MRI and brainstem auditory evoked potential evidence of eighth cranial nerve involvement in multiple sclerosis

Effectiveness of Brainstem Auditory Evoked Potentials Scoring in Evaluating Brainstem Dysfunction and Disability Among Individuals With Multiple Sclerosis

Purpose The brainstem dysfunction in multiple sclerosis (MS) often causes significant functional impairment leading to disability. This study aims to explore modified brainstem auditory evoked potential (BAEP) scores based on the pattern of BAEP abnormalities and relate with brainstem symptoms, brainstem functional system scores (BFSS), brainstem lesions, and disability. Method Forty-five participants with relapsing-remitting MS and 45 age- and gender-matched healthy controls underwent case history assessment, otoscopic examination, pure-tone audiometry, and BAEP testing. Also, neurological examination (Expanded Disability Status Scale, FSS scales) and magnetic resonance imaging were carried out on MS participants. Patterns of BAEP abnormalities were categorized and converted to BAEP scores. Results Out of 45 participants' brainstem symptoms, BFSS > 1, brainstem lesions (magnetic resonance imaging), and BAEP abnormalities were observed in 75.6%, 42.2%, 62.2%, and 55.56% of participants, respectively. Waves V and III abnormalities were more common among MS participants and showed a significant difference from the control group in the Mann-Whitney U test. Chi-square test did not show a significant association of BAEP abnormalities with brainstem symptoms and lesions but showed significant association with BFSS. The mean and standard deviation of BAEP scores in MS participants were 1.73 + 2.37. All healthy controls showed BAEP scores of 0. BAEP scores in MS participants showed significant correlation with BFSS scores and predict Expanded Disability Status Scale scores. Conclusion BAEP scores based on the pattern of BAEP abnormality can be a valid and useful measure in evaluating brainstem functions and predicting disability in MS.

Axon-glia interactions in the ascending auditory system

The auditory system detects and encodes sound information with high precision to provide a high-fidelity representation of the environment and communication. In mammals, detection occurs in the peripheral sensory organ (the cochlea) containing specialized mechanosensory cells (hair cells) that initiate the conversion of sound-generated vibrations into action potentials in the auditory nerve. Neural activity in the auditory nerve encodes information regarding the intensity and frequency of sound stimuli, which is transmitted to the auditory cortex through the ascending neural pathways. Glial cells are critical for precise control of neural conduction and synaptic transmission throughout the pathway, allowing for the precise detection of the timing, frequency, and intensity of sound signals, including the sub-millisecond temporal fidelity is necessary for tasks such as sound localization, and in humans, for processing complex sounds including speech and music. In this review, we focus on glia and glia-like cells that interact with hair cells and neurons in the ascending auditory pathway and contribute to the development, maintenance, and modulation of neural circuits and transmission in the auditory system. We also discuss the molecular mechanisms of these interactions, their impact on hearing and on auditory dysfunction associated with pathologies of each cell type.

Sequential Bilateral Hearing Loss in Multiple Sclerosis

Objectives: We describe a case of multiple sclerosis presenting with sequential bilateral hearing loss.

Methods: A 46-year-old woman underwent a series of audiological and neurologic evaluations for sequential bilateral hearing losses that occurred 6 months apart.

Results: Initially, the patient suffered from sudden left hearing loss, and magnetic resonance imaging documented an enhancing lesion in the left middle cerebellar peduncle. Six months later, another episode of sudden vertigo, right hearing loss, and right facial palsy developed. Magnetic resonance imaging disclosed a new lesion in the right middle cerebellar peduncle.

Conclusions: Sequential bilateral hearing loss may be a manifestation of multiple sclerosis. In younger patients with sudden hearing loss, multiple sclerosis should be included in the differential diagnosis.

Review : Gene Expression after Cerebral Ischemia

Global and focal ischemias induce a variety of gene families, including immediate early genes, cytokines, neurotransmitter receptors, and heat-shock proteins. The Janus-like effects of several of these gene prod ucts promote neuronal survival and degeneration. Therefore, determining the molecular pathways respon sible for the differential regulation of these genes is of paramount importance. The discovery of apoptosis as a mediator of delayed neuronal death has led to the identification of a number of other genes involved in postischemic brain damage. Future neuroprotective therapies for cerebral ischemia may be directed at preventing alterations in gene expression. NEUROSCIENTIST 5:238-253, 1999

Thalamocortical-auditory network alterations following cuprizone-induced demyelination

Background

Demyelination and remyelination are common pathological processes in many neurological disorders, including multiple sclerosis (MS). Clinical evidence suggests extensive involvement of the thalamocortical (TC) system in patients suffering from MS.

Methods

Using murine brain slices of the primary auditory cortex, we investigated the functional consequences of cuprizone-induced de- and remyelination on neuronal activity and auditory TC synaptic transmission in vitro.

Results

Our results revealed an impact of myelin loss and restoration on intrinsic cellular firing patterns, synaptic transmission, and neuronal plasticity in layer 3 and 4 neurons of the auditory TC network. While there was a complex hyper- and depolarizing shift of the resting membrane potential, spontaneous and induced action potential firing was reduced during demyelination and early remyelination. In addition, excitatory postsynaptic potential amplitudes were decreased and induction of LTP was reduced during demyelination.

Conclusions

These data indicate that demyelination-induced impairment of neurons and network activity within the TC system may underlie clinical symptoms observed in demyelinating diseases, corroborating human findings that disease progression is significantly correlated with microstructural tissue damage of the TC system. Further investigation into focal inflammation-induced demyelination models ex vivo and in vivo are needed to understand the functional implication of local and remote lesion formation on TC network activity in MS.

Association of multiple sclerosis and sudden sensorineural hearing loss

Background

Multiple sclerosis (MS) may affect other cranial nerves besides the optic nerve. Sudden sensorineural hearing loss (SSHL), possibly caused by a deficit in the auditory tract, including the vestibulocochlear nerve, is sometimes associated with MS.

Objectives

We aimed to assess the incidence of SSHL among MS patients, its frequency as an initial symptom of MS, and magnetic resonance imaging (MRI) findings associated with SSHL in MS.

Methods

We collected retrospectively all patients diagnosed with MS and SSHL at the Helsinki University Hospital between 2004 and 2014. Patients with both diagnoses were re-evaluated using hospital medical records, audiograms and head MRI scans.

Results

A total of 2736 patients were diagnosed with MS, 1581 patients with SSHL, and 18 patients (0.7% of all MS patients) with both; two patients presented with SSHL as an initial symptom of MS. The annual incidence of SSHL was 59.8/100 000 (95% confidence interval (CI) 37.7–94.9) in MS patients, and 12.4/100 000 (95% CI 11.8–13.0) in the normal population.

Conclusion

SSHL is a rare symptom of MS and is even less frequent as an initial symptom. Its incidence in MS patients, however, markedly exceeds that in the normal population.

Hearing disorders in multiple sclerosis

Multiple sclerosis (MS) is a disease that is both a focal inflammatory and a chronic neurodegenerative disease. The focal inflammatory component is characterized by destruction of central nervous system myelin, including the spinal cord; as such it can impair any central neural system, including the auditory system. While on the one hand auditory complaints in MS patients are rare compared to other senses, such as vision and proprioception, on the other hand auditory tests of precise neural timing are never "silent." Whenever focal MS lesions are detected involving the pontine auditory pathway, auditory tests requiring precise neural timing are always abnormal, while auditory functions not requiring such precise timing are often normal. Azimuth sound localization is accomplished by comparing the timing and loudness of the sound at the two ears. Hence tests of azimuth sound localization must obligatorily involve the central nervous system and particularly the brainstem. Whenever a focal lesion was localized to the pontine auditory pathway, timing tests were always abnormal, but loudness tests were not. Moreover, a timing test that included only high-frequency sounds was very often abnormal, even when there was no detectable focal MS lesion involving the pontine auditory pathway. This test may be a marker for the chronic neurodegenerative aspect of MS, and, as such could be used to complement the magnetic resonance imaging scan in monitoring the neurodegenerative aspect of MS. Studies of MS brainstem lesion location and auditory function have led to advances in understanding how the human brain processes sound. The brain processes binaural sounds independently for time and level in a two-stage process. The first stage is at the level of the superior olivary complex (SOC) and the second at a level rostral to the SOC.

The role of cervical and ocular vestibular-evoked myogenic potentials in the follow-up of vestibular neuritis

This study evaluates the recovery of vestibular nerve function after vestibular neuritis (VN) by vestibular-evoked myogenic potentials (VEMPs). Twenty-six patients with the diagnosis of VN were included. All patients underwent ocular VEMP (oVEMP) and cervical VEMP (cVEMP) recordings, at 6 days and 6 months from the onset of the symptoms. Of the 26 patients, 14 showed improvement on oVEMP at month 6 (group 1), and 12 showed no change or worsening on oVEMP at 6 months (group 2). At the same time, there was no change in the amplitudes of the cVEMP on either healthy or affected sides in both groups. Inability to perform the Fukuda test, and chronic white matter supratentorial lesions present on brain magnetic resonance imaging (MRI) were more frequent in patients with worse outcome on oVEMP (P = 0.044 and 0.045, respectively). Although involvement of the inferior branch of the vestibular nerve was not associated with oVEMP outcome, oVEMP latencies (N10 and P13) were associated with improvement or worsening in oVEMP amplitudes, showing that prolonged latencies correlate with 6-month improvement in oVEMP amplitudes (Pearson correlation -0.472, P = 0.041 and -0.580, P = 0.009, respectively). This study identified clinical, MRI and neurophysiological predictors of recovery in patients with superior VN, and offers additional insight into, and better understanding of, the role of VEMP in diagnosis and prognosis of patients with VN. Further studies are needed to validate this diagnostic procedure and to assess its clinical usefulness in VN management.

Pure-tone auditory thresholds are not chronically elevated in multiple sclerosis

Despite the fact that acute cases of multiple sclerosis (MS)-related pure-tone hearing loss have been reported in the literature, consensus is lacking as to the chronic influences of MS on pure-tone thresholds. Most studies examining such influences have been limited by small sample sizes, lack of statistical comparisons between patients and controls, and confounding of the hearing measure with influences from sex and age. To date, associations between pure-tone thresholds and central MS-related brain lesions have not been assessed. In this study, pure-tone thresholds ranging from 0.5 to 8 kHz were measured in 73 MS patients and 73 individually age- and gender-matched normal controls. In 63 MS patients, correlations were computed between the threshold values and MRI-determined lesion activity in 26 central brain regions. Although thresholds were strongly influenced by sex, age, and tonal frequency, no meaningful influences of MS were discerned. Moreover, no significant association between the threshold values and central MS-related lesion activity was evident in any brain region evaluated. This study, the largest on this topic to use carefully matched control subjects and the sole study to assess relationships between auditory thresholds and central MS-related lesions, strongly suggests that (a) MS is not chronically associated with pure-tone hearing loss and (b) pure-tone thresholds are unrelated to MS lesion activity in higher brain regions. These findings, along with general reports from the literature, support the concept that when MS-related hearing threshold deficits are found, they are episodic and primarily dependent on lesions within the eighth nerve or brainstem.

Sudden sensorineural hearing loss in multiple sclerosis: clinical course and possible pathogenesis

OBJECTIVE - To assess the symptom of sudden hearing loss in multiple sclerosis (MS). METHOD - We reviewed patient files in our MS clinic between January 2004 and November 2009 for symptoms of sudden hearing loss. RESULTS - We were able to identify 11 of 253 patients (4.35%) with sudden hearing loss. In seven patients, the hearing decline was the presenting symptom of MS and in all 11 patients, it appeared early in the course of the disease. There was no residual hearing deficit in 9/11 patients. In no patient was the condition bilateral and in none did it recur. CONCLUSION - Episodes of hearing loss are not uncommon in MS and have a good chance of complete recovery.

Auditory evoked potentials and multiple sclerosis

Multiple sclerosis (MS) is an inflammatory, demyelinating disease that can affect several areas of the central nervous system. Damage along the auditory pathway can alter its integrity significantly. Therefore, it is important to investigate the auditory pathway, from the brainstem to the cortex, in individuals with MS. OBJECTIVE: The aim of this study was to characterize auditory evoked potentials in adults with MS of the remittent-recurrent type. METHOD: The study comprised 25 individuals with MS, between 25 and 55 years, and 25 age- and gender-matched healthy controls (research and control groups). Subjects underwent audiological and electrophysiological evaluations. RESULTS: Statistically significant differences were observed between the groups regarding the results of the auditory brainstem response and the latency of the Na and P300 waves. CONCLUSION: Individuals with MS present abnormalities in auditory evoked potentials indicating dysfunction of different regions of the central auditory nervous system.

Molecular Mechanisms in the Pathogenesis and Treatment of Acute Ischemic Stroke

The management of acute ischemic stroke has not made significant strides since the introduction of recombinant tissue plasminogen activator (r-TPA) two decades ago. The use of other therapies, such as heparin, aspirin, dipyridamole, and/or clopidogrel, have only moderately aided in the treatment of this ischemic disease. Therefore, major medical innovative approaches are critically needed. Because of the side effects associated with r-TPA (specifically bleeding) and its limited 3-h therapeutic window, new studies using current developments encountered in the molecular biology of ischemia are being incorporated into the potential therapy of ischemic stroke. A review of the major advances in the field, including glutamate receptor blockade, magnesium infusion, inflammation blockade, apoptosis inhibition, and other therapies, is introduced with special emphasis on the molecular findings recognized as targets for a better and more effective treatment. As new therapies are being considered, the time of administration is becoming a central point of study for the application of novel therapeutic initiatives.

Neuroprotection (including hypothermia)

There have been over 2000 publications in the last year addressing the topic of neuroprotection. Novel and emerging therapeutic targets that have been explored include cerebral inflammation, hypothermia, neural transplantation and repair and gene therapy. Unfortunately, with few exceptions, the successes of experimental neuroprotection have not been translated into clinical practice. The possible reasons for the discrepancy between experimental success and clinical benefit are explored.

Bilateral trigeminal enhancement on magnetic resonance imaging in a patient with multiple sclerosis and trigeminal neuralgia

We report on clinical and instrumental findings of a multiple sclerosis (MS) patient with sudden right trigeminal neuralgia (TN). Magnetic resonance imaging (MRI), performed at TN onset, showed enlargement of both trigeminal nerves (TrN) at the root entry zone, with gadolinium enhancement of the cisternal portion. This is the first description of clinical and MRI findings indicative of peripheral involvement of the fifth cranial nerve in a MS patient complaining of TN. Our report shows the concomitant involvement of central and peripheral myelin in MS, and adds further highlights to the question regarding peripheral nerve involvement abnormalities associated with a disease considered limited to the central nervous system (CNS). Multiple Sclerosis 2007; 13: 814-816. http://msj.sagepub.com

Central auditory evaluation in multiple sclerosis: case report

Herein, we report a case of multiple sclerosis in which peripheral and central hearing, were evaluated through early (brainstem), middle and late auditory evoked potentials before and after corticosteroid therapy. Auditory evaluation revealed better performance on all post-treatment tests. In this case, central auditory function tests (behavioral and electrophysiological) identified the location of the impairment (brainstem), which was in agreement with the patient complaint. The speech in noise test and brainstem auditory evoked potentials are definitely appropriate in confirming brainstem lesions.

Surdités brusques idiopathiques

Idiopathic Sudden Sensorineural Hearing Loss (ISSHL) remains one of the major unsolved otologic emergencies. It is characterized by the onset of an unilateral sensorineural hearing loss developing within 24 hours, and averaging on pure tone audiogram at least 30 dB HL for three subsequent octave steps, with no marked vestibular symptoms and no identifiable cause. ISSHL is a syndrome covering several heterogeneous entities resulting from different pathogenetic mechanisms. At this time, the audiogram is the unique tool which may help clinicians to identify these entities and provide a classification based on 5 types of hearing loss. Numerous experimental and clinical studies have investigated the mechanisms by which infectious, ischemic, mechanic or immunologic insults may induce cochlear dysfunction. However, extrapolation to humans and rationale therapeutic approaches to ISSHL remain uncertain. SSHL being a diagnosis of exclusion, retrocochlear and neurologic etiologies should be eliminated. No argument allows to consider ISSHL a therapeutic emergency. More precisely, the experimental data presently available on cochlear physiology suggests that a treatment could have some chance to be effective if undertaken within minutes following the onset of ISSHL, a condition never encountered in daily practice. Conversely, it is not justifiable to impute the absence of hearing recovery to a delay in therapy. The various therapeutic strategies currently recommended are highly empirical and should be questionned in terms of cost-effectiveness, the most common being high-dose corticosteroids. New investigation tests are required for improving our approach to ISSHL.

Vestibular evoked myogenic potential: new perspectives in multiple sclerosis

Summary

Aim: To evaluate vestibular evoked myogenic potentials in patients with multiple sclerosis as method of diagnostic support.

Study design

Case-control.

Material and Method

We studied a group of normal individuals (n = 15) and a Studied group (n = 15) that comprised patients with diagnosis of multiple sclerosis. Both groups were submitted to vestibular evoked myogenic potential exam. In each ear it was applied 200 stimuli by clicks and repeated for 2 consecutive cycles with the purpose of evaluating reproducibility. The active electrode of surface was put on the superior S‡of sternocleidomastoid muscle and the reference electrode on the anterior border of the clavicle. The individuals were instructed to rotate theirs head to the opposite side to the stimulated ear.

Results

Vestibular evoked myogenic potential responses were prompt, reproducible and biphasic. The latency of wave P1 and N2 and P1-N2 amplitude showed a higher value in the studied group when compared with the normal group. There was no significant difference when the ears were compared in P1 and N2 amplitude. We noticed that individuals with multiple sclerosis showed no response in 30% of the cases. In evaluating the individuals of the Studied group with otoneurology symptoms and compared with individuals without symptoms, it was observed that P1 and N2 latencies and P1-N2 amplitude were higher in symptomatic cases.

Conclusion

Vestibular evoked myogenic potential was considered a good method of diagnostic support of vestibulospinal tract in cases of multiple sclerosis.

Acute tinnitus and hearing loss as the initial symptom of multiple sclerosis in a child

Acute hearing loss with or without tinnitus has been reported in a number of adult series of multiple sclerosis (MS), but is considered a rare phenomenon. It generally occurs during disease exacerbations, rather than as an isolated finding or presenting feature. We present the case of an 11-year-old girl in whom persistent tinnitus and reversible hearing loss were the sole manifestation of MS at initial presentation.

Cerebral neutrophil recruitment, histology, and outcome in acute ischemic stroke: an imaging-based study

BACKGROUND AND PURPOSE

Evidence now exists for a pathogenic role for neutrophils in acute cerebral ischemia. We have studied the patterns and temporal profile of cerebral neutrophil recruitment to areas of acute ischemic stroke (IS) and have attempted to correlate this with neurological status and outcome.

METHODS

Patients with cortical middle cerebral artery (MCA) IS were recruited within 24 hours of clinical onset. Neutrophil recruitment was studied using indium-111 (111In) troponolate-labeled neutrophils, planar imaging, and single-photon emission computed tomography (SPECT). Volume of brain infarction was calculated from concurrent computed tomography (CT). Hematoxylin and eosin sections were obtained postmortem (n=2). Outcome was measured using Barthel, Rankin, and National Institute of Health Stroke (NIHSS) scales.

RESULTS

Fifteen patients were studied. Significant 111In-neutrophil recruitment to ipsilateral hemisphere, as measured by asymmetry index (AI), was demonstrated within 24 hours of onset in 9 patients; this response was heterogenous between patients and on repeated measurement attenuated over time. Histologically, recruitment was confirmed within intravascular, intramural, and intraparenchymal compartments. Interindividual heterogeneity in neutrophil response did not correlate with infarct volume or outcome. In an exploratory analysis, neutrophil accumulation appeared to correlate significantly with infarct expansion (Spearman rho=0.66; P=0.03, n=12).

CONCLUSIONS

Neutrophils recruit to areas of ischemic brain within 24 hours of symptom onset. This recruitment attenuates over time and is confirmed histologically. While neutrophil accumulation may be associated with either the magnitude or the rate of infarct growth, these results require confirmation in future studies.

Pneumonia and urinary tract infection after acute ischaemic stroke: a tertiary analysis of the GAIN International trial

The third most common stroke complication is infection. We studied the rates of aspiration pneumonia and urinary tract infection (UTI), their risk factors and their effect on outcome in the 1455 Glycine Antagonist (Gavestinel) in Neuroprotection (GAIN) International patients with ischaemic stroke. Forward stepwise logistic regression and Cox proportional hazards modelling identified baseline factors that predicted events and the independent effect of events up to day 7 on poor stroke outcome at 3 months in patients alive at day 7, after correcting for prognostic factors. Higher baseline National Institute of Health Stroke Scale (NIHSS) and age, male gender, history of diabetes and stroke subtype predicted pneumonia, which occurred in 13.6% of patients. Female gender and higher baseline NIHSS and age predicted UTI, which occurred in 17.2% of patients. Pneumonia was associated with poor outcome by mortality (hazard ratio, 2.2; 95% confidence interval, 1.5-3.3), Barthel index (<60) (odds ratio, 3.8; 2.2-6.7), NIHSS (4.9; 1.7-14) and Rankin scale (>/=2) (3.4; 1.4-8.3). UTI was associated with Barthel index (1.9; 1.2-2.9), NIHSS (2.2; 1.2-4.0) and Rankin scale (3.1; 1.6-4.9). Pneumonia and UTI are independently associated with stroke poor outcome. Patients with identified risk factors must be closely monitored for infection.

Clinical effects of inhibiting leukocyte adhesion with monoclonal antibody to intercellular adhesion molecule-1 (enlimomab) in the treatment of partial-thickness burn injury

BACKGROUND

A randomized, prospective, multicenter, double-blind, placebo-controlled, phase II clinical trial was performed to determine whether inhibition of leukocyte adherence by administration of monoclonal antibody directed against intercellular adhesion molecule-1 would improve burn wound healing.

METHODS

One hundred ten patients with burn injury ranging from 10% to 30% total body surface area were enrolled. Fifty-six patients received placebo (saline) and 54 patients received murine monoclonal antibody to the human intercellular adhesion molecule-1 (enlimomab). Treatment was initiated within 6 hours of injury. Patients had three distinct partial-thickness wound sites assessed. Laser Doppler flowmetry was used to stratify wounds on the day of injury. Wounds were assessed for healing status on day 21 postburn and categorized as healed, nonhealed, or grafted.

RESULTS

Patients treated with enlimomab had a significantly increased percentage of wounds that healed spontaneously in less than 21 days overall and when stratified by burn wound laser Doppler blood flow readings for those wounds at greatest risk for nonhealing.

CONCLUSION

These results support the concept that leukocyte adherence is involved in the pathogenesis of burn wound necrosis and suggest a therapeutic mechanism for modulating the inflammatory response after the burn injury that may improve wound healing.

HuEP5C7 as a humanized monoclonal anti-E/P-selectin neurovascular protective strategy in a blinded placebo-controlled trial of nonhuman primate stroke

Although inhibiting interaction of beta(2) integrins with cognate immunoglobulin class adhesion receptor ligands is an effective neuroprotective strategy in small mammal models of stroke, the strategy has failed in human trials. A completely different antiadhesion receptor strategy was therefore rigorously tested in a model that may more closely approximate human reperfused stroke. Early leukoadhesive events in postischemic cerebral microvessels are mediated by upregulated selectin-class adhesion receptors on endothelial cells. Therefore, a blocking antibody prepared against common P- and E-selectin epitopes was humanized to suppress complement activation and tested in a reperfused hemispheric stroke model in Papio anubis (baboon). Histological examination of postischemic cerebral microvessels revealed a strong upregulation of E-and P-selectin expression. Placebo-blinded administration of the humanized anti-human E- and P-selectin monoclonal antibody (HuEP5C7, 20 mg/kg IV, n=9; placebo, n=9) immediately after the onset of 1 hour of temporary ischemia resulted in trends showing reduced polymorphonuclear leukocyte (PMN) infiltration into ischemic cortex, reduced infarct volumes (by 41%), improved neurological score (by 35%), and improved ability to self-care (by 39%). Importantly, there was no evidence of systemic complement activation, immune suppression, or pathological coagulopathy associated with this therapy. These data suggest that a humanized anti-E/P-selectin antibody approach is safe and may be effective as a clinical treatment for human stroke.

The role of leukocytes following cerebral ischemia: pathogenic variable or bystander reaction to emerging infarct?

Data accumulated over the last 10 years have led to the popular hypothesis that neutrophils and other inflammatory cells play a prominent role in the neuropathology of cerebral ischemia. This hypothesis was derived from a large number of studies involving three general observations: (1) leukocytes, particularly neutrophils, are present in ischemic tissue at the approximate time that substantial neuronal death occurs; (2) neutropenia is sometimes associated with reduced ischemic damage; and (3) treatments that prevent leukocyte vascular adhesion and extravasation into the brain parenchyma can be neuroprotective. This review reexamines the literature to ascertain its support for a pathogenic role for neutrophils in ischemia-induced neuronal loss. To accomplish this goal, we employed several logical theorems of "cause-effect" relationships, as they pertain to leukocytes and ischemic brain damage. Since the majority of studies focused on neutrophils as the most likely pathogenic inflammatory cell, this review necessarily does so here. We reasoned that if neutrophils play an important pathogenic (i.e., cause-effect) role in the neuronal damage that follows a stroke, then one should expect to find clear evidence that: (1) neutrophils invade the ischemic area prior to terminal stage infarction, (2) greater numbers of early appearing neutrophils are accompanied by evidence of greater neuronal loss, and (3) dose-related inhibition of neutrophil trafficking or activity produces a corresponding decrease in the degree of brain damage following ischemia. This review of the literature reveals that the existing evidence does not readily support any of these predictions and that, therefore, it consistently falls short of establishing a clear cause-effect relationship between leukocyte recruitment and the pathogenesis of ischemia. While the available evidence does not necessarily rule out a potential pathogenic role of neutrophils and other leukocytes, it nevertheless does expose serious weaknesses in the existing studies intended to support that hypothesis. For this reason we also offer suggestions for additional experiments and the inclusion of control groups that, in the future, might provide more effective or conclusive tests of the hypothesis.

Heterogeneity affecting outcome from acute stroke therapy: making reperfusion worse

BACKGROUND

Stroke patients are heterogeneous not only with respect to etiology but also in terms of preexisting clinical conditions. Approximately one fifth of patients with acute stroke are hyperglycemic and/or have had a recent infectious or inflammatory condition. Summary of Review-- Experimental research indicates that these factors can alter and accelerate the evolution of stroke and reperfusion injury, although these effects are complex and some may have a favorable impact. Both conditions involve activation of inflammatory and reactive oxygen mechanisms. In addition, hyperglycemia has concomitant deleterious vascular and metabolic effects that worsen infarct size and encourage hemorrhagic transformation in reperfusion models. Clinical data are less extensive but in general support an adverse impact on outcome.

CONCLUSIONS

After examining these data in detail, we concluded that the presence of these clinical conditions could assist in identification of those at increased risk for complications of reperfusion therapy. Furthermore, consideration of these factors may provide a rational basis for combination therapy and improve the clinical relevance of experimental stroke models.

Neuroprotection in ischemia-reperfusion injury: an antiinflammatory approach using a novel broad-spectrum chemokine inhibitor

Cerebral ischemia-reperfusion injury is associated with a developing inflammatory response with pathologic contributions from vascular leukocytes and endogenous microglia. Signaling chemokines orchestrate the communication between the different inflammatory cell types and the damaged tissue leading to cellular chemotaxis and lesion occupation. Several therapies aimed at preventing this inflammatory response have demonstrated neuroprotective efficacy in experimental models of stroke, but to date, few investigators have used the chemokines as potential therapeutic targets. In the current study, the authors investigate the neuroprotective action of NR58-3.14.3, a novel broad-spectrum inhibitor of chemokine function (both CXC and CC types), in a rat model of cerebral ischemia-reperfusion injury. Rats were subjected to 90 minutes of focal ischemia by the filament method followed by 72 hours of reperfusion. Both the lesion volume, measured by serial magnetic resonance imaging, and the neurologic function were assessed daily. Intravenous NR58-3.14.3 was administered, 2 mg/kg bolus followed by 0.5 mg/kg hour constant infusion for the entire 72-hour period. At 72 hours, the cerebral leukocytic infiltrate, tumor necrosis factor-alpha (TNF-alpha), and interleukin-8 (IL-8)-like cytokines were analyzed by quantitative immunofluorescence. NR58-3.14.3 significantly reduced the lesion volume by up to 50% at 24, 48, and 72 hours post-middle cerebral artery occlusion, which was associated with a marked functional improvement to 48 hours. In NR58-3.14.3-treated rats, the number of infiltrating granulocytes and macrophages within perilesional regions were reduced, but there were no detectable differences in inflammatory cell numbers within core ischemic areas. The authors reported increased expression of the cytokines, TNF-alpha, and IL-8-like cytokines within the ischemic lesion, but no differences between the NR58-3.14.3-treated rats and controls were reported. Although chemokines can have pro- or antiinflammatory action, these data suggest the overall effect of chemokine up-regulation and expression in ischemia-reperfusion injury is detrimental to outcome.

Cerebral ischemia and inflammation

Cerebral ischemia is accompanied by a marked inflammatory reaction that is initiated by ischemia-induced expression of cytokines, adhesion molecules, and other inflammatory mediators, including prostanoids and nitric oxide. Preclinical studies suggest that interventions that are aimed at attenuating such inflammation reduce the progression of brain damage that occurs during the late stages of cerebral ischemia. In particular, strategies that block the activity of inflammation-related enzymes, such as inducible nitric oxide synthase and cyclo-oxygenase-2, reduce ischemic damage with an extended therapeutic window. Although a clinical trial using murine antibodies against intercellular adhesion molecule-1 did not show benefit in patients with ischemic stroke, recent data indicate that immune activation induced by the heterologous protein may have played an important role in the failure of this trial. Therefore, there is a strong rationale for continuing to explore the efficacy of anti-inflammatory therapies in the treatment of the late stages of cerebral ischemia.

Inhibition of alpha4 integrin protects against transient focal cerebral ischemia in normotensive and hypertensive rats

BACKGROUND AND PURPOSE

The present study was performed to determine the role of alpha4 (CD49d), a member of the integrin family of adhesion molecules, in ischemic brain pathology.

METHODS

Male spontaneously hypertensive rats (SHR) or Sprague-Dawley rats underwent 60-minute middle cerebral artery occlusion (MCAO) followed by 23-hour reperfusion. Animals were injected intravenously with 2.5 mg/kg anti-rat alpha4 antibody (TA-2) or isotype control antibody (anti-human LFA-3 IgG(1), 1E6) 24 hours before MCAO. Infarct volume was quantified by staining of fresh tissue with tetrazolium chloride and myeloperoxidase activity measured in SHR tissue homogenates 24 hours after MCAO. In SHR, mean arterial blood pressure was recorded before and after MCAO in animals treated with TA-2 and 1E6. Fluorescence-activated cell sorting analysis was performed on peripheral blood leukocytes before and after MCAO.

RESULTS

TA-2 treatment significantly reduced total infarct volume by 57.7% in normotensive rats (1E6, 84.2+/-11.5 mm(3), n=17; TA-2, 35.7+/-5.9 mm(3), n=16) and 35.5% in hypertensive rats (1E6, 146.6+/-15.5 mm(3), n=15; TA-2, 94.4+/-25.8 mm(3), n=11). In both strains, TA-2 treatment significantly reduced body weight loss and attenuated the hyperthermic response to MCAO. In SHR, treatment with TA-2 significantly reduced brain myeloperoxidase activity. Resting mean arterial blood pressure was unaffected by treatment. Leukocyte counts were elevated in TA-2-treated rats. Fluorescence-activated cell sorting analysis demonstrated the ability of TA-2 to bind to CD3+, CD4+, CD8+, and CD11b+ cells in both naive animals and after MCAO.

CONCLUSIONS

These data demonstrate that inhibition of alpha4 integrin can protect the brain against ischemic brain injury and implicate endogenous alpha4 integrin in the pathogenesis of acute brain injury. The mechanism by which alpha4 integrin inhibition offers cerebroprotection is independent of blood pressure modulation and is likely due to inhibition of leukocyte function.

Current status of neuroprotective agents in the treatment of acute ischemic stroke

To keep ischemic brain cells alive, neuroprotective agents target events in the ischemic cascade that might be injurious to the cells. They can be divided broadly into groups that restore ion balance, block receptors, prevent reperfusion injury, or promote neuronal healing. To date, neuroprotective agents have either shown a lack of efficacy in clinical stroke trials or been limited by side effects. Ongoing clinical trials with novel agents are trying to enroll a more homogeneous population of stroke patients in an effort to demonstrate treatment benefit.

Antibody to the alpha4 integrin decreases infarct size in transient focal cerebral ischemia in rats

BACKGROUND AND PURPOSE

Inflammation, a process that involves neutrophils, lymphocytes, and monocytes, contributes to cerebral ischemic injury. Blockade of neutrophil adhesion to endothelium improves outcome after experimental stroke. In this study we sought to assess the contribution of lymphocytes and monocytes to ischemic brain injury.

METHODS

Male Lewis rats underwent 3 hours of middle cerebral artery occlusion followed by 45 hours of reperfusion. Two hours after the onset of ischemia, one group of animals received an intraperitoneal injection of antibodies to the alpha(4) integrin (n=16); another group was injected with an isotype control antibody (n=11). Neurological examination, body temperature, and body weight were assessed at different time points after stroke. Animals were killed 48 hours after the onset of ischemia for determination of infarct volume and leukocyte counts.

RESULTS

There were no significant differences in body temperature or weight at any time. Neurological scores (deficits) were significantly less in animals treated with anti-alpha(4) antibodies at 24 (2.0+/-1.2 versus 3. 0+/-0.4; P:=0.006) and 48 (2.0+/-1.2 versus 3.0+/-0.8; P:=0.011) hours after ischemia. Peripheral blood leukocyte counts were significantly higher in anti-alpha(4)-treated animals (6.8+/-2.2 x 10(9) versus 2.9+/-1.9 x 10(9); P:=0.001) and revealed a lymphocyte/monocyte predominance (86.0+/-16.2% versus 71.0+/-15.6%; P:=0.008). Infarct volume was significantly less in animals treated with antibodies to alpha(4) (120.1+/-51.21 versus 173.7+/-42.29 mm(3); P:=0.012).

CONCLUSIONS

These data support a role for lymphocytes and monocytes in cerebral ischemic injury and show that blockade of alpha(4), even when instituted after the onset of ischemia, can improve neurological outcome and decrease infarct volume.

Acute ischemic stroke : polymorphonuclear leukocyte membrane fluidity and cytosolic Ca(2+) concentration at baseline and after chemotactic activation

BACKGROUND AND PURPOSE

Several reports have considered the role of systemic leukocytes in acute ischemic stroke (AIS). Initially, greater attention was focused on the leukocyte count and subsequently on their adhesiveness, aggregation, rheology, and activation. The aim of this study was the evaluation of certain polymorphonuclear leukocyte (PMN) parameters, reflecting their rheology and activation, in subjects with AIS.

METHODS

In a group of 19 subjects with AIS and in a control group of 18 subjects with asymptomatic vascular atherosclerotic disease, we evaluated the PMN membrane fluidity and cytosolic Ca(2+) concentration at baseline and after in vitro chemotactic activation with 4-phorbol 12-myristate 13-acetate (PMA) and N-formyl-methionyl-leucyl-phenylalanine (fMLP).

RESULTS

From the obtained data, it is evident that at baseline only PMN membrane fluidity distinguishes control subjects from AIS subjects. After PMN activation with PMA and fMLP, prolonged for 5 and 15 minutes, we found an increase in PMN cytosolic Ca(2+) concentration and a decrease in PMN membrane fluidity only in subjects with AIS.

CONCLUSIONS

These findings emphasize that in subjects with AIS a functional alteration of systemic PMN cells is clearly expressed during chemotactic activation, although the mechanism of this abnormality is not yet explained.

Neuroprotection of Acute Ischemic Stroke: Where are We?

Neuroprotective treatments for acute ischemic stroke are targeted at the large array of cellular biochemical and metabolic disturbances that occur after focal brain ischemia to prevent the evolution of injury toward irreversibility. Enhanced comprehension about the pathophysiology of focal brain ischemia has expanded the number of neuroprotective modalities under development and identification of the most likely target for these therapies. Many of the neuroprotective interventions are targeted at reducing calcium influx into ischemic cells and the downstream consequences of excessive intracellular calcium. Other neuroprotective strategies include: free radical scavengers, hyperpolarization of resting transmembrane potentials, and inhibition of the inflammatory response and growth factors. Some interventions potentially may enhance recovery and have neuroprotective effects (i.e., basic fibroblast growth factor [bFGF] and citicoline). Despite the lack of proven clinical efficacy with any neuroprotective intervention, the future will hopefully yield convincing evidence that neuroprotection can be effective and then be ultimately combined with thrombolysis to maximize improvement after ischemic stroke.

Pathobiology of ischaemic stroke: an integrated view

Brain injury following transient or permanent focal cerebral ischaemia (stroke) develops from a complex series of pathophysiological events that evolve in time and space. In this article, the relevance of excitotoxicity, peri-infarct depolarizations, inflammation and apoptosis to delayed mechanisms of damage within the peri-infarct zone or ischaemic penumbra are discussed. While focusing on potentially new avenues of treatment, the issue of why many clinical stroke trials have so far proved disappointing is addressed. This article provides a framework that can be used to generate testable hypotheses and treatment strategies that are linked to the appearance of specific pathophysiological events within the ischaemic brain.

Mechanisms and consequences of phagocyte adhesion to endothelium

Leukocyte adhesion to endothelium is essential for the development of an appropriate immune-inflammatory response. The vital importance of leukocyte-endothelial adhesive interactions in host defense and homeostasis is illustrated by the clinical manifestations of patients with congenital defects of leukocyte adhesion functions. However, under some circumstances leukocyte adhesion to endothelium may instead lead to vascular and tissue damage. In recent years, there has been remarkable progress in the understanding of the molecular basis of leukocyte adhesion to endothelium, and this knowledge has led to a new approach to immunomodulation in human disease, ie 'antiadhesion' therapy. This review focuses on cell adhesion molecules mediating adhesion of circulating phagocytes to vascular endothelium, on congenital defects of phagocyte adhesion in man, and on the current status of antiadhesion therapy directed towards phagocyte and endothelial adhesion molecules. We will also consider markers of phagocyte activation, which may provide a means to identify those patients who would benefit most from antiadhesion therapy.

Effect of traumatic brain injury in mice deficient in intercellular adhesion molecule-1: assessment of histopathologic and functional outcome

Intercellular adhesion molecule-1 (ICAM-1) is an adhesion molecule of the immunoglobulin family expressed on endothelial cells that is upregulated in brain as part of the acute inflammatory response to traumatic brain injury (TBI). ICAM-1 mediates neurologic injury in experimental meningitis and stroke; however, its role in the pathogenesis of TBI is unknown. We hypothesized that mutant mice deficient in ICAM-1 (-/-) would have decreased neutrophil accumulation, diminished histologic injury, and improved functional neurologic outcome versus ICAM-1 +/+ wild type control mice after TBI. Anesthetized ICAM-1 -/- mice and wild-type controls were subjected to controlled cortical impact (CCI, 6 m/sec, 1.2 mm depth). Neutrophils in brain parenchyma and ICAM-1 on vascular endothelium were assessed by immunohistochemistry in cryostat brain sections from the center of the contusion 24 h after TBI (n = 4/group). Separate groups of wild-type and ICAM-1-deficient mice (n = 9-10/group) underwent motor (wire grip test, days 1-5) and cognitive (Morris water maze [MWM], days 14-20) testing. Lesion volume was determined by image analysis 21 days following TBI. Robust expression of ICAM-1 was readily detected in choroid plexus and cerebral endothelium at 24 h in ICAM-1 +/+ mice but not in ICAM-1 -/- mice. No differences between groups were observed in brain neutrophil accumulation (9.4 +/- 2.2 versus 11.1 +/- 3.0 per x100 field, -/- versus +/+), wire grip score, MWM latency, or lesion volume (7.24 +/- 0.63 versus 7.21 +/- 0.45 mm3, -/- versus +/+). These studies fail to support a role for ICAM-1 in the pathogenesis of TBI.

Clinical trial update: neuroprotection against acute ischaemic stroke

One of the most recent advances and hopes in stroke therapy concerns neuroprotection, which has recently been investigated in several clinical trials. Furthermore, some new neuroprotective drugs, which are based on newly identified cellular and molecular mechanisms that underlie the development of focal ischaemic injury, will be tested in stroke patients in the future. It must be emphasized, however, that the concept and application of neuroprotection must remain within the frame of the global network and organization of acute stroke care, because neuroprotection at best may become only a link among many other management strategies for acute stroke.

Cytokines and cell adhesion molecules in cerebral ischemia: experimental bases and therapeutic perspectives

The possibility of reopening an occluded cerebral artery by means of thrombolysis has renewed interest in a number of the several mechanisms that are active during acute cerebral ischemia. Over recent years, it has become apparent that leukocytes play a central role not only during the healing stage of brain infarction but also during the early phases of cerebral ischemia, when it is postulated that these cells produce harmful effects, particularly in the presence of reperfusion. This review is based on the critical analysis of more than 150 publications dealing with the role of leukocytes and some inflammatory mediators (cytokines, chemokines, and adhesion molecules) in cerebral ischemia. Animal studies indicate that leukocyte involvement is promoted by a variety of inflammatory molecules produced immediately after the onset of cerebral ischemia. Considerable experimental evidence suggests that these mediators play a key role in the progression from ischemia to irreversible injury (ie, cellular death and necrosis). However, the precise role of each molecule alone remains to be further elucidated as well as in relation to the complex network existing among different mediators. Progress in our understanding of the inflammatory mechanisms operating in cerebral ischemia has enabled the testing of new compounds with promising results in animals; in contrast, one recent controlled trial of an anti-leukocyte molecule in acute stroke patients showed negative results. This discrepancy may derive in part from our incomplete understanding of the complexity of the inflammatory mechanisms involved in cerebral ischemia. Our analysis suggests that until sufficient knowledge of the underlying disease mechanisms is acquired, more care should be taken when testing new and potentially efficacious drugs in stroke patients.

Inflammation and acute stroke

There are now overwhelming data suggesting that inflammation contributes to cerebral ischemic injury. The mechanisms that lead to the inflammatory response which follows stroke, however, are not fully understood. This review will highlight the most recent advances in our knowledge as well as the early experience of using anti-inflammatory strategies to treat acute stroke.

Doxycycline treatment reduces ischemic brain damage in transient middle cerebral artery occlusion in the rat

Agents that inhibit leukocyte adhesion including intercellular adhesion molecule-1 antibodies (anti-ICAM-1) have shown beneficial effects in experimental central nervous system (CNS) ischemia. Doxycycline inhibits leukocyte function in vitro by binding divalent cations and reduces spinal cord reperfusion injury. The authors used a clinically relevant model of focal CNS reperfusion injury to test whether treatment with doxycycline would reduce cerebral ischemic damage and improve functional outcome. Reversible middle cerebral artery occlusion was produced in adult Sprague-Dawley rats by advancing a filament into the internal carotid artery for 2 h. Animals received either i.p. doxycycline (10 mg/kg) (N = 13) or saline (N = 11) 30 min before ischemia, followed by 10 mg/kg every 8 h x 6. Both functional assessment (5 point neurologic scale) and infarct volume was evaluated at 48 h. Functional efficacy: doxycycline 0.5 +/- 0.2 (mean +/- SE) vs control 1.3 +/- 0.3 (p = 0.03). Infarct volume: doxycycline 56 +/- 18 mm3 vs control 158 +/- 44 mm3 (p = 0.03); This protective effect supports the role of doxycycline in reducing CNS reperfusion injury.