Adenosine triphosphate and hemoglobin in vasospastic monkeys

Intravenous milrinone for treatment of delayed cerebral ischaemia following subarachnoid haemorrhage: a pooled systematic review

Small trials have demonstrated promising results utilising intravenous milrinone for the treatment of delayed cerebral ischaemia (DCI) after subarachnoid haemorrhage (SAH). Here we summarise and contextualise the literature and discuss the future directions of intravenous milrinone for DCI. A systematic, pooled analysis of literature was performed in accordance with the PRISMA statement. Methodological rigour was analysed using the MINORS criteria. Extracted data included patient population; treatment protocol; and clinical, radiological, and functional outcome. The primary outcome was clinical resolution of DCI. Eight hundred eighteen patients from 10 single-centre, observational studies were identified. Half (n = 5) of the studies were prospective and all were at high risk of bias. Mean age was 52 years, and females (69%) outnumbered males. There was a similar proportion of low-grade (WFNS 1-2) (49.7%) and high-grade (WFNS 3-5) (50.3%) SAH. Intravenous milrinone was administered to 523/818 (63.9%) participants. Clinical resolution of DCI was achieved in 375/424 (88%), with similar rates demonstrated with intravenous (291/330, 88%) and combined intra-arterial-intravenous (84/94, 89%) therapy. Angiographic response was seen in 165/234 (71%) receiving intravenous milrinone. Hypotension (70/303, 23%) and hypokalaemia (31/287, 11%) were common drug effects. Four cases (0.5%) of drug intolerance occurred. Good functional outcome was achieved in 271/364 (74%) patients. Cerebral infarction attributable to DCI occurred in 47/250 (19%), with lower rates in asymptomatic spasm. Intravenous milrinone is a safe and feasible therapy for DCI. A signal for efficacy is demonstrated in small, low-quality trials. Future research should endeavour to establish the optimal protocol and dose, prior to a phase-3 study.

ATP-evoked sustained vasoconstrictions mediated by heteromeric P2X1/4 receptors in cerebral arteries

BACKGROUND AND PURPOSE

Current knowledge states that vasoconstrictor responses to ATP are mediated by rapidly desensitizing ligand-gated P2X1 receptors in vascular smooth muscle cells (VSMCs). However, ATP is implicated in contributing to pathological conditions involving sustained vasoconstrictor response such as cerebral vasospasm. The purpose of this study is to test the hypothesis that the stimulation of VSMC P2XR receptors (P2XRs) contributes to ATP-evoked sustained vasoconstrictions in rat middle cerebral arteries (RMCAs).

METHODS

Reverse transcription- polymerase chain reaction, Western blot, and immunocytochemistry were used to analyze expression of mRNA and proteins in RMCAs VSMCs. Ionic currents and calcium responses were investigated using patch-clamp and confocal imaging techniques, respectively. Functional responses were confirmed using wire myography.

RESULTS

Expression of mRNA and protein for P2X1R and P2X4R subunits was identified in RMCA VSMCs. Confocal imaging in fluo-3-loaded VSMCs showed that ATP and a selective P2XR agonist, αβmeATP, evoked similar dose-dependent increases in [Ca(2+)]i. Patch-clamp experiments identified 2 components of P2XR-mediated currents: consisting of a fast desensitizing phase mediated by homomeric P2X1Rs and a slowly desensitizing phase involving heteromeric P2X1/4Rs. Isometric tension measurements showed that ≈80%:20% of initial ATP-evoked vasoconstriction in RMCA is mediated by homomeric P2X1Rs and heteromeric P2X1/4Rs, respectively. The sustained slowly desensitizing and rapidly recovering from desensitization responses are mediated by heteromeric P2X1/4Rs.

CONCLUSIONS

This study reveals for the first time that apart from rapidly desensitizing homomeric P2X1Rs, heteromeric P2X1/4Rs contribute to the sustained component of the purinergic-mediated vasoconstriction in RMCA. Our study, therefore, identifies possible novel targets for therapeutical intervention in cerebral circulation.

Unfractionated heparin: multitargeted therapy for delayed neurological deficits induced by subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is associated with numerous "delayed neurological deficits" (DNDs) that have been attributed to multiple pathophysiological mechanisms, including ischemia, microthrombosis, free radical damage, inflammation, and vascular remodeling. To date, effective prophylactic therapy for SAH-induced DNDs has been elusive, due perhaps to the multiplicity of mechanisms involved that render typical, single-agent therapy seemingly futile. We hypothesized that heparin, which has multiple underappreciated salutary effects, might be useful as a multitargeted prophylactic agent against SAH-induced DNDs. We performed a comprehensive review of the literature to evaluate the potential utility of heparin in targeting the multiple pathophysiological mechanisms that have been identified as contributing to SAH-induced DNDs. Our literature review revealed that unfractionated heparin can potentially antagonize essentially all of the pathophysiological mechanisms known to be activated following SAH. Heparin binds >100 proteins, including plasma proteins, proteins released from platelets, cytokines, and chemokines. Also, heparin complexes with oxyhemoglobin, blocks the activity of free radicals including reactive oxygen species, antagonizes endothelin-mediated vasoconstriction, smooth muscle depolarization, and inflammatory, growth and fibrogenic responses. Our review suggests that the use of prophylactic heparin following SAH may warrant formal study.

p53 may play an orchestrating role in apoptotic cell death after experimental subarachnoid hemorrhage

OBJECTIVE

Secondary brain injury after subarachnoid hemorrhage (SAH) is poorly understood. As a result, there are few treatment options. Consequently, SAH is associated with a high rate of morbidity and mortality. In an effort to combat these problems, the role of apoptosis was examined in the whole brain after SAH. In particular, the role of p53 and the three major apoptotic cascades were studied, the caspase-dependent and caspase-independent cascades and the mitochondrial pathway.

METHODS

In this study, 195 Sprague-Dawley rats were divided into three groups, including sham, nontreatment, and treatment (Pifithrin-alpha; BIOMOL, Inc., Plymouth Meeting, PA) groups. The monofilament puncture model was used to induce SAH and the animals were subsequently sacrificed at 24 and 72 hours. Western blot analysis, histology, physiological parameters, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling, and immunohistological techniques were used to demonstrate the role of p53 and the apoptotic cascades in the rat brain after SAH. In addition, outcome was determined based on mortality rates and neurological outcome scores.

RESULTS

We found that p53 and associated apoptotic proteins were up-regulated after SAH and that downstream mediators of apoptosis were negatively influenced by the inhibition of p53 by Pifithrin-alpha. Furthermore, we found that apoptotic inhibition resulted in less cell death and an overall favorable outcome in the treated animals.

CONCLUSION

These results suggest that apoptosis may be an important cause of cell death in the brain after SAH and that p53 may play an orchestrating role regarding apoptosis in SAH.

Mechanisms of early brain injury after subarachnoid hemorrhage

Apoptosis is the term given to programmed cell death, which has been widely connected to a number of intracranial pathologies including stroke, Alzheimer's disease, and more recently subarachnoid hemorrhage (SAH). Subarachnoid hemorrhage is a disease, without any form of effective treatment, that affects mainly the young and middle aged and as a result is responsible for severe disability in otherwise healthy and productive individuals. Despite intense research efforts in the field, we currently possess a very limited understanding of the underlying mechanisms that result in injury after SAH. However, a number of studies have recently indicated that apoptosis may be a major player in the pathogenesis of secondary brain injury after SAH. As a result, the apoptotic cascades present a number of potential therapeutic opportunities that may ameliorate secondary brain injury after SAH. Experimental data suggest that these cascades occur very early after the initial insult and may be related directly to physiologic sequela commonly associated with SAH. It is imperative, therefore, to obtain a thorough understanding of the early events that occur after SAH, which will enable future therapies to be developed.

Metabotropic Ca(2+) channel-induced Ca(2+) release and ATP-dependent facilitation of arterial myocyte contraction

Voltage-gated Ca(2+) channels in arterial myocytes can mediate Ca(2+) release from the sarcoplasmic reticulum and, thus, induce contraction without the need of extracellular Ca(2+) influx. This metabotropic action of Ca(2+) channels (denoted as calcium-channel-induced calcium release or CCICR) involves activation of G proteins and the phospholipase C-inositol 1,4,5-trisphosphate pathway. Here, we show a form of vascular tone regulation by extracellular ATP that depends on the modulation of CCICR. In isolated arterial myocytes, ATP produced facilitation of Ca(2+)-channel activation and, subsequently, a strong potentiation of CCICR. The facilitation of L-type channel still occurred after full blockade of purinergic receptors and inhibition of G proteins with GDPbetaS, thus suggesting that ATP directly interacts with Ca(2+) channels. The effects of ATP appear to be highly selective, because they were not mimicked by other nucleotides (ADP or UTP) or vasoactive agents, such as norepinephrine, acetylcholine, or endothelin-1. We have also shown that CCICR can trigger arterial cerebral vasoconstriction in the absence of extracellular calcium and that this phenomenon is greatly facilitated by extracellular ATP. Although, at low concentrations, ATP does not induce arterial contraction per se, this agent markedly potentiates contractility of partially depolarized or primed arteries. Hence, the metabotropic action of L-type Ca(2+) channels could have a high impact on vascular pathophysiology, because, even in the absence of Ca(2+) channel opening, it might mediate elevations of cytosolic Ca(2+) and contraction in partially depolarized vascular smooth muscle cells exposed to small concentrations of agonists.

Haemoglobin and ATP levels in CSF from a dog model of vasospasm

Haemoglobin and adenosine 5'-triposphate (ATP) released from lysed erythrocytes have been postulated to be responsible for delayed cerebral vasospasm after subarachnoid haemorrhage (SAH). However, the concentrations of haemoglobin and ATP in cerebrospinal fluid (CSF) in patients or in an animal model of vasospasm have not been reported. In this study, 12 mongrel dogs underwent a double blood injection via the cisterna magna on day 0 and 2, after an initial collection of CSF. On day 3, 5 or 7, the dogs were sacrificed after a second collection of CSF. An angiogram was recorded on day 0 and on the day of sacrifice. Results showed that the diameter of the dog's basilar artery was reduced 20% on day 3 (P > 0.05), 35% on day 5 (P < 0.05) and 45% on day 7 (P < 0.05). The concentrations of OxyHb, deOxyHb and MetHb in CSF were increased (P < 0.05), and all peaked on day 3. OxyHb and MetHb remained significantly higher than control (day 0) from day 3 to day 7, while deOxyHb remained at a high level on day 5 but returned to normal on day 7. In contrast, ATP was decreased (P < 0.05) on days 5 and 7 after SAH compared with day 0. The results indicate that haemoglobin might be involved in the development of cerebral vasospasm. The possible role of ATP in vasospasm remains unclear.

Role of adenosine 5'-triphosphate in vasospasm after subarachnoid hemorrhage: human investigations

OBJECTIVE

Adenosine 5'-triphosphate (ATP) is a vasoactive compound found in high concentrations inside erythrocytes. This compound may contribute to vasospasm after subarachnoid hemorrhage (SAH). We assessed the hypothesis that ATP contributes to vasospasm in humans.

METHODS

ATP and hemoglobin concentrations were measured in cerebrospinal fluid (CSF) from humans with SAH and in blood incubated in vitro. The vasoactivity of the human CSF samples and of fractionated (fractions with molecular weight greater than or less than 10 kDa) and unfractionated blood incubated in vitro was assessed by application of samples to canine basilar artery segments under isometric tension.

RESULTS

ATP in human CSF declined within 72 hours of SAH to concentrations too low to contract cerebral arteries. Vasoactivity of human CSF correlated with the concentration of hemoglobin. The vasoactivity of incubated erythrocyte hemolysates remained high despite a decline in ATP concentrations. Fractionation of incubated erythrocyte hemolysates showed that for incubation periods up to 7 days, all vasoactivity was in a fraction of molecular weight greater than 10 kDa.

CONCLUSION

ATP is unlikely to contribute to vasospasm because the concentrations in CSF after SAH in humans are not high enough to cause vasospasm after 72 hours. The vasoactivity of erythrocyte hemolysate is not related to the ATP or ferrous hemoglobin content but may be related to the total hemoglobin content. Therefore, ATP is unlikely to be a major cause of clinically significant delayed vasospasm.

Immediate early gene expression in vascular smooth-muscle cells synergistically induced by hemolysate components

OBJECT

Vasospasm after subarachnoid hemorrhage is associated with changes in modulators of vascular tone in the arterial wall and is related to the presence of erythrocyte hemolysate in the subarachnoid space. The purpose of this study was to determine the compounds in erythrocyte hemolysate that are responsible for changing smooth-muscle cell gene expression.

METHODS

Rat aorta smooth-muscle cells were exposed to erythrocyte hemolysate in vitro and the effects on immediate early gene messenger (m)RNA levels were determined by competitive reverse transcriptase-polymerase chain reaction. Message levels for c-fos, jun B, and c-jun were increased in the presence of hemolysate, reaching maximum expression between 30 and 60 minutes, whereas the level of jun D mRNA was unaffected. Increasing doses of hemolysate caused greater expression of c-fos and jun B, but not c-jun. Adenosine triphosphate and hemoglobin, possible spasmogens present in hemolysate, caused much smaller and more rapid increases in c-fos expression than whole hemolysate. Size fractionation showed that all of the c-fos mRNA-inducing activity of hemolysate was recovered with molecules greater than 6 kD. Following separation of hemolysate proteins by hydrophobic interaction chromatography, only one of the three fractions had partial activity. Recombining the three fractions, however, yielded greater c-fos activation than any combination of two.

CONCLUSIONS

Multiple high-molecular-weight components present in erythrocytes have synergistic effects on gene expression in smooth-muscle cells. The differences in patterns of gene induction suggest that multiple signaling pathways are activated.

Etiology of cerebral vasospasm

Cerebral vasospasm is a gradual onset and prolonged constriction of the cerebral arteries in the subarachnoid space after subarachnoid hemorrhage. The principal cause is the surrounding blood clot. The significance of vasospasm is that flow through the constricted arteries may be reduced sufficiently to cause cerebral infarction. Subarachnoid blood clot is sufficient to cause vasospasm; it does not require additional arterial injury, intracranial hypertension or brain infarction, although these elements are often coexistent. The blood released at the time of aneurysmal rupture into the alien subarachnoid environment is an extraordinarily complex mix of cellular and extracellular elements that evolves as clotting occurs; cells disintegrate; local inflammation, phagocytosis and repair take place; severe constriction alters the metabolism and structure of the arterial wall as well as the balance of vasoconstrictor and dilator substances produced by its endothelium, neurogenic network and perhaps smooth muscle cells.