents in SAH patients. This may be explained by the complexity of SAH as a plethora of inflammatory pathways have been shown to be activated in the disease. By determining how these pathways may overlap and interact, we hope to better understand the developmental processes of SAH complications and how to prevent them. The goal of this review is to provide insight into the available evidence regarding the molecular pathways involved in the development of inflammation following SAH and how SAH complications may arise as a result of these inflammatory pathways.

Microvascular Dysfunction and Cognitive Impairment

The impact of vascular risk factors on cognitive function has garnered much interest in recent years. The appropriate distribution of oxygen, glucose, and other nutrients by the cerebral vasculature is critical for proper cognitive performance. The cerebral microvasculature is a key site of vascular resistance and a preferential target for small vessel disease. While deleterious effects of vascular risk factors on microvascular function are known, the contribution of this dysfunction to cognitive deficits is less clear. In this review, we summarize current evidence for microvascular dysfunction in brain. We highlight effects of select vascular risk factors (hypertension, diabetes, and hyperhomocysteinemia) on the pial and parenchymal circulation. Lastly, we discuss potential links between microvascular disease and cognitive function, highlighting current gaps in our understanding.

Accuracy of ultrasound in assessing cerebellar haemorrhages in very low birthweight babies

OBJECTIVE

To assess diagnostic accuracy of cranial ultrasound (CUS) performed through the anterior fontanelle (AF) and mastoid fontanelle (MF) in detecting cerebellar haemorrhages (CBH) in very low birthweight (VLBW) infants.

SETTING

Third-level neonatal intensive care unit (NICU).

DESIGN

VLBW infants consecutively admitted at Gaslini Children's Hospital between February 2012 and September 2013 underwent both CUS and MR susceptibility-weighted imaging (SWI). CUS was performed at days 1, 2, 3 and 7 after birth, then weekly until term-equivalent age. All CUS examinations were performed through AF and MF using an 8 Mhz convex probe. Depending on the size, CBHs were classified as massive, limited or microhaemorrhages. Diagnostic accuracy of CUS through AF and MF in detecting all types of CBHs was assessed by comparing it with SWI, used as the gold-standard technique.

RESULTS

140 VLBW infants were included. CUS sensitivity in detecting massive CBH through both AF and MF was excellent (100%). However, CUS sensitivity through AF dropped down to 16.7% (95% CI 1% to 46%) in cases of limited CBH, with sensitivity through MF remaining good (83.3%; 95% CI 53% to 100%). None of the microhaemorrhages diagnosed by SWI was identified by CUS, despite the use of MF. Specificity of CUS in detecting all degrees of CBH through both AF and MF was excellent (100%).

CONCLUSIONS

Routine use of MF allows a better detection of limited CBH when compared with AF. Overall sensitivity of CUS in detecting CBH is low when microhaemorrhages are included. In other words, microhaemorrhages proved to be undetectable by CUS.

Cerebellar hemorrhagic injury in premature infants occurs during a vulnerable developmental period and is associated with wider neuropathology

BACKGROUND

Cerebellar hemorrhagic injury (CHI) is being recognized more frequently in premature infants. However, much of what we know about CHI neuropathology is from autopsy studies that date back to a prior era of neonatal intensive care. To update and expand our knowledge of CHI we reviewed autopsy materials and medical records of all live-born preterm infants (<37 weeks gestation) autopsied at our institution from 1999-2010 who had destructive hemorrhagic injury to cerebellar parenchyma (n = 19) and compared them to matched non-CHI controls (n = 26).

RESULTS

CHI occurred at a mean gestational age of 25 weeks and involved the ventral aspect of the posterior lobe in almost all cases. CHI arose as a large hemorrhage or as multiple smaller hemorrhages in the emerging internal granule cell layer of the developing cortex or in the nearby white matter. Supratentorial germinal matrix hemorrhage occurred in 95% (18/19) of CHI cases compared to 54% (14/26) of control cases (p = 0.003). The cerebellar cortex frequently showed focal neuronal loss and gliosis (both 15/19, 79%) in CHI cases compared to control cases (both 1/26, 4% p < 0.0001). The cerebellar dentate had more neuronal loss (8/15, 53%) and gliosis (9/15, 60%) in CHI cases than controls (both 0/23, 0%; p < 0.0001). The inferior olivary nuclei showed significantly more neuronal loss in CHI (10/17, 59%) than in control cases (5/26, 19%) (p = 0.0077). All other gray matter sites examined showed no significant difference in the incidence of neuronal loss or gliosis between CHI and controls.

CONCLUSIONS

We favor the possibility that CHI represents a primary hemorrhage arising due to the effects of impaired autoregulation in a delicate vascular bed. The incidences of neuronal loss and gliosis in the inferior olivary and dentate nuclei, critical cerebellar input and output structures, respectively were higher in CHI compared to control cases and may represent a transsynpatic degenerative process. CHI occurs during a critical developmental period and may render the cerebellum vulnerable to additional deficits if cerebellar growth and neuronal connectivity are not established as expected. Therefore, CHI has the potential to significantly impact neurodevelopmental outcome in survivors.

Cerebellum of the premature infant: rapidly developing, vulnerable, clinically important

Brain abnormality in surviving premature infants is associated with an enormous amount of neurodevelopmental disability, manifested principally by cognitive, behavioral, attentional, and socialization deficits, most commonly with only relatively modest motor deficits. The most recognized contributing neuropathology is cerebral white matter injury. The thesis of this review is that acquired cerebellar abnormality is a relatively less recognized but likely important cause of neurodevelopmental disability in small premature infants. The cerebellar disease may be primarily destructive (eg, hemorrhage, infarction) or primarily underdevelopment. The latter appears to be especially common and relates to a particular vulnerability of the cerebellum of the small premature infant. Central to this vulnerability are the extraordinarily rapid and complex developmental events occurring in the cerebellum. The disturbance of development can be caused either by direct adverse effects on the cerebellum, especially the distinctive transient external granular layer, or by indirect remote trans-synaptic effects. This review describes the fascinating details of cerebellar development, with an emphasis on events in the premature period, the major types of cerebellar abnormality acquired during the premature period, their likely mechanisms of occurrence, and new insights into the relation of cerebellar disease in early life to subsequent cognitive/behavioral/attentional/socialization deficits.

Brain injury in premature infants: a complex amalgam of destructive and developmental disturbances

Brain injury in premature infants is of enormous public health importance because of the large number of such infants who survive with serious neurodevelopmental disability, including major cognitive deficits and motor disability. This type of brain injury is generally thought to consist primarily of periventricular leukomalacia (PVL), a distinctive form of cerebral white matter injury. Important new work shows that PVL is frequently accompanied by neuronal/axonal disease, affecting the cerebral white matter, thalamus, basal ganglia, cerebral cortex, brain stem, and cerebellum. This constellation of PVL and neuronal/axonal disease is sufficiently distinctive to be termed "encephalopathy of prematurity". The thesis of this Review is that the encephalopathy of prematurity is a complex amalgam of primary destructive disease and secondary maturational and trophic disturbances. This Review integrates the fascinating confluence of new insights into both brain injury and brain development during the human premature period.

Regulation of cerebral microvascular endothelial cell cyclooxygenase-2 message and activity by blood derived vasoactive agents

We have investigated the effects of prolonged treatment of cerebral microvascular endothelial cells with vasoconstrictor products of blood clot hemolysis on prostanoid production and cyclooxygenase (COX)/prostacyclin synthase activity and message. Confluent primary cultures of endothelial cells derived from piglet cerebral microvessels were incubated with endothelin-1 (ET-1; 10 nM) or thromboxane A(2) analog U-46619 (1 microM), alone or combined, and COX/prostacyclin synthase activity determined following exposure of treated cells to arachidonic acid (10 microM) for 30 min. 6-KetoPGF(1)alpha and PGE(2) levels in the medium were determined using radioimmunoassay. Effect of treatments on COX-2 message was determined by RNAse Protection Assay. Combined treatment with ET-1 (10 nM) and U-46619 (1 microM) for 24h significantly reduced 6-ketoPGF(1)alpha and PGE(2) levels in the media by 57% and 33%. Treatment of cells with U-46619 alone increased both 6-ketoPGF(1)alpha and PGE(2) level in the media by 170% and 42%. Incubation of control cells with arachidonic acid (10 microM) for 30 min increased 6-ketoPGF(1)alpha and PGE(2) production by 163% and 567%. Pretreatment with ET-1 or U-46619 alone for 24h had no significant effect on 6-ketoPGF(1)alpha produced from exogenous arachidonic acid. However, PGE(2) production from exogenous arachidonic acid by cells pretreated with ET-1 but not with U-46619 was attenuated by 35%. Combined treatment with ET-1 and U-46619 reduced both PGE(2) and 6-ketoPGF(1)alpha production from arachidonic acid by 14% and 40%, respectively. Acute incubation of cells with ET-1 or U-46619 did not have any significant effects on COX-2 mRNA. In conclusion, combined ET-1 and U-46619 reduced prostanoid production. The reduction cannot be fully explained by changes in COX/prostacyclin synthase activity and/or message, but the changes could be due to reduced availability of free arachidonic acid potentially resulting from inhibition of endothelial phospholipase A(2).

L-type voltage-dependent Ca2+ channels in cerebral microvascular endothelial cells and ET-1 biosynthesis

We investigated the role of intracellular calcium concentration ([Ca2+]i) in endothelin-1 (ET-1) production, the effects of potential vasospastic agents on [Ca2+]i, and the presence of L-type voltage-dependent Ca2+ channels in cerebral microvascular endothelial cells. Primary cultures of endothelial cells isolated from piglet cerebral microvessels were used. Confluent cells were exposed to either the thromboxane receptor agonist U-46619 (1 microM), 5-hydroxytryptamine (5-HT; 0.1 mM), or lysophosphatidic acid (LPA; 1 microM) alone or after pretreatment with the Ca2+-chelating agent EDTA (100 mM), the L-type Ca2+ channel blocker verapamil (10 microM), or the antagonist of receptor-operated Ca2+ channel SKF-96365 HCl (10 microM) for 15 min. ET-1 production increased from 1.2 (control) to 8.2 (U-46619), 4.9 (5-HT), or 3.9 (LPA) fmol/microg protein, respectively. Such elevated ET-1 biosynthesis was attenuated by verapamil, EDTA, or SKF-96365 HCl. To investigate the presence of L-type voltage-dependent Ca2+ channels in endothelial cells, the [Ca2+]i signal was determined fluorometrically by using fura 2-AM. Superfusion of confluent endothelial cells with U-46619, 5-HT, or LPA significantly increased [Ca2+]i. Pretreatment of endothelial cells with high K+ (60 mM) or nifedipine (4 microM) diminished increases in [Ca2+]i induced by the vasoactive agents. These results indicate that 1) elevated [Ca2+]i signals are involved in ET-1 biosynthesis induced by specific spasmogenic agents, 2) the increases in [Ca2+]i induced by the vasoactive agents tested involve receptor as well as L-type voltage-dependent Ca2+ channels, and 3) primary cultures of cerebral microvascular endothelial cells express L-type voltage-dependent Ca2+ channels.

Glutamate transporters in neonatal cerebellar subarachnoid hemorrhage

We have previously described the immunoreactivities of glutamate transporters, EAAT4 and GLAST, in the developing human cerebellum. In the present report, we demonstrate the different expression of EAAT4 and GLAST in the pathologic condition, neonatal subarachnoid hemorrhage. EAAT4 and GLAST were characteristically disturbed in the cerebellar cortices beneath the subarachnoid hemorrhage. In preterm infants with subarachnoid hemorrhage the decrease in EAAT4 immunoreactivity was more prominent than in term infants, and GLAST immunoreactivity in the inner granular cell layer decreased and reappeared later than in term infants with subarachnoid hemorrhage. Although Bergmann's glia removes glutamate from the extracellular space surrounding Purkinje cells in the early stage of hypoxic-ischemic brain damage, the reaction of EAAT4 and GLAST in the cerebellar cortex under the subarachnoid hemorrhage was decreased, and immature glia had a delayed reaction. These characteristics of glutamate transporters in immature cells may lead to cell death and olivocerebellar degeneration.

Enhanced pial arteriolar sensitivity to bioactive agents following exposure to endothelin-1

Effects of prior exposure of pial arterioles to endothelin-1 (ET-1) (10(-9) M) on the constriction induced by the by-products of hemolyzed blood (5-HT, LTC4, LPA, and thromboxane analog U-46619) were examined. Piglets (age: 1-3 d) anesthetized with a mixture of ketamine hydrochloride and acepromazine were implanted with cranial windows, and anesthesia was maintained with alpha-chloralose. Topical applications of the by-products of hemolyzed blood mildly constricted pial arterioles. Following prior exposure of the microvessels to ET-1, application of the by-products of hemolyzed blood produced significantly potentiated and long-lasting constrictions compared to the controls. In another experiment, pretreatment of pial arterioles with U-46619 (10(-8) M) also potentiated the constriction induced by ET-1. The constriction produced was fast and longer-lasting. Thus, these data show that by-products of hemolyzed blood, though not potent vasoconstrictors per se, potently constricted pial arterioles in the presence of ET-1. The same agents in the CSF can also potentiate constriction induced by ET-1. Hence, by-products of hemolyzed blood may play a significant role in the initiation and maintenance of cerebral arterial narrowing observed following intracranial bleeding.

Regulation of ET-1 biosynthesis in cerebral microvascular endothelial cells by vasoactive agents and PKC

Endothelin-1 (ET-1) is the most potent vasoconstrictor agent known. ET-1 is elevated in the cerebrospinal fluid following hemorrhage and brain injury and can compromise cerebral microvascular homeostasis. The modulation of ET-1 production by cerebral microvascular endothelial cells and the mechanism by which such changes take place are very important in our understanding of the pathological roles of ET-1. In the present study, we investigated the effects of vasoconstrictor agents that can be released from hemolyzed blood, cAMP-dependent dilators, and the role of protein kinase C (PKC) in the regulation of ET-1 production by piglet cerebral microvascular endothelial cells in culture. ET-1 was measured by RIA. 1) Cerebral microvascular endothelial cells synthesize and release ET-1 into the media; 2) 5-hydroxytryptamine (5-HT), lysophosphatidic acid (LPA), thromboxane analog U-46619, fetal bovine serum (20%), and phorbol 12-myristate 13-acetate significantly increase ET-1 production; 3) basal and vasoconstrictor agent-induced increases in ET-1 production by endothelial cells may be mediated via PKC; 4) cAMP-dependent vasodilators attenuate the basal production of ET-1 by cerebral microvessels; and 5) pretreatment of endothelial cells with a higher concentration of LPA, U-46619, or 5-HT counterbalances the cAMP-dependent dilator agent-induced reduction in basal ET-1 production. Therefore, by-products of hemolyzed blood can stimulate the production of ET-1 by a PKC-mediated mechanism. cAMP-dependent dilators can attenuate the vasoconstrictor agent-induced elevation in ET-1 production. These results suggest that cerebral microvascular homeostasis could be compromised by effects of interactions among vasoactive agents released during conditions injurious to the brain and they may further the understanding of potential contributions of hemolyzed blood clots to subarachnoid hemorrhage-induced vasospasm.