Perioperatively Inhaled Hydrogen Gas Diminishes Neurologic Injury Following Experimental Circulatory Arrest in Swine

This study used a swine model of mildly hypothermic prolonged circulatory arrest and found that the addition of 2.4% inhaled hydrogen gas to inspiratory gases during and after the ischemic insult significantly decreased neurologic and renal injury compared with controls. With proper precautions, inhalational hydrogen may be administered safely through conventional ventilators and may represent a complementary therapy that can be easily incorporated into current workflows. In the future, inhaled hydrogen may diminish the sequelae of ischemia that occurs in congenital heart surgery, cardiac arrest, extracorporeal life-support events, acute myocardial infarction, stroke, and organ transplantation.

Somatic SLC35A2 variants in the brain are associated with intractable neocortical epilepsy

OBJECTIVE

Somatic variants are a recognized cause of epilepsy-associated focal malformations of cortical development (MCD). We hypothesized that somatic variants may underlie a wider range of focal epilepsy, including nonlesional focal epilepsy (NLFE). Through genetic analysis of brain tissue, we evaluated the role of somatic variation in focal epilepsy with and without MCD.

METHODS

We identified somatic variants through high-depth exome and ultra-high-depth candidate gene sequencing of DNA from epilepsy surgery specimens and leukocytes from 18 individuals with NLFE and 38 with focal MCD.

RESULTS

We observed somatic variants in 5 cases in SLC35A2, a gene associated with glycosylation defects and rare X-linked epileptic encephalopathies. Nonsynonymous variants in SLC35A2 were detected in resected brain, and absent from leukocytes, in 3 of 18 individuals (17%) with NLFE, 1 female and 2 males, with variant allele frequencies (VAFs) in brain-derived DNA of 2 to 14%. Pathologic evaluation revealed focal cortical dysplasia type Ia (FCD1a) in 2 of the 3 NLFE cases. In the MCD cohort, nonsynonymous variants in SCL35A2 were detected in the brains of 2 males with intractable epilepsy, developmental delay, and magnetic resonance imaging suggesting FCD, with VAFs of 19 to 53%; Evidence for FCD was not observed in either brain tissue specimen.

INTERPRETATION

We report somatic variants in SLC35A2 as an explanation for a substantial fraction of NLFE, a largely unexplained condition, as well as focal MCD, previously shown to result from somatic mutation but until now only in PI3K-AKT-mTOR pathway genes. Collectively, our findings suggest a larger role than previously recognized for glycosylation defects in the intractable epilepsies. Ann Neurol 2018.

Prediction of safe duration of hypothermic circulatory arrest by near-infrared spectroscopy

OBJECTIVE

Hypothermic circulatory arrest is widely used for adults with aortic arch disease as well as for children with congenital heart disease. At present, no method exists for monitoring safe duration of circulatory arrest. Near-infrared spectroscopy is a new technique for noninvasive monitoring of cerebral oxygenation and energy state. In the current study, the relationship between near-infrared spectroscopy data and neurologic outcome was evaluated in a survival piglet model with hypothermic circulatory arrest.

METHODS

Thirty-six piglets (9.36 +/- 0.16 kg) underwent circulatory arrest under varying conditions with continuous monitoring by near-infrared spectroscopy (temperature 15 degrees C or 25 degrees C, hematocrit value 20% or 30%, circulatory arrest time 60, 80, or 100 minutes). Each setting included 3 animals. Neurologic recovery was evaluated daily by neurologic deficit score and overall performance category. Brain was fixed in situ on postoperative day 4 and examined by histologic score.

RESULTS

Oxygenated hemoglobin signal declined to a plateau (nadir) during circulatory arrest. Time to nadir was significantly shorter with lower hematocrit value (P <.001) and higher temperature (P <.01). Duration from reaching nadir until reperfusion ("oxygenated hemoglobin signal nadir time") was significantly related to histologic score (r (s) = 0.826), neurologic deficit score (r (s) = 0.717 on postoperative day 1; 0.716 on postoperative day 4), and overall performance category (r (s) = 0.642 on postoperative day 1; 0.702 on postoperative day 4) (P <.001). All animals in which oxygenated hemoglobin signal nadir time was less than 25 minutes were free of behavioral or histologic evidence of brain injury.

CONCLUSION

Oxygenated hemoglobin signal nadir time determined by near-infrared spectroscopy monitoring is a useful predictor of safe duration of circulatory arrest. Safe duration of hypothermic circulatory arrest is strongly influenced by perfusate hematocrit value and temperature during circulatory arrest.

Desmuslin, an intermediate filament protein that interacts with alpha -dystrobrevin and desmin

Dystrobrevin is a component of the dystrophin-associated protein complex and has been shown to interact directly with dystrophin, alpha1-syntrophin, and the sarcoglycan complex. The precise role of alpha-dystrobrevin in skeletal muscle has not yet been determined. To study alpha-dystrobrevin's function in skeletal muscle, we used the yeast two-hybrid approach to look for interacting proteins. Three overlapping clones were identified that encoded an intermediate filament protein we subsequently named desmuslin (DMN). Sequence analysis revealed that DMN has a short N-terminal domain, a conserved rod domain, and a long C-terminal domain, all common features of type 6 intermediate filament proteins. A positive interaction between DMN and alpha-dystrobrevin was confirmed with an in vitro coimmunoprecipitation assay. By Northern blot analysis, we find that DMN is expressed mainly in heart and skeletal muscle, although there is some expression in brain. Western blotting detected a 160-kDa protein in heart and skeletal muscle. Immunofluorescent microscopy localizes DMN in a stripe-like pattern in longitudinal sections and in a mosaic pattern in cross sections of skeletal muscle. Electron microscopic analysis shows DMN colocalized with desmin at the Z-lines. Subsequent coimmunoprecipitation experiments confirmed an interaction with desmin. Our findings suggest that DMN may serve as a direct linkage between the extracellular matrix and the Z-discs (through plectin) and may play an important role in maintaining muscle cell integrity.

Filamin 2 (FLN2): A muscle-specific sarcoglycan interacting protein

Mutations in genes encoding for the sarcoglycans, a subset of proteins within the dystrophin-glycoprotein complex, produce a limb-girdle muscular dystrophy phenotype; however, the precise role of this group of proteins in the skeletal muscle is not known. To understand the role of the sarcoglycan complex, we looked for sarcoglycan interacting proteins with the hope of finding novel members of the dystrophin-glycoprotein complex. Using the yeast two-hybrid method, we have identified a skeletal muscle-specific form of filamin, which we term filamin 2 (FLN2), as a gamma- and delta-sarcoglycan interacting protein. In addition, we demonstrate that FLN2 protein localization in limb-girdle muscular dystrophy and Duchenne muscular dystrophy patients and mice is altered when compared with unaffected individuals. Previous studies of filamin family members have determined that these proteins are involved in actin reorganization and signal transduction cascades associated with cell migration, adhesion, differentiation, force transduction, and survival. Specifically, filamin proteins have been found essential in maintaining membrane integrity during force application. The finding that FLN2 interacts with the sarcoglycans introduces new implications for the pathogenesis of muscular dystrophy.

Gangliocytoma masquerading as a prolactinoma. Case report

The authors describe the case of a 36-year-old man who presented with bitemporal hemianopsia and a serum prolactin concentration of 1440 ng/ml. Magnetic resonance imaging of the pituitary revealed a presumed macroadenoma with suprasellar and temporal lobe extension. Although the patient's prolactin level was lowered to 55 ng/ml by bromocriptine therapy, no tumor shrinkage occurred. Fourteen months later, progression of visual field defects necessitated transsphenoidal resection, which was incomplete. Immunocytochemical analysis of the biopsy tissue was positive for prolactin and, in view of the clinical picture, more detailed analysis was not performed. External-beam radiotherapy was given 2 years later because of enlargement of residual tumor. Subsequently, despite a fall in the serum prolactin concentration to less than 20 ng/ml in response to the course of bromocriptine, the mass displayed further extension into the temporal lobe. Nine years after the patient's initial presentation, he underwent transfrontal craniotomy for sudden deterioration in visual acuity caused by hemorrhage into the mass. No adenohypophyseal tissue was identified in the resected tissue. The mass was composed of dysplastic neurons that were strongly immunoreactive for synaptophysin and neurofilament (indicating neural differentiation) and prolactin. Review of the original biopsy specimen indicated that the prolactin-positive cells had striking neuronal morphological characteristics. The final diagnosis in this case is prolactin-secreting gangliocytoma. Although exceedingly rare, this disease must be added to the differential diagnosis in cases of "prolactinoma" when bromocriptine therapy is followed by a marked decline in serum prolactin that is not accompanied by significant tumor shrinkage. Furthermore, in such instances, consideration should be given to "obtaining a biopsy sample prior to electing for radiotherapy.

Oxygenation strategy and neurologic damage after deep hypothermic circulatory arrest. II. hypoxic versus free radical injury

OBJECTIVES

Laboratory studies suggest that myocardial reperfusion injury is exacerbated by free radicals when pure oxygen is used during cardiopulmonary bypass. In phase I of this study we demonstrated that normoxic perfusion during cardiopulmonary bypass does not increase the risk of microembolic brain injury so long as a membrane oxygenator with an arterial filter is used. In phase II of this study we studied the hypothesis that normoxic perfusion increases the risk of hypoxic brain injury after deep hypothermia with circulatory arrest.

METHODS

With membrane oxygenators with arterial filters, 10 piglets (8-10 kg) underwent 120 minutes of deep hypothermia and circulatory arrest at 15 degrees C, were rewarmed to 37 degrees C, and were weaned from bypass. In 5 piglets normoxia (PaO2 64-181 mm Hg) was used during cardiopulmonary bypass and in 5 hyperoxia (PaO2 400-900 mm Hg) was used. After 6 hours of reperfusion the brain was fixed for histologic evaluation. Near-infrared spectroscopy was used to monitor cerebral oxyhemoglobin and oxidized cytochrome a,a3 concentrations.

RESULTS

Histologic examination revealed a significant increase in brain damage in the normoxia group (score 12.4 versus 8.6, P =.01), especially in the neocortex and hippocampal regions. Cytochrome a,a 3 and oxyhemoglobin concentrations tended to be lower during deep hypothermia and circulatory arrest in the normoxia group (P =.16).

CONCLUSIONS

In the setting of prolonged deep hypothermia and circulatory arrest with membrane oxygenators, normoxic cardiopulmonary bypass significantly increases histologically graded brain damage with respect to hyperoxic cardiopulmonary bypass. Near-infrared spectroscopy suggests that the mechanism is hypoxic injury, which presumably overwhelms any injury caused by increased oxygen free radicals.

A novel sialyl Lewis X analog attenuates cerebral injury after deep hypothermic circulatory arrest

BACKGROUND

The initial step in the inflammatory process, which can be initiated by cardiopulmonary bypass and by ischemia/reperfusion, is mediated by interactions between selectins on endothelial cells and on neutrophils. We studied the effects of selectin blockade using a novel Sialyl Lewis X analog (CY-1503) on recovery after deep hypothermic circulatory arrest in a piglet model.

METHODS

Twelve Yorkshire piglets were subjected to cardiopulmonary bypass, 30 minutes of cooling, 100 minutes of circulatory arrest at 15 degrees C, and 40 minutes of rewarming. Five animals received a bolus of 60 mg/kg of CY-1503 and an infusion (3 mg/kg per hour) for 24 hours from reperfusion (group O), and 7 randomly selected control piglets received saline solution (group C). Body weight and total body water content were evaluated 3 hours and 24 hours after reperfusion by a bio-impedance technique. Neurologic recovery of animals was evaluated daily by neurologic deficit score (0 = normal, 500 = brain death) and overall performance categories (1 = normal, 5 = brain death). The brain was fixed in situ on the fourth postoperative day and examined by histologic score (0 = normal, 5+ = necrosis) in a blinded fashion.

RESULTS

Two of 7 animals in group C died. The neurologic deficit score was significantly lower in group O than in group C (postoperative day 1, P <.001; postoperative day 2, P =.02). The overall performance category was significantly lower in group O than in group C on postoperative day 2 (P =.01). Percentage total body water after cardiopulmonary bypass was significantly higher in group C than in group O (P =.03). Histologic score tended to be higher in group C than in group O, but this difference did not reach statistical significance (group O = 0.5 +/- 0.7; group C = 1.3 +/- 1.off

CONCLUSION

Blockade of selectin adhesion molecules by saturation with a Sialyl Lewisx analog accelerates recovery after 100 minutes of deep hypothermic circulatory arrest in a piglet survival model.

Molecular organization of sarcoglycan complex in mouse myotubes in culture

The sarcoglycans are a complex of four transmembrane proteins (alpha, beta, gamma, and delta) which are primarily expressed in skeletal muscle and are closely associated with dystrophin and the dystroglycans in the muscle membrane. Mutations in the sarcoglycans are responsible for four autosomal recessive forms of muscular dystrophy. The function and the organization of the sarcoglycan complex are unknown. We have used coimmunoprecipitation and in vivo cross-linking techniques to analyze the sarcoglycan complex in cultured mouse myotubes. We demonstrate that the interaction between beta- and delta-sarcoglycan is resistant to high concentrations of SDS and alpha-sarcoglycan is less tightly associated with other members of the complex. Cross-linking experiments show that beta-, gamma-, and delta-sarcoglycan are in close proximity to one another and that delta-sarcoglycan can be cross-linked to the dystroglycan complex. In addition, three of the sarcoglycans (beta, gamma, and delta) are shown to form intramolecular disulfide bonds. These studies further our knowledge of the structure of the sarcoglycan complex. Our proposed model of their interactions helps to explain some of the emerging data on the consequences of mutations in the individual sarcoglycans, their effect on the complex, and potentially the clinical course of muscular dystrophies.

Dystrophin and Dp140 in the adult rodent kidney

Full-length dystrophin and a truncated carboxy-terminal isoform, Dp140, also encoded by the dystrophin gene, are expressed in rodent kidney. Dystrophin is localized to the vascular smooth muscle and mesangial cells. Dp140 was initially identified in the brain as well as kidney. In kidney, Dp140 is localized to the basal surface of tubule epithelial cells. Morphology and double-labeling suggest that it is restricted to the ascending loop of Henle, distal convoluted tubule, and proximal end of the collecting ducts. Because both dystrophin and Dp140 contain the same carboxy-terminal domain--which in skeletal muscle forms a link to integral membrane proteins and in turn to the extracellular matrix--Dp140 in the tubule epithelium might contribute to anchoring the basal aspect of the cells to the basement membrane. The identification of dystrophin gene products in kidney parenchyma also raises the possibility of subtle renal abnormalities, not previously suspected, as part of the Duchenne muscular dystrophy phenotype.

Postischemic hyperthermia exacerbates neurologic injury after deep hypothermic circulatory arrest

BACKGROUND

Aggressive surface warming is a common practice in the pediatric intensive care unit. However, recent rodent data emphasize the protective effect of mild (2 degrees - 3 degrees C) hypothermia after cerebral ischemia. This study evaluates different temperature regulation strategies after deep hypothermic circulatory arrest with a survival piglet model.

METHODS

Fifteen piglets were randomly assigned to 3 groups. All groups underwent 100 minutes of deep hypothermic circulatory arrest at 15 degrees C. Brain temperature was maintained at 34 degrees C for 24 hours after cardiopulmonary bypass in group I, 37 degrees C in group II, and 40 degrees C in group III. Neurobehavioral recovery was evaluated daily for 3 days after extubation by neurologic deficit score (0, normal; 500, brain death) and overall performance category (1, normal; 5, brain death). Histologic examination was assessed for hypoxic-ischemic injury (0, normal; 5, necrosis) in a blinded fashion.

RESULTS

All results are expressed as mean +/- standard deviation. Recovery of neurologic deficit score (12.0 +/- 17.8, 47.0 +/- 49.95, 191.0 +/- 179.83; P = .05 for group I vs III), overall performance category (1.0 +/- 0.0, 1.4 +/- 0.6, 2.8 +/- 1.3; P < .05 for group I vs III), and histologic scores (0.0 +/- 0.0, 1.0 +/- 1.2, 2.8 +/- 1.8; P < .05 for group I vs III cortex) were significantly worse in hyperthermic group III. These findings were associated with a significantly lower cytochrome aa3 recovery determined by near-infrared spectroscopy in group III animals (P = .0041 for group I vs III). No animal recovered to baseline electroencephalographic value by 48 hours after deep hypothermic circulatory arrest. Recovery was significantly delayed in the hyperthermic group III animals, with a lower amplitude 14 hours after the operation, which gradually increased with time (P < .05 for group III vs groups I and II).

CONCLUSIONS

Mild postischemic hyperthermia significantly exacerbates functional and structural neurologic injury after deep hypothermic circulatory arrest and should therefore be avoided.

Caveolin-3 in muscular dystrophy

The dystrophin-glycoprotein complex (DGC) serves as a link between cytoplasmic actin, the membrane and the extracellular matrix of striated muscle. Genetic defects in genes encoding a subset of DGC proteins result in muscular dystrophy and a secondary decrease in other DGC proteins. Caveolae are dynamic structures that have been implicated in a number of functions including endocytosis, potocytosis and signal transduction. Caveolin (VIP-21) is thought to play a structural role in the formation of non-clathrin-coated vesicles in a number of different cell types. Caveolin-3, or M-caveolin, was identified as a muscle-specific form of the caveolin family. We show that caveolin-3 co-purifies with dystrophin, and that a fraction of caveolin-3 is a dystrophin-associated protein. We isolated the gene for human caveolin-3 and mapped it to chromosome 3p25. We determined the genomic organization of human caveolin-3 and devised a screening strategy to look for mutations in caveolin-3 in patients with muscular dystrophy. Of 82 patients screened, two nucleotide changes were found that resulted in amino acid substitutions (G55S and C71W); these changes were not seen in a control population. The amino acid changes map to a functionally important domain in caveolin-3, suggesting that these are not benign polymorphisms and instead are disease-causing mutations.

Effects of oncotic pressure and hematocrit on outcome after hypothermic circulatory arrest

BACKGROUND

A recent study found that a higher-perfusate hematocrit was associated with improved neurologic recovery after deep hypothermic circulatory arrest. The current study examined the relative contributions of oxygen delivery and colloid oncotic pressure to this result, as well as the efficacy of different colloidal agents and modified ultrafiltration.

METHODS

Twenty-six piglets were randomized into five groups (n = 5 or 6 animals per group): control group 1--blood and crystalloid prime, hematocrit of 20%; group 2--blood and hetastarch prime, hematocrit of 20%; group 3--blood and pentafraction prime, hematocrit of 20%; group 4--blood and crystalloid prime with 10 minutes of modified ultrafiltration; group 5--whole blood prime, hematocrit of 30%. All groups underwent 60 minutes of deep hypothermic circulatory arrest at 15 degrees C.

RESULTS

Groups 2 and 3 showed less body weight gain (analysis of variance, p = 0.001; group 2 versus group 1, p = 0.0009; group 3 versus group 1, p = 0.0009) and body water content after cardiopulmonary bypass (analysis of variance, p = 0.001; group 2 versus group 1, p = 0.003; group 3 versus group 1, p = 0.013). Group 5 showed more rapid recovery of phosphocreatine and intracellular acidosis, as measured by magnetic resonance spectroscopy, during rewarming than group 1 did (phosphocreatine, p = 0.0329; intracellular acidosis, p = 0.0462). Group 3 also showed accelerated recovery of intracellular acidosis (p = 0.0411). Cytochrome a,a3 recovery, determined by near-infrared spectroscopy, was significantly better in group 5 than in group 1 and worse in group 2 than in group 1 after rewarming. The neurologic deficit score and overall performance category score were best in group 5 (neurologic deficit score, p = 0.012; overall performance category score, p = 0.046) on the first postoperative day. Group 3 also had a better overall performance category score than group 1 did (p = 0.0068). Only group 1 and 2 animals showed histologic damage.

CONCLUSIONS

Both higher hematocrit and higher colloid oncotic pressure with pentafraction improve cerebral recovery after deep hypothermic circulatory arrest. The higher hematocrit improves cerebral oxygen delivery but does not reduce total body edema. Modified ultrafiltration after cardiopulmonary bypass is less effective than having a higher initial prime hematocrit or colloid oncotic pressure.

Dp140: alternatively spliced isoforms in brain and kidney

Dp140, a protein composed of the distal rod domain and carboxy-terminal domain of dystrophin, is expressed only in brain and kidney; transcription is initiated at a unique first exon located in dystrophin intron 44. Both tissues express specific isoforms with distinct alternative splicing of exons 71-74 and 78. The carboxy-terminal domain of Dp140 is identical to that of full-length 427-kDa dystrophin, and it is this region that is associated, with the "dystrophin-associated protein" complex in skeletal muscle. Alternative splicing encodes domains that have been shown to be protein-binding regions; thus this alternative splicing may regulate the association of Dp140 with integral membrane proteins. The 5' flanking region of genomic DNA adjacent to the Dp140 first exon contains a variety of transcription factor-binding motifs, some of which could regulate neuroglial-specific gene expression.

Molecular characterization of Br-cadherin, a developmentally regulated, brain-specific cadherin

Cadherins are a family of transmembrane proteins that play a crucial role in cell adhesion and in morphogenesis. Several of the cadherins are expressed in the nervous system, but none is neuron-specific. We characterize a new member of the cadherin family, Br-cadherin, which is present exclusively in the central nervous system. Although the Br-cadherin protein is confined to the central nervous system, its mRNA is present in several additional tissues, suggesting that there is posttranscriptional control of this gene's expression. Within the central nervous system, Br-cadherin appears to be expressed specifically by neurons. In the mouse, its expression becomes detectable during the first postnatal week, which corresponds temporally to the onset of synaptogenesis and dendrite outgrowth in the brain. This pattern of expression is consistent with a role for Br-cadherin in neuronal development, perhaps specifically with synaptogenesis.

Higher hematocrit improves cerebral outcome after deep hypothermic circulatory arrest

BACKGROUND

Various degrees of hemodilution are currently in clinical use during deep hypothermic circulatory arrest to counteract deleterious rheologic effects linked with brain injury by previous reports.

MATERIAL AND METHODS

Seventeen piglets were randomly assigned to three groups. Group I piglets (n = 7) received colloid and crystalloid prime (hematocrit < 10%), group II piglets (n = 5) received blood and crystalloid prime (hematocrit 20%), group III piglets (n = 5) received blood prime (hematocrit 30%). All groups underwent 60 minutes of deep hypothermic circulatory arrest at 15 degrees C with continuous magnetic resonance spectroscopy and near-infrared spectroscopy Neurologic recovery was evaluated for 4 days (neurologic deficit score 0, normal, to 500, brain death; overall performance category 1, normal, to 5, brain death). Neurohistologic score (0, normal, to 5+, necrosis) was assessed after the animals were euthanized on day 4.

RESULTS

Group I had significant loss of phosphocreatine and intracellular acidosis during early cooling (phosphocreatine in group I, 86.3% +/- 26.8%; group II, 117.3% +/- 8.6%; group III, 110.9% +/- 2.68%; p = 0.0008; intracellular pH in group I, 6.95 +/- 0.18; group II, 7.28 +/- 0.04; group III, 7.49 +/- 0.04; p = 0.0048). Final recovery was the same for all groups. Cytochrome aa3 was more reduced in group I during deep hypothermic circulatory arrest than in either of the other groups (group I, -43.6 +/- 2.6; group II, -16.0 +/- 5.2; group III, 1.3 +/= 3.1; p < 0.0001). Neurologic deficit score was best preserved in group III (p < 0.05 group II vs group III) on the first postoperative day, although this difference diminished with time and all animals were neurologically normal after 4 days. Histologic assessment was worst among group I in neocortex area (group I, 1.33 +/- 0.3; group II, 0.22 +/- 0.1; group III, 0.40 +/- 0.2, p < 0.05, group I vs group II; p = 0.0287, group I vs group III).

CONCLUSION

Extreme hemodilution during cardiopulmonary bypass may cause inadequate oxygen delivery during early cooling. The higher hematocrit with a blood prime is associated with improved cerebral recovery after deep hypothermic circulatory arrest.

Intermittent whole-body perfusion with "somatoplegia' versus blood perfusate to extend duration of circulatory arrest

BACKGROUND

Continuous whole-body perfusion for > 3 hours with a cold asanguineous blood substitute, hypothermosol (HTS) solution, has been reported to preserve organ function. We used this solution in a survival animal model to evaluate its possible application in extending the safe duration of deep hypothermic circulatory arrest (DHCA).

METHODS AND RESULTS

Fifteen piglets were placed on cardiopulmonary bypass (CPB), were cooled to a nasopharyngeal temperature of 15 degrees C, and underwent 100 minutes of DHCA. Control animals (group C, n = 5) had uninterrupted DHCA, group HTS animals were perfused with maintenance HTS for 5 minutes every 25 minutes during DHCA (n = 5), and group B animals were intermittently perfused as for group HTS with the blood in the bypass circuit (n = 5). Cerebral oxygenation was assessed with near-infrared spectroscopy throughout CPB and DHCA. Animals were allowed to recover after CPB and underwent daily neurobehavioral evaluation by the neurological deficit score (NDS: 0, normal; 500, brain death) and overall performance categories (OPC: 1, normal; 5, brain death). Blood samples were drawn on postoperative day (POD) 1 for selected biochemistry analysis. On POD 4, the brain of each animal was perfusion-fixed for histological evaluation, and a neurohistological score (NHS: 0, normal; 5+, necrosis) was assigned for the degree of neuronal injury. All animals except one from group HTS survived surgery. Mean perfusion pressures were significantly elevated in group B compared with group C and group HTS during the rewarming phase (P < .05). The HbO2 signal increased in all groups during the cooling phase of CPB and remained significantly above baseline only in group B during DHCA (P < .05). SGOT, LDH, ALP, and CPK levels on POD 1 were elevated above baseline in all groups. The increase in SGOT and ALP was significantly greater in group HTS than in the other groups (P < .02). The NDS was lower in group B on each postoperative evaluation, being significant relative to group C and group HTS on POD 1 (P < .05) and significantly lower than group C on POD 2 (P < .05). The OPC score was significantly lower in group B than in group C and group HTS on POD 2 (P < .05) and significantly lower than in group C on PODs 3 and 4 (P < .05). The NHS was lower in group B than in the other 2 groups, being significant relative to group C in the neocortex (P < .007).

CONCLUSIONS

Intermittent whole-body asanguineous perfusion with hypothermosol solution does not extend cerebral protection in a porcine survivor model of DHCA. Neurobehavioral and histological outcomes are improved in animals receiving intermittent blood perfusion during prolonged DHCA.

Mild and severe muscular dystrophy caused by a single gamma-sarcoglycan mutation

Autosomal recessive muscular dystrophy is genetically heterogeneous. One form of this disorder, limb-girdle muscular dystrophy type 2C (LGMD 2C), is prevalent in northern Africa and has been shown to be associated with a single mutation in the gene encoding the dystrophin-associated protein gamma-sarcoglycan. The previous mutation analysis of gamma-sarcoglycan required the availability of muscle biopsies. To establish a mutation assay for genomic DNA, the intron-exon structure of the gamma-sarcoglycan gene was determined, and primers were designed to amplify each of the exons encoding gamma-sarcoglycan. We studied a group of Brazilian muscular dystrophy patients for mutations in the gamma-sarcoglycan gene. These patients were selected on the basis of autosomal inheritance and/or the presence of normal dystrophin and/or deficiency of alpha-sarcoglycan immunostaining. Four of 19 patients surveyed had a single, homozygous mutation in the gamma-sarcoglycan gene. The mutation identified in these patients, all of African-Brazilian descent, is identical to that seen in the North African population, suggesting that even patients of remote African descent may carry this mutation. The phenotype in these patients varied considerably. Of four families with an identical mutation, three have a severe Duchenne-like muscular dystrophy. However, one family has much milder symptoms, suggesting that other loci may be present that modify the severity of the clinical course resulting from gamma-sarcoglycan gene mutations.

Mutations that disrupt the carboxyl-terminus of gamma-sarcoglycan cause muscular dystrophy

Recently, mutations in the genes encoding several of the dystrophin-associated proteins have been identified that produce phenotypes ranging from severe Duchenne-like autosomal recessive muscular dystrophy to the milder limb-girdle muscular dystrophies (LGMDs). LGMD type 2C is generally associated with a more severe clinical course and is prevalent in northern Africa. A previous study identified a single base pair deletion in the gene encoding the dystrophin-associated protein gamma-sarcoglycan in a number of Tunisian muscular dystrophy patients. To investigate whether gamma-sarcoglycan gene mutations cause autosomal recessive muscular dystrophy in other populations, we studied 50 muscular dystrophy patients from the United States and Italy. The muscle biopsies from these 50 patients showed no abnormality of dystrophin but did show diminished immunostaining for the dystrophin-associated protein alpha-sarcoglycan. Four patients with a severe muscular dystrophy phenotype were identified with homozygous, frameshifting mutations in gamma-sarcoglycan. Two of the four have microdeletions that disrupt the distal carboxyl-terminus of gamma-sarcoglycan yet result in a complete absence of gamma-and beta-sarcoglycan suggesting the importance of this region for stability of the sarcoglycan complex. This region of gamma-sarcoglycan, like beta-sarcoglycan, has a number of cysteine residues similar to those in epidermal growth factor cysteine-rich regions.

University of Wisconsin cerebroplegia in a piglet survival model of circulatory arrest

BACKGROUND

Previous acute studies in immature piglets at our institution have demonstrated improved recovery of cerebral blood flow, intracellular pH, and high-energy phosphates with the administration of multidose University of Wisconsin solution as cerebroplegia during a period of deep hypothermic circulatory arrest (HCA). In an effort to define further the clinical applicability of this technique, we have developed a survival model of swine cardiopulmonary bypass (CPB) and HCA.

METHODS

12 Yorkshire pigs (age 4 to 5 weeks) were placed on CPB via the right femoral artery and right atrium. Animals were cooled to a rectal temperature of 15 degrees C and submitted to 90 minutes of HCA. Group UW (n = 6) received a single infusion of 50 mL/kg of 4 degrees C University of Wisconsin solution delivered antegrade to the cerebral circulation. The control group (n = 6) received no intervention. Animals were reperfused, rewarmed to 35 degrees C, and weaned from CPB. Neurologic assessments using neurologic deficit scoring (0 = normal, 500 = brain death) and overall performance categories (1 = normal, 5 = brain death) were performed at 24-hour intervals for 5 days. On the 5th postoperative day all brains were perfusion-fixed and examined for histologic evidence of neuronal injury (0 = normal, 5 = severe injury).

RESULTS

All animals were extubated 18 to 20 hours postoperatively. There was no significant difference between the mean neurologic score of the two groups. The mean day 5 neurologic deficit score was 108 for the UW group and 68 for the control group (p > 0.05). The day 5 overall performance category was 2.8 for the UW group and 2.0 for the control group (p > 0.05). Three of the UW animals but none of the control animals experienced generalized seizures. Histologic examination revealed more severe damage in UW animals, primarily in the cerebral cortex. Injury was more widespread in UW animals, involving cerebellum and hippocampus. The mean histologic injury score was 3.8 for UW animals and 2.4 for the control group (p = 0.06).

CONCLUSIONS

A clinically relevant survival model of CPB with HCA in immature swine is feasible. Cold UW solution as single-dose cerebroplegia is not beneficial, and may be injurious to the immature swine brain subjected to CPB and HCA. Further studies are indicated to determine optimal composition and administration of cerebroplegic solutions.

Dp140: a novel 140 kDa CNS transcript from the dystrophin locus

We have identified a 7.5 kb transcript from the dystrophin locus which encodes a novel 140 kDa protein (Dp140). Based on immunoblotting Dp140 consists of the distal rod domain and C-terminus of 427 kDa dystrophin and is found throughout the CNS. This protein is transcribed from an alternative promoter in the dystrophin locus upstream to exon 45. The unique 5' first exon is conserved between rat and human. The transcript has a 1 kb 5' untranslated region, and the first methionine initiation codon occurs in exon 51, predicting a protein of 140 kDa. Several studies report that Duchenne dystrophy patients with deletions in the exon 45-52 region have an increased incidence of cognitive impairment. Such deletions would affect expression of 427 kDa dystrophin and this shorter 140 kDa isoform but not the recently described small distal transcripts Dp116 or Dp71, suggesting particular importance to CNS function.

The distribution of dystrophin in the murine central nervous system: an immunocytochemical study

A mild non-progressive cognitive defect is a feature of the fatal X-linked disease, Duchenne muscular dystrophy. Recent studies have identified the genetic defect and the resulting loss of the protein dystrophin, and shown that dystrophin messenger RNA and protein are present in normal brain tissue. We have performed western immunoblotting and fluorescence immunocytochemistry using a sensitive antibody made against a large fragment of the dystrophin molecule to study the regional, cellular and subcellular distribution of dystrophin in the mammalian brain. The brains of B10 (control) and mdx (dystrophin deficient null mutant) mouse brain were compared on a point-by-point basis to verify that only dystrophin and not autosomal dystrophin related protein or cross-reacting proteins were being identified. In addition three murine neurologic mutants, nervous, lurcher, and weaver, were studied to refine the localization of dystrophin. In western immunoblots, dystrophin is present in all regions of the brain and in greatest abundance in the cerebellum. Dystrophin, as demonstrated in immunofluorescence, is present in neurons, but not in glia or myelin, and forms punctate foci associated with the plasma membrane of perikarya and dendrites, but not axons. While dystrophin is abundant in cerebral cortical neurons and cerebellar Purkinje cells, it is absent from most subcortical neurons, the granule cells of fascia dentata, and cerebellar neurons other than Purkinje cells. The absence of dystrophin in the cerebellum of the Purkinje cell deficient mutants nervous and lurcher, and its presence in the granule cell deficient mutant weaver indicate that dystrophin is a component of Purkinje cells rather than closely apposed afferents to those cells. The distribution and localization of dystrophin suggests a role in organizing the plasma membrane, possibly as an anchor of the postsynaptic apparatus, a possible basis for the cognitive defect in Duchenne dystrophy.

An alternative dystrophin transcript specific to peripheral nerve

Transcription of the 2.5 megabase dystrophin gene gives rise to multiple isoforms. We describe a 5.2 kilobase transcript, expressed specifically in peripheral nerve, that initiates at a previously unrecognized exon located approximately 850 basepairs upstream of dystrophin exon 56. The likely product of this transcript (Dp116) is detected by C-terminal dystrophin antibodies exclusively in peripheral nerve and cultured Schwann cells. Dp116 is located along the Schwann cell membrane but is not present in the compact myelin lamellae or in axons. Dp116 lacks actin-binding and spectrin-like rod domains, arguing that it functions differently in the Schwann cell than does the major dystrophin transcript in muscle.

Cerebral neoplastic angioendotheleosis complicated by hypercalcaemia

This is a case report of a 67 year old man who presented with a fluctuating level of consciousness and myoclonic jerks caused in part by hypercalcaemia. The diagnosis of cerebral neoplastic angioendotheleosis was only made later on brain biopsy and is the first report of the occurrence of hypercalcaemia in neoplastic angioendotheleosis.

Localization of dystrophin to postsynaptic regions of central nervous system cortical neurons

Moderate non-progressive cognitive impairment is a consistent feature of Duchenne muscular dystrophy (DMD), although no central nervous system (CNS) abnormality has been identified. Recent studies have elucidated the molecular defect in DMD, including the absence of the protein dystrophin in affected individuals. Normal brain tissue contains dystrophin messenger RNA and dystrophin is present in low abundance in the brain and seems to be regulated in this tissue, at least in part, by a promoter that differs from that in muscle. Until now, antibodies and immunocytochemical methods used to demonstrate dystrophin at the plasma membrane of mouse and human muscle have proven inadequate to localize precisely dystrophin in the mammalian CNS. We have now made an antibody (anti 6-10) which is much more sensitive than those previously available to immunolabel dystrophin in the CNS. Using this antibody, we found that in the mouse, dystrophin is particularly abundant in the neurons of the cerebral and cerebellar cortices, and that it is localized at postsynaptic membrane specializations. Dystrophin may have a different role in neurons than in muscle, and an alteration at the synaptic level may be the basis of the cognitive impairment in DMD.

Progressive medullary failure associated with neurofibrillary degeneration

A clinicopathological report is presented of a British male, aged 59 years, who died after an illness of 10 years, manifested by progressive respiratory failure, ptosis, and dysphagia. At no time was there evidence of ophthalmoplegia, Parkinsonism or dementia. At necropsy the main finding was of neurofibrillary tangles in the neurons of the pontine and medullary reticular formation, with particularly severe involvement of the nucleus ambiguus, dorsal motor nucleus of the vagus and nucleus tractus solitarius. Morphologically, by light and electron microscopy and immunostaining, the tangles were similar to those of other neurofibrillary degenerative diseases. Although similar in some respects to progressive supranuclear palsy and amyotrophic lateral sclerosis of the Guam type, the combination of clinical and neuropathological features suggest that this is a distinct disease entity.

Lhermitte-Duclos disease (dysplastic gangliocytoma): a case report with CT and MRI

A 31 year old female was admitted with a one month history of left foot drop and diplopia. CT of the posterior fossa revealed gross displacement of the 4th ventricle by a large non-enhancing cerebellar mass but gave no indication of its nature. MRI sequences showed two masses within the left cerebellar hemisphere extending into the vermis and demonstrated a very unusual septation within the lesion. In addition both cerebellar tonsils were displaced below the foramen magnum and there was a syrinx extending from C2 to the conus. At operation a demarcated lesion was excised from the apparently normal surrounding cerebellar tissue and proved histologically to be Lhermitte-Duclos disease. We believe that these are the first diagnostic magnetic resonance images of this condition.

Serotoninergic differentiation of quail neural crest cells in vitro

The in vitro differentiation of quail neural crest cells into serotoninergic neurons is reported. Serotoninergic neurons were identified by two independent methods, formaldehyde-induced histofluorescence and indirect staining with antiserotonin antibodies. Serotonin-positive cells first appeared on the third day in culture, simultaneously, or slightly prior to the first pigmented cells and adrenergic neurons. Comparable numbers of serotoninergic cells were found in crest cell cultures derived from vagal, thoracic/upper lumbar, and lumbosacral levels of the neuraxis. The neural crest origin of the serotonin neurons was further corroborated by the demonstration that cultures of somites, notochords, and neural tubes (three tissues adjacent to the neural crest and thus the most likely contaminants of crest cell cultures) did not contain serotonin-producing cells, and that mast cells were absent in crest cell cultures. The identification of serotoninergic neurons in quail neural crest cell cultures makes an important addition to the number of neural crest derivatives that are capable of differentiating in culture. Furthermore, it suggests that the in vitro culture system will prove a valid approach to the elucidation of the cellular and molecular mechanisms that govern neural crest cell differentiation.

Immunohistochemical study of the development of serotonergic neurons in the rat CNS

In this study the development of serotonergic (5-HT) neurons is followed from their initiation of transmitter synthesis until the establishment of an essentially mature morphology. We have used the new and sensitive technique of 5-HT immunocytochemistry to visualize the precise features of this process. The great stability of this method, and the feasibility of counter-staining tissue sections permits the visualization of dendritic processes and axon terminals, as well as perikarya, and facilitates the localization of these structures with respect to non-5-HT components of the neuropil. Serial transverse and sagittal sections of rat fetuses on embryonic days (ED) 13, 14, 15, 17, 19 and 21, and postnatal rats on days 1, 3, 4 and 10 were examined. A detailed photomicrographic map showing the locations of 5-HT neurons at all prenatal stages is provided. The development of 5-HT neurons is evaluated in terms of their cellular morphology, particularly dendritic architecture, the relationship of these cells to the development of the surrounding brainstem, and the morphology and packing density of the 5-HT nuclei. From these considerations a model is proposed of the pattern of cell migration within the nuclei that give rise to the ascending 5-HT projections. At E14 a relatively simple configuration of bilateral superior (rostral) and inferior (caudal) 5-HT cell groups is present. In the period extending from E14 to E19 several subgroupings of these cells develop, presumably as the result of differential cell migration. Based on the predominant dendritic orientation of these cells it is possible to reconstruct their probable migratory paths. At E19 the 5-HT neurons are distributed in groups that are similar to those seen in the adult. In the time from E19 until the end of the first postnatal week there is rapid growth of 5-HT dendrites and a marked decrease in cellular packing density. These alterations shape the nuclear aggregates into the form seen in the adult. The development of the 5-HT cell groups is discussed in the context of known features of neurogenesis, migration, and axonal projections of the raphe and medial reticular nuclei of the brainstem. The possibility is raised that the decrease in cellular packing density in the 5-HT nuclei may reflect the appearance of the non-5-HT components of the raphe nuclei.

An immunohistochemical study of serotonin neuron development in the rat: ascending pathways and terminal fields

The ontogeny of the serotonergic axonal projections may be divided into three periods: one of initial axon elongation (E12-E16), the development of selective pathways (E15-E19) and terminal field development (E19-E21). All serotonergic axons that enter the prosencephalon ascend in the medial forebrain bundle From this bundle fascicles of immunoreactive axons enter several well-defined fiber tracts: specifically, the fasciculus retroflexus, stria medullaris, external capsule, fornix, and supracallosal stria. Axons from these pathways form terminal arborizations in the thalamus, hypothalamus, basal and limbic forebrain, and cerebral cortex. Serotonergic axons appear to be guided by pre-existing non-serotonergic tracts in reaching targets in the forebrain. Innervation of the cerebral cortex is a prolonged process extending from E19 through PND21. Axons enter directly into the marginal and intermediate zones of the immature cortex, at the medial, frontal and lateral edges of the hemisphere, and subsequently spread tangentially to cover the hemispheres. Terminal ramifications then arise from the bilaminar axons and fill in the middle cortical layers. This growth pattern gives rise to tangential and radial gradients in innervation density. While the growth of serotonin axons across the forebrain appears to be a continuous, sequential process, the development of terminal innervation is highly heterogeneous, occurring at different times and at different rates from region to region. Serotonergic axons do not innervate immature, primarily proliferative neuronal populations. The delay in serotonin innervation of the suprachiasmatic nucleus, striatum, and middle cortical layers long after the axons have reached these structures suggests that the formation of serotonin axon terminals is dependent on maturation of other elements in local neuronal circuitry.

Noradrenergic and serotonergic fibers innervate complementary layers in monkey primary visual cortex: an immunohistochemical study

Antisera directed against human dopamine beta-hydroxylase or serotonin were used to characterize the noradrenergic and serotonergic innervation patterns within the primary visual cortex of the squirrel monkey. The noradrenergic and serotonergic projections exhibit a high degree of laminar complementarity: layers V and VI receive a dense noradrenergic projection and a very sparse serotonergic projection, whereas layer IV receives a very dense serotonergic projection and is largely devoid of noradrenergic fibers. In addition, the noradrenergic fibers manifest a geometric order that is not so readily apparent in the distribution of serotonergic fibers. These patterns of innervation imply that the two transmitter systems affect different stages of cortical information processing--the raphe-cortical serotonergic projection preferentially innervates the spiny stellate cells of layers IVa and IVc, whereas the ceruleo-cortical noradrenergic projection innervates pyramidal cells.

The structure of cerebral cortex in the rat following prenatal administration of 6-hydroxydopamine

The early, prenatal formation of noradrenergic projections to the forebrain has led to the proposition that these axons exert a trophic influence on cerebral cortex during ontogeny. To test this hypothesis, we have examined a number of different structural features of cortical development following prenatal lesions of the ascending noradrenergic axons. The parameters that were analyzed include cytoarchitecture, dendritic morphology, and the distribution of monoaminergic and nonmonoaminergic cortical afferents. Rat fetuses were administered the catecholamine neurotoxin 6-hydroxydopamine (6-OHDA) by transuterine, intraperitoneal injection on embryonic day 17. Vehicle-injected controls and fetuses treated with the catecholamine uptake inhibitor desmethylimipramine (DMI) prior to 6-OHDA were prepared. After reaching maturity (200-300 g), the brain of treated and control rats were examined using Nissl and Golgi preparations (for cytoarchitecture and dendritic morphology), histofluorescence (for monoaminergic afferents, especially dopaminergic axons), and serotonin and dopamine-beta-hydroxylase (DBH) immunocytochemistry. Effective lesioning of the ascending noradrenergic system was confirmed in each case, using DBH immunocytochemistry. Prenatal treatment with 6-OHDA resulted in complete and long-lasting destruction of the noradrenergic innervation of the cerebral cortex, along with hyperinnervation of the diencephalon and brain stem. Despite the widespread denervation of cerebral cortex, no significant alterations in cytoarchitecture, dendritic morphology, or spine counts were found in treated brains. In particular, no abnormalities were observed in the apical dendrites of layer VI pyramidal cells, based on qualitative criteria. The distribution, density and morphology of serotonergic and dopaminergic afferents were unaffected. Thalamocortical afferents had developed normally as reflected by the cortical barrels. In 33% of the 6-OHDA-treated fetuses foci of ectopic neurons were found at the cortical surface. The ectopias contain neuronal processes, somata, and synapses interspersed with collagen and other connective tissue elements. While the ectopias may result from selective damage to the noradrenergic neurons, the finding of similar (but smaller) malformations in DMI-protected animals is equally consistent with a non-specific effect of 6-OHDA upon non-adrenergic cells. The examination of intervening stages will be needed to resolve this question. Based on the parameters of cortical structure analyzed in this study we conclude that the neocortex develops normally even in the absence of the noradrenergic system.

Characterization of the monoaminergic innervation of immature rat neocortex: a histofluorescence analysis

In the neocortex of 6-day-old rat, abundant axon terminals which exhibit specific catecholamine fluorescence are found in all regions and throughout all cortical layers. The overall density of axons in 6-day-old cortex is similar to the density in the adult cortex. In immature cortex, there are two distinct fluorescent plexuses, both presumably noradrenergic, one in the molecular layer and another in the lower half of the cortex. The superficial plexus is composed primarily of horizontal fibers, and the deep plexus of a dense feltwork of obliquely oriented fibers suggestive of a terminal field. The cortical plate itself is traversed by a few vertical processes. Following lesions of the midbrain tegmentum no fluorescent axons are seen in cortex, providing evidence that the fluorescent axons in cortex arise from brain stem neurons. The deep and superficial plexuses can be differentially visualized depending on the histochemical techniques employed and on pharmacological treatment, such as loading with a monoamine congener. Both deep and superficial axons are shown to contain endogenous catecholamines but those fibers in the deep plexus are filled to far less than their maximum capacity. The pharmaco-histochemical differences between axons in the two plexuses suggest that there may exist two distinct catecholaminergic projections to lateral neocortex. The demonstration of an extensive cortical monoamine innervation early in ontogeny supports the possibility that monoamine neurons play an important role in information processing and/or developmental interactions in the immature brain.