Isoflurane neuroprotection in rat hippocampal slices decreases with aging: changes in intracellular Ca2+ regulation and N-methyl-D-aspartate receptor-mediated Ca2+ influx

Perioperative Neurocognitive Disorder: State of the Preclinical Science

The purpose of this article is to provide a succinct summary of the different experimental approaches that have been used in preclinical postoperative cognitive dysfunction research, and an overview of the knowledge that has accrued. This is not intended to be a comprehensive review, but rather is intended to highlight how the many different approaches have contributed to our understanding of postoperative cognitive dysfunction, and to identify knowledge gaps to be filled by further research. The authors have organized this report by the level of experimental and systems complexity, starting with molecular and cellular approaches, then moving to intact invertebrates and vertebrate animal models. In addition, the authors' goal is to improve the quality and consistency of postoperative cognitive dysfunction and perioperative neurocognitive disorder research by promoting optimal study design, enhanced transparency, and "best practices" in experimental design and reporting to increase the likelihood of corroborating results. Thus, the authors conclude with general guidelines for designing, conducting and reporting perioperative neurocognitive disorder rodent research.

Isoflurane enhances the malignant potential of glioblastoma stem cells by promoting their viability, mobility in vitro and migratory capacity in vivo

BACKGROUND

Isoflurane is one of the most common general anaesthetics used during surgical procedures, including tumour resection. However, the effects of isoflurane on the viability and migration capacity of cancer cells, specifically in the context of brain cancer cells, remain unclear. Therefore, the aim of this study was to evaluate the influence that isoflurane has on the function of glioblastoma stem cells (GCSs) in regards to cell proliferation, survival and migration.

METHOD

U251-GSCs were exposed to isoflurane at clinically relevant concentrations and incubation times. The effects on proliferation, survival and migration capacities of the cells were evaluated in vitro. The potential risk was assessed in mice by intracranial injection of U251-GSCs pretreated with isoflurane. Furthermore, the average tumour volume and migration distance of U251-GSCs from the tumour centre were calculated.

RESULTS

Exposure of U251-GSCs to 1.2% isoflurane for 6 h resulted in increased proliferation (P<0.05) and decreased apoptosis rate (P<0.05) when compared with the control group. In addition, isoflurane exposure caused increased migration capacity in vitro (P<0.05) and the distance migrated was increased in vivo (P<0.05).

CONCLUSION

Clinically relevant concentrations and incubation times of isoflurane could promote the viability and mobility of U251-GSCs, suggesting this general anaesthetic may have detrimental effects in glioblastoma by facilitating its growth and migration.

Dual effects of isoflurane on proliferation, differentiation, and survival in human neuroprogenitor cells

BACKGROUND

Previous studies have demonstrated that isoflurane can provide both neuroprotection and neurotoxicity in various tissue culture models and in rodent developing brains. The cellular and molecular mechanisms mediating these dual effects are not clear, but the exposure level and duration of isoflurane appear to be determinant factors.

METHODS

Using the ReNcell CX (Millipore, Billerica, MA) human neural progenitor cell line, the authors investigated the impact of prolonged exposure to varying isoflurane concentrations on cell survival and neurogenesis. In addition, the authors assessed the impact of short isoflurane preconditioning on elevation of cytosolic Ca concentration and cytotoxic effects mediated by prolonged isoflurane exposures and the contribution of inositol-1,4,5-trisphosphate or ryanodine receptor activation to these processes.

RESULTS

Short exposures to low isoflurane concentrations promote proliferation and differentiation of ReNcell CX cells, with no cell damage. However, prolonged exposures to high isoflurane concentrations induced significant ReNcell CX cell damage and inhibited cell proliferation. These prolonged exposures suppressed neuronal cell fate and promoted glial cell fate. Preconditioning of ReNcell CX cultures with short exposures to low concentrations of isoflurane ameliorated the effects of prolonged exposures to isoflurane. Pretreatment of ReNcell cultures with inositol-1,4,5-trisphosphate or ryanodine receptor antagonists mostly prevented isoflurane-mediated effects on survival, proliferation, and differentiation. Finally, isoflurane-preconditioned cultures showed significantly less isoflurane-evoked changes in calcium concentration.

CONCLUSION

The commonly used general anesthetic isoflurane exerts dual effects on neuronal stem cell survival, proliferation, and differentiation, which may be attributed to differential regulation of calcium release through activation of endoplasmic reticulum localized inositol-1,4,5-trisphosphate and/or ryanodine receptors.

Anesthetic neurotoxicity

Concerns for toxic effects of anesthesia to the brains of the young and the elderly are mounting. While experimental evidence for such effects in the developing brain is strong, the underlying mechanisms are less well understood and debate continues as to whether young humans are at risk for anesthetic neurotoxicity. The phenomenon of postoperative cognitive deterioration in the elderly remains controversial. Time course, severity, and whether or not it persists long term are under debate. For both patient groups, today's evidence is not sufficient to guide change in clinical practice. Well-designed research is therefore imperative to tackle this critical issue.

The potential dual effects of anesthetic isoflurane on Aβ-induced apoptosis

β-amyloid protein (Aβ)-induced neurotoxicity is the main component of Alzheimer's disease (AD) neuropathogenesis. Inhalation anesthetics have long been considered to protect against neurotoxicity. However, recent research studies have suggested that the inhalation anesthetic isoflurane may promote neurotoxicity by inducing apoptosis and increasing Aβ levels. We therefore set out to determine whether isoflurane can induce dose- and time-dependent dual effects on Aβ-induced apoptosis: protection versus promotion. H4 human neuroglioma cells, primary neurons from naive mice, and naive mice were treated with Aβ and/or isoflurane, and levels of caspase-3 cleavage (activation), apoptosis, Bcl-2, Bax, and cytosolic calcium were determined. Here we show for the first time that the treatment with 2% isoflurane for six hours or 30 minutes potentiated, whereas the treatment with 0.5% isoflurane for six hours or 30 minutes attenuated, the Aβ-induced caspase-3 activation and apoptosis in vitro. Moreover, anesthesia with 1.4% isoflurane for two hours potentiated, whereas the anesthesia with 0.7% isoflurane for 30 minutes attenuated, the Aβ-induced caspase-3 activation in vivo. The high concentration isoflurane potentiated the Aβ-induced reduction in Bcl-2/Bax ratio and caused a robust elevation of cytosolic calcium levels. The low concentration isoflurane attenuated the Aβ-induced reduction in Bcl-2/Bax ratio and caused only a mild elevation of cytosolic calcium levels. These results suggest that isoflurane may have dual effects (protection or promotion) on Aβ-induced toxicity, which potentially act through the Bcl-2 family proteins and cytosolic calcium. These findings would lead to more systematic studies to determine the potential dual effects of anesthetics on AD-associated neurotoxicity.

Age-associated differences in activation of Akt/GSK-3beta signaling pathways and inhibition of mitochondrial permeability transition pore opening in the rat heart

Pretreatment with isoflurane decreased myocardial infarction size in young rats (3-5 months) but not in old rats (20-24 months). To understand the mechanisms underlying the failure to protect the old myocardium, differences in phosphorylation of Akt/GSK-3beta and age-associated differences in mitochondrial permeability transition pore (mPTP) opening in the aging heart in vivo were measured. Isoflurane significantly increased Akt and GSK-3beta phosphorylation in the young groups. In contrast, levels of p-Akt and p-GSK-3beta were highly elevated in the old sham control groups. Isoflurane preconditioning significantly reduced the fall in NAD(+) levels induced by ischemia/reperfusion injury in the young animals, reflecting the inhibition of mPTP opening. In the old animals, however, isoflurane failed to prevent the fall in NAD(+) levels induced by ischemia/reperfusion injury. Lack of isoflurane-induced cardioprotective effects, seen in the old animals, can be explained by age-related differences in Akt/GSK-3beta signaling pathway and the inability to reduce mPTP opening following ischemia/reperfusion injury.

Anaesthetic mechanisms: update on the challenge of unravelling the mystery of anaesthesia.Eur J Anaesthesiol. 2009;26:807-820. [PMID: 19494779 DOI: 10.1097/EJA.0b013e32832d6b0f]

General anaesthesia is administered each day to thousands of patients worldwide. Although more than 160 years have passed since the first successful public demonstration of anaesthesia, a detailed understanding of the anaesthetic mechanism of action of these drugs is still lacking. An important early observation was the Meyer-Overton correlation, which associated the potency of an anaesthetic with its lipid solubility. This work focuses attention on the lipid membrane as a likely location for anaesthetic action. With the advent of cellular electrophysiology and molecular biology techniques, tools to dissect the components of the lipid membrane have led, in recent years, to the widespread acceptance of proteins, namely receptors and ion channels, as more likely targets for the anaesthetic effect. Yet these accumulated data have not produced a comprehensive explanation for how these drugs produce central nervous system depression. In this review, we follow the story of anaesthesia mechanisms research from its historical roots to the intensely neurophysiological research regarding it today. We will also describe recent findings that identify specific neuroanatomical locations mediating the actions of some anaesthetic agents.

Excitotoxicity in rat's brain induced by exposure of manganese and neuroprotective effects of pinacidil and nimodipine

Manganese (Mn) is an essential trace element for humans. However, manganism would be caused by excessive Mn. The mechanisms underlying excitotoxicity induced by manganism are poorly understood. As it is known to us, glutamate (Glu) is the most prevalent excitatory neurotransmitter. To determine the possible role of dysfunction of Glu transportation and metabolism in Mn-induced excitotoxicity, the rats were ip injected with different dose of MnCl(2) (0, 50, 100, and 200 micromol/kg), the levels of Mn and activities of GS, PAG, Na(+)-K(+)-ATPase, and Ca(2+)-ATPase in striatum were investigated. In addition, effect of 20.38 micromol/kg pinacidil (K(+) channel opener) or 2.4 micromol/kg nimodipine (Ca(2+) channel blocker) were studied at 200 micromol/kg MnCl(2). With dose-dependent inhibition of GS, Na(+)-K(+)-ATPase, and Ca(2+)-ATPase activities, increase of Mn levels and PAG activity were observed. Further investigation indicated that pre-treatment of pinacidil or nimodipine reversed toxic effect of MnCl(2) significantly. These results suggested that MnCl(2) could induce dysfunction of Glu transportation and metabolism by augmenting the excitotoxicity dose-dependently; pinacidil and nimodipine might antagonize manganese neurotoxicity.

Isoflurane attenuates pulmonary interleukin-1beta and systemic tumor necrosis factor-alpha following mechanical ventilation in healthy mice

BACKGROUND

Mechanical ventilation (MV) induces an inflammatory response in healthy lungs. The resulting pro-inflammatory state is a risk factor for ventilator-induced lung injury and peripheral organ dysfunction. Isoflurane is known to have protective immunological effects on different organ systems. We tested the hypothesis that the MV-induced inflammatory response in healthy lungs is reduced by isoflurane.

METHODS

Healthy C57BL6 mice (n=34) were mechanically ventilated (tidal volume, 8 ml/kg; positive end-expiratory pressure, 4 cmH(2)O; and fraction of inspired oxygen, 0.4) for 4 h under general anesthesia using a mix of ketamine, medetomidine and atropine (KMA). Animals were divided into four groups: (1) Unventilated control group; (2) MV group using KMA anesthesia; (3) MV group using KMA with 0.25 MAC isoflurane; (4) MV group using KMA with 0.75 MAC isoflurane. Cytokine levels were measured in lung homogenate and plasma. Leukocytes were counted in lung tissue.

RESULTS

Lung homogenates: MV increased pro-inflammatory cytokines. In mice receiving KMA+ isoflurane 0.75 MAC, no significant increase in interleukin (IL)-1beta was found compared with non-ventilated control mice. PLASMA: MV induced a systemic pro-inflammatory response. In mice anesthetized with KMA+ isoflurane (both 0.25 and 0.75 MAC), no significant increase in tumor necrosis factor (TNF)-alpha was found compared with non-ventilated control mice.

CONCLUSIONS

The present study is the first to show that isoflurane attenuates the pulmonary IL-1beta and systemic TNF-alpha response following MV in healthy mice.

Is anesthesia bad for the newborn brain?

Although certain data suggest that common general anesthetics may be neurotoxic to immature animals, there are also data suggesting that these same anesthetics may be neuroprotective against hypoxicischemic injury, and that inadequate analgesia during painful procedures may lead to increased neuronal cell death in animals and long-term behavioral changes in humans. The challenge for the pediatric anesthesia community is to design and implement studies in human infants to ascertain the safety of general anesthesia. In this article, the authors review the relevant preclinical and clinical data that are currently available on this topic.

New concepts in treatment of pediatric traumatic brain injury

Emerging evidence suggests unique age-dependent responses following pediatric traumatic brain injury. The anesthesiologist plays a pivotal role in the acute treatment of the head-injured pediatric patient. This review provides important updates on the pathophysiology, diagnosis, and age-appropriate acute management of infants and children with severe traumatic brain injury. Areas of important clinical and basic science investigations germane to the anesthesiologist, such as the role of anesthetics and apoptosis in the developing brain, are discussed.

Brain protection: current and future options

The ability to reduce brain injury before, during or after an ischaemic injury, irrespective of the cause, remains an exciting prospect. In this article, we will discuss some of the current research behind cerebral protection, which will include the use of anaesthetic agents, as well as therapies targeted specifically at the complex cascades following brain injury.

Arctic ground squirrel (Spermophilus parryii) hippocampal neurons tolerate prolonged oxygen-glucose deprivation and maintain baseline ERK1/2 and JNK activation despite drastic ATP loss

Oxygen-glucose deprivation (OGD) initiates a cascade of intracellular responses that culminates in cell death in sensitive species. Neurons from Arctic ground squirrels (AGS), a hibernating species, tolerate OGD in vitro and global ischemia in vivo independent of temperature or torpor. Regulation of energy stores and activation of mitogen-activated protein kinase (MAPK) signaling pathways can regulate neuronal survival. We used acute hippocampal slices to investigate the role of ATP stores and extracellular signal-regulated kinase (ERK)1/2 and Jun NH(2)-terminal kinase (JNK) MAPKs in promoting survival. Acute hippocampal slices from AGS tolerated 30 mins of OGD and showed a small but significant increase in cell death with 2 h OGD at 37 degrees C. This tolerance is independent of hibernation state or season. Neurons from AGS survive OGD despite rapid ATP depletion by 3 mins in interbout euthermic AGS and 10 mins in hibernating AGS. Oxygen-glucose deprivation does not induce JNK activation in AGS and baseline ERK1/2 and JNK activation is maintained even after drastic depletion of ATP. Surprisingly, inhibition of ERK1/2 or JNK during OGD had no effect on survival, whereas inhibition of JNK increased cell death during normoxia. Thus, protective mechanisms promoting tolerance to OGD by AGS are downstream from ATP loss and are independent of hibernation state or season. Journal of Cerebral Blood Flow & Metabolism (2008) 28, 1307-1319; doi:10.1038/jcbfm.2008.20; published online 9 April 2008.

Isoflurane-induced caspase-3 activation is dependent on cytosolic calcium and can be attenuated by memantine

Increasing evidence indicates that caspase activation and apoptosis are associated with a variety of neurodegenerative disorders, including Alzheimer's disease. We reported that anesthetic isoflurane can induce apoptosis, alter processing of the amyloid precursor protein (APP), and increase amyloid-beta protein (Abeta) generation. However, the mechanism by which isoflurane induces apoptosis is primarily unknown. We therefore set out to assess effects of extracellular calcium concentration on isoflurane-induced caspase-3 activation in H4 human neuroglioma cells stably transfected to express human full-length APP (H4-APP cells). In addition, we tested effects of RNA interference (RNAi) silencing of IP(3) receptor, NMDA receptor, and endoplasmic reticulum (ER) calcium pump, sacro-/ER calcium ATPase (SERCA1). Finally, we examined the effects of the NMDA receptor partial antagonist, memantine, in H4-APP cells and brain tissue of naive mice. EDTA (10 mM), BAPTA (10 microM), and RNAi silencing of IP(3) receptor, NMDA receptor, or SERCA1 attenuated caspase-3 activation. Memantine (4 microM) inhibited isoflurane-induced elevations in cytosolic calcium levels and attenuated isoflurane-induced caspase-3 activation, apoptosis, and cell viability. Memantine (20 mg/kg, i.p.) reduced isoflurane-induced caspase-3 activation in brain tissue of naive mice. These results suggest that disruption of calcium homeostasis underlies isoflurane-induced caspase activation and apoptosis. We also show for the first time that the NMDA receptor partial antagonist, memantine, can prevent isoflurane-induced caspase-3 activation and apoptosis in vivo and in vitro. These findings, indicating that isoflurane-induced caspase activation and apoptosis are dependent on cytosolic calcium levels, should facilitate the provision of safer anesthesia care, especially for Alzheimer's disease and elderly patients.

The Use of the Excimer Laser-assisted Anastomosis Technique Alleviates Neuroanesthesia During Cerebral High-flow Revascularization

In patients with complex intracranial aneurysms or skull base tumors, parent vessel occlusion and flow replacement by high-flow bypass surgery is a demanding therapy, both for the neurosurgeon and the neuroanesthesiologist. One reason for this is the need for prolonged temporary occlusion of a major cerebral artery, which carries a high risk of perioperative ischemia and necessitates versatile neuroprotective measures during anesthesia. Recently, a novel excimer laser-assisted nonocclusive anastomosis (ELANA) technique has been introduced, circumventing the need for temporary occlusion of cerebral vessels. We hypothesized that the use of this ELANA technique would facilitate also the neuroanesthesiologic management of these patients. To test this, we reviewed the details of the neuroanesthesiologic management of patients undergoing ELANA high-flow bypass surgery at our institution. Twenty-nine patients with giant aneurysms (n=27) or skull base tumor (n=2) who were undergoing parent vessel occlusion and permanent flow replacement by high-flow bypass surgery using the ELANA technique were investigated retrospectively. The records of the patients were analyzed for induction and maintenance of anesthesia, fluid therapy, transfusion requirements, hemodynamic parameters, and brain protective strategies. Although we are not able to provide a sufficient body of cohort data to compare the neuroanesthesiologic management of patients undergoing the conventional anastomosis technique with management using the ELANA technique, in each of our reported cases the conventional anastomosis technique would have entailed a high probability of prolonged temporary occlusion that would, in turn, have warranted intensive brain-protective strategies. The observation that use of the ELANA technique precluded the necessity of brain-protective strategies without entailing perioperative cerebral infarction suggests that the ELANA technique supports the neurosurgeon in creating difficult permanent intracranial anastomoses and also facilitates neuroanesthesiologic management of patients undergoing cerebral high-flow revascularization procedures.

Carotid endarterectomy

Carotid endarterectomy (CEA) is performed to prevent embolic stroke in patients with atheromatous disease at the carotid bifurcation. There is now substantial evidence to support early operation in symptomatic patients, ideally within 2 weeks of the last neurological symptoms. Thus, the anaesthetist may be faced with a high risk patient in whom there has been limited time for preoperative preparation. The operation may be performed under local or general anaesthesia. The advantages and disadvantages of both are explored in this review. Carotid shunting may offer a degree of cerebral protection, but carries its own risks and has not been proved to reduce morbidity and mortality. The use of carotid shunts is based on clinical judgement, awake neurological monitoring, and the use of monitors of cerebral perfusion. There is no ideal monitor of cerebral perfusion in the patient receiving general anaesthesia. Both the intraoperative and postoperative periods may be witness to dramatic haemodynamic changes that may compromise the cerebral or myocardial circulations. In particular, postoperative hypotension may compromise both myocardial and cerebral perfusion, and severe hypertension can cause cerebral hyperperfusion. There is as yet limited evidence to guide the management of these problems. In summary, CEA can yield significant benefit, but those with the most to gain from the operation also present the greatest challenge to the anaesthetist.

Brain protection by anesthetic agents

PURPOSE OF REVIEW

Patients at risk for perioperative stroke, or those who have suffered recent cerebral injury, may benefit from neuroprotective properties of anesthetic agents during surgery. This manuscript reviews recent clinical and experimental evidence for neuroprotective effects of common anesthetic agents, and presents potential mechanisms involved in anesthetic neuroprotection.

RECENT FINDINGS

Although strong experimental data support a neuroprotective potential of several anesthetic agents, specifically isoflurane and xenon, consistent long-term protection by either agent has not been demonstrated. Unfortunately, there is a lack of clinical studies that would support the use of any one anesthetic agent over the others. Mechanisms of neuroprotection by anesthetic agents appear to involve suppression of excitatory neurotransmission, and potentiation of inhibitory activity, which may contribute to the reduction of excitotoxic injury. Activation of intracellular signaling cascades that lead to altered expression of protective genes may also be involved.

SUMMARY

Solid experimental evidence supports neuroprotection by anesthetic agents. It is too early to recommend any specific agent for clinical use as a neuroprotectant, however. Further study is warranted to unravel relevant mechanisms and to appreciate the potential clinical relevance of experimental findings.