Hypothermic Neuroprotection Research Articles

Influence of Cooling duration on Efficacy in Cardiac Arrest Patients (ICECAP): study protocol for a multicenter, randomized, adaptive allocation clinical trial to identify the optimal duration of induced hypothermia for neuroprotection in comatose, adult survivors of after out-of-hospital cardiac arrest

BackgroundCardiac arrest is a common and devastating emergency of both the heart and brain. More than 380,000 patients suffer out-of-hospital cardiac arrest annually in the USA. Induced cooling of comatose patients markedly improved neurological and functional outcomes in pivotal randomized clinical trials, but the optimal duration of therapeutic hypothermia has not yet been established.MethodsThis study is a multi-center randomized, response-adaptive, duration (dose) finding, comparative effectiveness clinical trial with blinded outcome assessment. We investigate two populations of adult comatose survivors of cardiac arrest to ascertain the shortest duration of cooling that provides the maximum treatment effect. The design is based on a statistical model of response as defined by the primary endpoint, a weighted 90-day mRS (modified Rankin Scale, a measure of neurologic disability), across the treatment arms. Subjects will initially be equally randomized between 12, 24, and 48 h of therapeutic cooling. After the first 200 subjects have been randomized, additional treatment arms between 12 and 48 h will be opened and patients will be allocated, within each initial cardiac rhythm type (shockable or non-shockable), by response adaptive randomization. As the trial continues, shorter and longer duration arms may be opened. A maximum sample size of 1800 subjects is proposed. Secondary objectives are to characterize: the overall safety and adverse events associated with duration of cooling, the effect on neuropsychological outcomes, and the effect on patient-reported quality of life measures.DiscussionIn vitro and in vivo studies have shown the neuroprotective effects of therapeutic hypothermia for cardiac arrest. We hypothesize that longer durations of cooling may improve either the proportion of patients that attain a good neurological recovery or may result in better recovery among the proportion already categorized as having a good outcome. If the treatment effect of cooling is increasing across duration, for at least some set of durations, then this provides evidence of the efficacy of cooling itself versus normothermia, even in the absence of a normothermia control arm, confirming previous RCTs for OHCA survivors of shockable rhythms and provides the first prospective controlled evidence of efficacy in those without initial shockable rhythms.Trial registrationClinicalTrials.gov NCT04217551. Registered on 30 December 2019.

Influence of Cooling duration on Efficacy in Cardiac Arrest Patients (ICECAP): study protocol for a multicenter, randomized, adaptive allocation clinical trial to identify the optimal duration of induced hypothermia for neuroprotection in comatose, adult survivors of after out-of-hospital cardiac arrest.

Cardiac arrest is a common and devastating emergency of both the heart and brain. More than 380,000 patients suffer out-of-hospital cardiac arrest annually in the United States. Induced cooling of comatose patients markedly improved neurological and functional outcomes in pivotal randomized clinical trials, but the optimal duration of therapeutic hypothermia has not yet been established. This study is a multi-center randomized, response-adaptive, duration (dose) finding, comparative effectiveness clinical trial with blinded outcome assessment. We investigate two populations of adult comatose survivors of cardiac arrest to ascertain the shortest duration of cooling that provides the maximum treatment effect. The design is based on a statistical model of response as defined by the primary endpoint, a weighted 90-day mRS (modified Rankin Scale, a measure of neurologic disability), across the treatment arms. Subjects will initially be equally randomized between 12, 24, and 48 hours of therapeutic cooling. After the first 200 subjects have been randomized, additional treatment arms between 12 and 48 hours will be opened and patients will be allocated, within each initial cardiac rhythm type (shockable or non-shockable), by response adaptive randomization. As the trial continues, shorter and longer duration arms may be opened. A maximum sample size of 1800 subjects is proposed. Secondary objectives are to characterize: the overall safety and adverse events associated with duration of cooling, the effect on neuropsychological outcomes, and the effect on patient reported quality of life measures. In-vitro and in-vivo studies have shown the neuroprotective effects of therapeutic hypothermia for cardiac arrest. We hypothesize that longer durations of cooling may improve either the proportion of patients that attain a good neurological recovery or may result in better recovery among the proportion already categorized as having a good outcome. If the treatment effect of cooling is increasing across duration, for at least some set of durations, then this provides evidence of the efficacy of cooling itself versus normothermia, even in the absence of a normothermia control arm, confirming previous RCTs for OHCA survivors of shockable rhythms and provides the first prospective controlled evidence of efficacy in those without initial shockable rhythms. ClinicalTrials.gov (NCT04217551, 2019-12-30).

Modulation of NLRP3 inflammasome-related-inflammation via RIPK1/RIPK3-DRP1 or HIF-1α signaling by phenothiazine in hypothermic and normothermic neuroprotection after acute ischemic stroke

BackgroundInflammation and subsequent mitochondrial dysfunction and cell death worsen outcomes after revascularization in ischemic stroke. Receptor-interacting protein kinase 1 (RIPK1) activated dynamin-related protein 1 (DRP1) in a NLRPyrin domain containing 3 (NLRP3) inflammasome-dependent fashion and Hypoxia-Inducible Factor (HIF)-1α play key roles in the process. This study determined how phenothiazine drugs (chlorpromazine and promethazine (C + P)) with the hypothermic and normothermic modality impacts the RIPK1/RIPK3-DRP1 and HIF-1α pathways in providing neuroprotection. MethodsA total of 150 adult male Sprague-Dawley rats were subjected to 2 h middle cerebral artery occlusion (MCAO) followed by 24 h reperfusion. 8 mg/kg of C + P was administered at onset of reperfusion. Infarct volumes, mRNA and protein expressions of HIF-1α, RIPK1, RIPK3, DRP-1, NLRP3-inflammation and cytochrome c-apoptosis were assessed. Apoptotic cell death, infiltration of neutrophils and macrophages, and mitochondrial function were evaluated. Interaction between RIPK1/RIPK3 and HIF-1α/NLRP3 were determined. In SH-SY5Y cells subjected to oxygen/glucose deprivation (OGD), the normothermic effect of C + P on inflammation and apoptosis were examined. ResultsC + P significantly reduced infarct volumes, mitochondrial dysfunction (ATP and ROS concentration, citrate synthase and ATPase activity), inflammation and apoptosis with and without induced hypothermia. Overexpression of RIPK1, RIPK3, DRP-1, NLRP3-inflammasome and cytochrome c-apoptosis were all significantly reduced by C + P at 33 °C and the RIPK1 inhibitor (Nec1s), suggesting hypothermic effect of C + P via RIPK1/RIPK3-DRP1pathway. When body temperature was maintained at 37 °C, C + P and HIF-1α inhibitor (YC-1) reduced HIF-1α expression, leading to reduction in mitochondrial dysfunction, NLRP3 inflammasome and cytochrome c-apoptosis, as well as the interaction of HIF-1α and NLRP3. These were also evidenced in vitro, indicating a normothermic effect of C + P via HIF-1α. ConclusionHypothermic and normothermic neuroprotection of C + P involve different pathways. The normothermic effect was mediated by HIF-1α, while hypothermic effect was via RIPK1/RIPK3-DRP1 signaling. This provides a theoretical basis for future precise exploration of hypothermic and normothermic neuroprotection.

Impact of therapeutic hypothermia (whole body cooling) on severely asphyxiated term neonates: a prospective non-randomized comparative study in an Indian tertiary care setting

Background: Early application of Therapeutic Hypothermia within 6 hours of birth is neuroprotective. We aimed at examining whether therapeutic hypothermia alongside standard optimal intensive care improves immediate survival outcome and reduces neuro-disability. Methods: This was a prospective non-randomized study involving inborn and out born newborns admitted at NICU, carried out from March 2022 to December 2022. Eligible candidates were enrolled as cases and therapeutic hypothermia was offered while rest were included as a control group and monitored likewise for the overall survival and neurological outcome. These babies were followed up till 1 month and 3 months of age to assess neurological outcome. Results: In this study, a total of 47 patients were enrolled both from extramural and intramural NICU set ups. Of them, 22 patients were offered Therapeutic Hypothermia and 25 patients were given standard post asphyxia care. 7 out of 9 inborn patients and 3 out of 13 out born neonates who were offered therapeutic hypothermia survived whereas 5 out of 11 inborn and 4 out of 14 out born neonates who were offered standard post asphyxia care survived. Conclusions: Therapeutic hypothermia cannot be attributed to significant increase or decrease in mortality when compared with standard care group. No inference could be made about hypothermic neuroprotection in the follow up study. Overall survival outcome was better in inborn patients than that of outborn. Inborn neonates subjected to therapeutic hypothermia, showed a trend towards better survival than those given standard post asphyxia care.

Hypothermia promotes tunneling nanotube formation and the transfer of astrocytic mitochondria into oxygen-glucose deprivation/reoxygenation-injured neurons

Mitochondrial transfer occurs between cells, and it is important for damaged cells to receive healthy mitochondria to maintain their normal function and protect against cell death. Accumulating evidence suggests that the functional mitochondria of astrocytes are released and transferred to oxygen–glucose deprivation/reoxygenation (OGD/R)-injured neurons. Mild hypothermia (33 °C) is capable of promoting this process, which partially restores the function of damaged neurons. However, the pathways and mechanisms by which mild hypothermia facilitates mitochondrial transfer remain unclear. We are committed to studying the role of mild hypothermia in neuroprotection to provide reliable evidences and insights for the clinical application of mild hypothermia in brain protection. Tunneling nanotubes (TNTs) are considered to be one of the routes through which mitochondria are transferred between cells. In this study, an OGD/R-injured neuronal model was successfully established, and TNTs, mitochondria, neurons and astrocytes were double labeled using immunofluorescent probes. Our results showed that TNTs were present and involved in the transfer of mitochondria between cells in the mixed-culture system of neurons and astrocytes. When neurons were subjected to OGD/R exposure, TNT formation and mitochondrial transportation from astrocytes to injured neurons were facilitated. Further analysis revealed that mild hypothermia increased the quantity of astrocytic mitochondria transferred into damaged neurons through TNTs, raised the mitochondrial membrane potential (MMP), and decreased the neuronal damage and death during OGD/R. Altogether, our data indicate that TNTs play an important role in the endogenous neuroprotection of astrocytic mitochondrial transfer. Furthermore, mild hypothermia enhances astrocytic mitochondrial transfer into OGD/R-injured neurons via TNTs, thereby promoting neuroprotection and neuronal recovery.

Whole-Blood Gene Expression Profile After Hypoxic-Ischemic Encephalopathy

Induced hypothermia, the standard treatment for hypoxic-ischemic encephalopathy (HIE) in high-income countries (HICs), is less effective in the low-income populations in South Asia, who have the highest disease burden. To investigate the differences in blood genome expression profiles of neonates with HIE from an HIC vs neonates with HIE from South Asia. This case-control study analyzed data from (1) a prospective observational study involving neonates with moderate or severe HIE who underwent whole-body hypothermia between January 2017 and June 2019 and age-matched term healthy controls in Italy and (2) a randomized clinical trial involving neonates with moderate or severe HIE in India, Sri Lanka, and Bangladesh recruited between August 2015 and February 2019. Data were analyzed between October 2020 and August 2023. Whole-blood RNA that underwent next-generation sequencing. The primary outcomes were whole-blood genome expression profile at birth associated with adverse outcome (death or disability at 18 months) after HIE in the HIC and South Asia cohorts and changes in whole-genome expression profile during the first 72 hours after birth in neonates with HIE and healthy controls from the HIC cohort. Blood samples for RNA extraction were collected before whole-body hypothermia at 4 time points (6, 24, 48, and 72 hours after birth) for the HIC cohort. Only 1 blood sample was drawn within 6 hours after birth for the South Asia cohort. The HIC cohort was composed of 35 neonates (21 females [60.0%]) with a median (IQR) birth weight of 3.3 (3.0-3.6) kg and gestational age of 40.0 (39.0-40.6) weeks. The South Asia cohort consisted of 99 neonates (57 males [57.6%]) with a median (IQR) birth weight of 2.9 (2.7-3.3) kg and gestational age of 39.0 (38.0-40.0) weeks. Healthy controls included 14 neonates (9 females [64.3%]) with a median (IQR) birth weight of 3.4 (3.2-3.7) kg and gestational age of 39.2 (38.9-40.4) weeks. A total of 1793 significant genes in the HIC cohort and 99 significant genes in the South Asia cohort were associated with adverse outcome (false discovery rate <0.05). Only 11 of these genes were in common, and all had opposite direction in fold change. The most significant pathways associated with adverse outcome were downregulation of eukaryotic translation initiation factor 2 signaling in the HIC cohort (z score = -4.56; P < .001) and aldosterone signaling in epithelial cells in the South Asia cohort (z score = null; P < .001). The genome expression profile of neonates with HIE (n = 35) at birth, 24 hours, 48 hours, and 72 hours remained significantly different from that of age-matched healthy controls in the HIC cohort (n = 14). This case-control study found that disease mechanisms underlying HIE were primarily associated with acute hypoxia in the HIC cohort and nonacute hypoxia in the South Asia cohort. This finding might explain the lack of hypothermic neuroprotection.

Abstract TP26: Hypothermic and Non-Hypothermic Neuroprotection by Phenothiazine in Acute Ischemic Stroke: Modulation of NLRP3 Inflammasome-Related-Inflammation via Different Pathways of RIPK1/RIPK3-DRP1 or HIF-1α

Background: Inflammation after successful revascularization worsened outcomes in ischemic stroke. NLRPyrin domain containing 3 (NLRP3) inflammasome mediated inflammatory responses, in which receptor-interacting protein kinase (RIPK1) activated dynamin-related protein 1 (DRP1) in a RIPK3-dependent fashion. Hypoxia-inducible factor 1α (HIF-1α) regulated ischemic inflammation through NLRP3 inflammasome complex, thus apoptosis after stroke. Phenothiazine, including chlorpromazine and promethazine (C+P), induced hypothermic and non-hypothermic neuroprotection. We determined effects of RIPK1/RIPK3-DRP1 or HIF-1α pathways underlying the dual neuroprotection by C+P. Methods: 144 adult male Sprague-Dawley rats were subjected to 2 h of middle cerebral artery occlusion (MCAO), followed by 24 h reperfusion. 8mg/kg of C+P was injected at the onset of reperfusion. Infarct volumes, mRNA and protein expressions of HIF-1α, RIPK1, RIPK3, DRP-1, NLRP3-inflammation (NLRP3, ASC, Caspase-1, IL-1β and IL-18) and cytochrome C-apoptosis (cytochrome C, APAF-1, Caspase-9 and Caspase-3) were assessed. Apoptotic cell death, and the infiltration of neutrophils and macrophages were evaluated. Co-localization of RIPK1/RIPK3 and HIF-1α/NLRP3 were determined. Results: C+P significantly reduced brain inflammation, neuronal apoptosis and immune cell infiltration, with or without hypothermia. C+P with induced-hypothermia and RIPK1 inhibitor significantly reduced infarct volumes, the expression of RIPK1, RIPK3, DRP-1, NLRP3-inflammation process and cytochrome C-apoptosis, as well as the co-localization of RIPK1/RIPK3, suggesting the hypothermic effect underlying the RIPK1/RIPK3-DRP1 pathway. In non-hypothermia effect, HIF-1α expression was reduced by C+P or HIF-1α inhibitor, in concomitant with reduced NLRP3 inflammasome, cytochrome C-apoptosis, and decreased interaction of HIF-1α and NLRP3. Conclusion: Hypothermic and non-hypothermic neuroprotection of C+P involve different pathways. The hypothermic effect was via RIPK1/RIPK3-DRP1 signaling, while non-hypothermic effect was mediated by HIF-1α. This provides a theoretical basis for future precise exploration of hypothermic and non-hypothermic neuroprotection.

Hypothermia for Neuroprotection in Adults After Cardiac Arrest.

Hypothermia for Neuroprotection in Adults After Cardiac Arrest.

Dual-sized hollow particle incorporated fibroin thermal insulating coatings on catheter for cerebral therapeutic hypothermia

Selective endovascular hypothermia has been used to provide cooling-induced cerebral neuroprotection, but current catheters do not support thermally-insulated transfer of cold infusate, which results in an increased exit temperature, causes hemodilution, and limits its cooling efficiency. Herein, air-sprayed fibroin/silica-based coatings combined with chemical vapor deposited parylene-C capping film was prepared on catheter. This coating features in dual-sized-hollow-microparticle incorporated structures with low thermal conductivity. The infusate exit temperature is tunable by adjusting the coating thickness and infusion rate. No peeling or cracking was observed on the coatings under bending and rotational scenarios in the vascular models. Its efficiency was verified in a swine model, and the outlet temperature of coated catheter (75μm thickness) was 1.8-2.0°C lower than that of the uncoated one. This pioneering work on catheter thermal insulation coatings may facilitate the clinical translation of selective endovascular hypothermia for neuroprotection in patients with acute ischemic stroke.

Hypothermic neuroprotection by targeted cold autologous blood transfusion in a non-human primate stroke model

Over decades, nearly all attempts to translate the benefits of therapeutic hypothermia in stroke models of lower-order species to stroke patients have failed. Potentially overlooked reasons may be biological gaps between different species and the mismatched initiation of therapeutic hypothermia in translational studies. Here, we introduce a novel strategy of selective therapeutic hypothermia in a non-human primate ischemia-reperfusion model, in which autologous blood was cooled ex vivo and the cool blood transfusion was administered at the middle cerebral artery just after the onset of reperfusion. Cold autologous blood cooled the targeted brain rapidly to below 34 °C while the rectal temperature remained around 36 °C with the assistance of a heat blanket during a 2-h hypothermic process. Therapeutic hypothermia or extracorporeal-circulation related complications were not observed. Cold autologous blood treatment reduced infarct sizes, preserved white matter integrity, and improved functional outcomes. Together, our results suggest that therapeutic hypothermia, induced by cold autologous blood transfusion, was achieved in a feasible, swift, and safe way in a non-human primate model of stroke. More importantly, this novel hypothermic approach conferred neuroprotection in a clinically relevant model of ischemic stroke due to reduced brain damage and improved neurofunction. This study reveals an underappreciated potential for this novel hypothermic modality for acute ischemic stroke in the era of effective reperfusion.

Cerebral Glucose Concentration in Neonatal Hypoxic–Ischemic Encephalopathy during Therapeutic Hypothermia

To determine cerebral glucose concentration and its relationship with glucose infusion rate (GIR) and blood glucose concentration in neonatal encephalopathy during therapeutic hypothermia (TH). This was an observational study in which cerebral glucose during TH was quantified by magnetic resonance (MR) spectroscopy and compared with mean blood glucose at the time of scan. Clinical data (gestational age, birth weight, GIR, sedative use) that could affect glucose use were collected. The severity and pattern of brain injury on MR imaging were scored by a neuroradiologist. Student t test, Pearson correlation, repeated measures ANOVA, and multiple regression analysis were performed. Three-hundred-sixty blood glucose values and 402MR spectra from 54 infants (30 female infants; mean gestational age 38.6± 1.9weeks) were analyzed. In total, 41 infants had normal-mild and 13 had moderate-severe injury. Median GIR and blood glucose during TH were 6.0mg/kg/min (IQR 5-7) and 90mg/dL (IQR 80-102), respectively. GIR did not correlate with blood or cerebral glucose. Cerebral glucose was significantly greater during than after TH (65.9± 22.9 vs 60.0± 25.2mg/dL, P<.01), and there was a significant correlation between blood glucose and cerebral glucose during TH (basal ganglia: r=0.42, thalamus: r=0.42, cortical gray matter: r=0.39, white matter: r=0.39, all P<.01). There was no significant difference in cerebral glucose concentration in relation to injury severity or pattern. During TH, cerebral glucose concentration is partly dependent on blood glucose concentration. Further studies to understand brain glucose use and optimal glucose concentrations during hypothermic neuroprotection are needed.

Whole-Body Hypothermia, Cerebral Magnetic Resonance Biomarkers, and Outcomes in Neonates With Moderate or Severe Hypoxic-Ischemic Encephalopathy Born at Tertiary Care Centers vs Other Facilities

The association between place of birth and hypothermic neuroprotection after hypoxic-ischemic encephalopathy (HIE) in low- and middle-income countries (LMICs) is unknown. To ascertain the association between place of birth and the efficacy of whole-body hypothermia for protection against brain injury measured by magnetic resonance (MR) biomarkers among neonates born at a tertiary care center (inborn) or other facilities (outborn). This nested cohort study within a randomized clinical trial involved neonates at 7 tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh between August 15, 2015, and February 15, 2019. A total of 408 neonates born at or after 36 weeks' gestation with moderate or severe HIE were randomized to receive whole-body hypothermia (reduction of rectal temperatures to between 33.0 °C and 34.0 °C; hypothermia group) for 72 hours or no whole-body hypothermia (rectal temperatures maintained between 36.0 °C and 37.0 °C; control group) within 6 hours of birth, with follow-up until September 27, 2020. 3T MR imaging, MR spectroscopy, and diffusion tensor imaging. Thalamic N-acetyl aspartate (NAA) mmol/kg wet weight, thalamic lactate to NAA peak area ratios, brain injury scores, and white matter fractional anisotropy at 1 to 2 weeks and death or moderate or severe disability at 18 to 22 months. Among 408 neonates, the mean (SD) gestational age was 38.7 (1.3) weeks; 267 (65.4%) were male. A total of 123 neonates were inborn and 285 were outborn. Inborn neonates were smaller (mean [SD], 2.8 [0.5] kg vs 2.9 [0.4] kg; P = .02), more likely to have instrumental or cesarean deliveries (43.1% vs 24.7%; P = .01), and more likely to be intubated at birth (78.9% vs 29.1%; P = .001) than outborn neonates, although the rate of severe HIE was not different (23.6% vs 17.9%; P = .22). Magnetic resonance data from 267 neonates (80 inborn and 187 outborn) were analyzed. In the hypothermia vs control groups, the mean (SD) thalamic NAA levels were 8.04 (1.98) vs 8.31 (1.13) among inborn neonates (odds ratio [OR], -0.28; 95% CI, -1.62 to 1.07; P = .68) and 8.03 (1.89) vs 7.99 (1.72) among outborn neonates (OR, 0.05; 95% CI, -0.62 to 0.71; P = .89); the median (IQR) thalamic lactate to NAA peak area ratios were 0.13 (0.10-0.20) vs 0.12 (0.09-0.18) among inborn neonates (OR, 1.02; 95% CI, 0.96-1.08; P = .59) and 0.14 (0.11-0.20) vs 0.14 (0.10-0.17) among outborn neonates (OR, 1.03; 95% CI, 0.98-1.09; P = .18). There was no difference in brain injury scores or white matter fractional anisotropy between the hypothermia and control groups among inborn or outborn neonates. Whole-body hypothermia was not associated with reductions in death or disability, either among 123 inborn neonates (hypothermia vs control group: 34 neonates [58.6%] vs 34 [56.7%]; risk ratio, 1.03; 95% CI, 0.76-1.41), or 285 outborn neonates (hypothermia vs control group: 64 neonates [46.7%] vs 60 [43.2%]; risk ratio, 1.08; 95% CI, 0.83-1.41). In this nested cohort study, whole-body hypothermia was not associated with reductions in brain injury after HIE among neonates in South Asia, irrespective of place of birth. These findings do not support the use of whole-body hypothermia for HIE among neonates in LMICs. ClinicalTrials.gov Identifier: NCT02387385.

A Global Review of the Perioperative Care of Patients With Aneurysmal Subarachnoid Hemorrhage Undergoing Microsurgical Repair of Ruptured Intracerebral Aneurysm.

To describe the perioperative care of patients with aneurysmal subarachnoid hemorrhage (aSAH) who undergo microsurgical repair of a ruptured intracerebral aneurysm. An English language survey examined 138 areas of the perioperative care of patients with aSAH. Reported practices were categorized as those reported by <20%, 21% to 40%, 41% to 60%, 61% to 80%, and 81% to 100% of participating hospitals. Data were stratified by Worldbank country income level (high-income or low/middle-income). Variation between country-income groups and between countries was presented as an intracluster correlation coefficient (ICC) and 95% confidence interval (CI). Forty-eight hospitals representing 14 countries participated in the survey (response rate 64%); 33 (69%) hospitals admitted ≥60 aSAH patients per year. Clinical practices reported by 81 to 100% of the hospitals included placement of an arterial catheter, preinduction blood type/cross match, use of neuromuscular blockade during induction of general anesthesia, delivering 6 to 8mL/kg tidal volume, and checking hemoglobin and electrolyte panels. Reported use of intraoperative neurophysiological monitoring was 25% (41% in high-income and 10% in low/middle-income countries), with variation between Worldbank country-income group (ICC 0.15, 95% CI 0.02-2.76) and between countries (ICC 0.44, 95% CI 0.00-0.68). The use of induced hypothermia for neuroprotection was low (2%). Before aneurysm securement, variable in blood pressure targets was reported; systolic blood pressure 90 to 120mmHg (30%), 90 to 140mmHg (21%), and 90 to 160mmHg (5%). Induced hypertension during temporary clipping was reported by 37% of hospitals (37% each in high and low/middle-income countries). This global survey identifies differences in reported practices during the perioperative management of patients with aSAH.

New Therapeutic Paradigms in Neonatal Hypoxic-Ischemic Encephalopathy.

In neonates with hypoxic-ischemic encephalopathy (HIE), neuroprotection mediated by therapeutic hypothermia (TH) is the standard of care in developed nations; however TH may be not beneficial or contraindicated in developing world. Moreover, in most of the clinical trials, hypothermic neuroprotection was incomplete because many infants still die or suffer significant neurological sequelae. Therefore, finding innovative, neuroprotective compounds for this encephalopathy represents an important and urgent need. In reference to the recent review by Zhou , ACS Chem. Neurosci. 2023 14, 1-9, in this viewpoint, we discuss the therapeutic role of ketone bodies and thiamine in neonatal HIE, their possible synergistic effect, and how these micronutrients may provide additive neuroprotection to TH and improve safer and effective treatment strategies also helpful in low-middle-income countries.

Influence of RRM, RGG and Potential Phosphorylated Sites in Cold-Inducible Protein RBM3 on its Subcellular Localization and Neuroprotective Effects.

As a potent mediator of hypothermic neuroprotection, the cold-inducible protein RBM3 is characterized with one RNA-recognition motifs (RRM) and one arginine-glycine-rich (RGG) domain. It is known that these conserved domains are required for nuclear localization in some RNA-binding proteins. However, little is known about the actual role of RRM and RGG domains in subcellular localization of RBM3. To clarify it, various mutants of human Rbm3 gene were constructed. Plasmids were transfected into cells and the localization of RBM3 protein and its varias mutants in cells and role in neuroprotection. In human neuroblastoma SH-SY5Y cells, either a truncation of RRM domain (aa 1-86) or RGG domain (aa 87-157) led to an obvious cytoplasmic distribution, compared to a predominant nuclear localization of whole RBM3 protein (aa 1-157). In contrast, mutants in several potential phosphorylated sites of RBM3, including Ser102, Tyr129, Ser147, and Tyr155, did not alter the nuclear localization of RBM3. Similarly, mutants in two Di-RGG motif sites also did not affect the subcellular distribution of RBM3. Lastly, the role of Di-RGG motif in RGG domains was further investigated. The mutant of double arginines in either Di-RGG motif-1 (Arg87/90) or -2 (Arg99/105) exhibited a higher cytoplasmic localization, indicating that both Di-RGG motifs are required for nucleic localization of RBM3. Our data suggest that RRM and RGG domains are both required for the nuclear localization of RBM3, with two Di-RGG domain being crucial for nucleocytoplasmic shuttling of RBM3.

549: ANALYSIS OF NEUROPROTECTIVE COLD SHOCK PROTEINS IN A MULTICENTER STUDY OF PEDIATRIC CARDIAC ARREST

Introduction: The efficacy of hypothermic neuroprotection varies by age. Cold exposure stimulates production of cold stress hormones (CSHs) which trigger thermogenesis and may be neuroprotective. FGF21 is a neuroprotective CSH that requires the Beta-klotho (KLB) co-receptor to signal. KLB is abundant in the newborn brain, decreases with age, and is virtually absent in adults. Thus, infants and young children may uniquely benefit from FGF21/KLB mediated neuroprotection. In vitro studies revealed that FGF21 upregulates the powerful neuroprotectant RNA-Binding Motif-3 (RBM3) in developmentally immature neurons (but not mature neurons). We sought to characterize FGF21 and RBM3 serum levels in children after cardiac arrest (CA) and evaluate their interdependence. Methods: Secondary analysis of serum samples collected in a multi-institutional prospective observational study evaluating biomarkers after pediatric CA. We measured FGF21 (Luminex) and RBM3 (ELISA) levels. All patients with serum from at least two timepoints (0-24h, 24-48h, 48-72h) were included. We also included serum from healthy controls. FGF21 and RBM3 levels at each timepoint were compared to controls (Wilcoxon-Ranksum); the relationship between FGF21/RBM3 at each timepoint was also evaluated (Spearman). Results: A total of 296 samples from 111 post-arrest patients were analyzed, and 20 samples from controls. Median age of the post-arrest cohort was 31.3 months (IQR: 6.9-129.9); 37.3 months (IQR: 18.6-63.6) for controls. Median FGF21 levels in the controls was 282pg/mL (IQR: 64-736), and did not differ significantly at 0-24h, 24-48h, and 48-72h (383 [IQR: 72-867], 723 [IQR: 167-1,688] and 552 [IQR: 210-1,225], respectively, P>0.05). Median control RBM3 was 2,944pg/mL (IQR: 969-8,241), and did not differ significantly at 0-24h, 24-48h, and 48-72h (1,538 [IQR: 757-4,146], 1,454 [625-3,543] and 1,526 [IQR: 613-3,591], respectively, P>0.05). FGF21 and RBM3 were correlated at 0-24h and 48-72h (Spearman’s coefficient of 0.384 and 0.223, respectively; P< 0.05 for both). Conclusions: After pediatric CA, serum FGF21 levels trend upward and RBM3 levels downward and correlate at early and late timepoints. Ongoing studies are examining their relationship to age, demographics, CA endophenotype, use of hypothermia, other serum biomarkers, and outcomes.

Mitochondrial calcium buffering depends upon temperature and is associated with hypothermic neuroprotection against hypoxia-ischemia injury.

Hypothermia (HT) is a standard of care in the management of hypoxic-ischemic brain injury (HI). However, therapeutic mechanisms of HT are not well understood. We found that at the temperature of 32°C, isolated brain mitochondria exhibited significantly greater resistance to an opening of calcium-induced permeability transition pore (mPTP), compared to 37°C. Mitochondrial calcium buffering capacity (mCBC) was linearly and inversely dependent upon temperature (25°C—37°C). Importantly, at 37°C cyclosporine A did not increase mCBC, but significantly increased mCBC at lower temperature. Because mPTP contributes to reperfusion injury, we hypothesized that HT protects brain by improvement of mitochondrial tolerance to mPTP activation. Immediately after HI-insult, isolated brain mitochondria demonstrated very poor mCBC. At 30 minutes of reperfusion, in mice recovered under normothermia (NT) or HT, mCBC significantly improved. However, at four hours of reperfusion, only NT mice exhibited secondary decline of mCBC. HT-mice maintained their recovered mCBC and this was associated with significant neuroprotection. Direct inverted dependence of mCBC upon temperature in vitro and significantly increased mitochondrial resistance to mPTP activation after therapeutic HT ex vivo suggest that hypothermia-driven inhibition of calcium-induced mitochondrial mPTP activation mechanistically contributes to the neuroprotection associated with hypothermia.

Preparation and characterization of silk fibroin/silica thermal insulation coatings on catheters

Clinical practice of therapeutic hypothermia for neuroprotection in acute cerebral ischemia has been hindered by the warming effect on the cold infusate along the pathway, which results from the poor thermal resistance of the traditional interventional catheter. In this study, thermal insulation coatings with different spray parameters and coating suspension compositions were prepared by air-spraying on a nylon substrate for biomedical application. The surface morphology and microstructure of coatings were investigated by scanning electron microscopy, X-ray diffraction and Fourier transform infrared spectroscopy. Silk fibroin (SF) and hollow silica-based nanospheres (HSBNSs) were successfully sprayed on the nylon substrate. The thermal conductivity of the coating measured by a light flash apparatus was down to 0.00105 W/(m K). The tape test indicated that the coatings containing SF, HSBNSs and glyceryl had good adhesion, showing that air-spraying is a promising method to enhance the thermal insulation performance of traditional catheters for cerebral hypothermia therapy.

Abstract WP24: Pharmacological Hypothermia (PH) Promotes Plasticity Through RNA Binding Motif 3 (RBM3)-Mediated Cold Shock Pathway Following Ischemic Stroke

Background: Phenothiazine, including chlorpromazine and promethazine (C+P), induce hypothermia and neuroprotection after stroke. Immediately after stroke onset, there is a neuroplasticity window within which rehabilitation is especially effective. Recent studies have indicated that hypothermia-induced neuroplasticity involves the RBM3-mediated cold shock pathway, but it is unknown whether this pathway participates in neuroprotection and neuroplasticity in the context of pharmacological hypothermia (PH) induced by C+P after stroke. Methods: Adult Sprague-Dawley rats were divided in 3 groups: (1) sham; (2) stroke; (3) stroke treated with C+P before reperfusion. Long-term functional outcomes were determined by grid walk tests, rota-rod tests, beam balance tests, forelimb placing tests, adhesive tape touch and adhesive tape removal at 7 through 28 days. mRNA and protein quantities of cold shock pathway [RBM3, eukaryotic initiation factor 2 alpha (eIF2α), and reticulon 3 (RTN3)] and neuroplasticity [synaptophysin (SYN), post-synaptic density protein-95 (PSD-95), Tau, and recombinant growth associated protein 43 (GAP43)] were assessed by real-time PCR and western blot at day 1, 7 and 28 after reperfusion. Additionally, expression of RTN3 and eIF2α, and the co-localization of SYN and PSD95 was measured in primary neurons which subjected to oxygen/glucose deprivation (OGD) with RBM3 knockdown. Results: PH significantly improved functional outcomes at day 7 and 28. At day 1, mRNA and protein expression of RBM3 and RTN3 were significantly increased, and eIF2α was dephosphorylated by PH after stroke. mRNA and protein levels of SYN, Tau and GAP43 were all increased by PH at day 7 and 28. Furthermore, in OGD with shRBM3 group, levels of RTN3 and eIF2α dephosphorylation were significantly decreased, and the co-localization of SYN and PSD95 were significantly reduced compared with OGD group at 24 h without shRBM3. Conclusion: Our study has provided evidence, for the first time, for a novel mechanism underlying hypothermia in which the neuroplasticity and rehabilitation were achieved after ischemic stroke. Our findings suggest that the RBM3-induce cold shock pathway is a potential target of hypothermia for neuroprotection and neurorehabilitation.

Intravascular hypothermia for cerebral ischemia after microsurgical clipping of complex MCA aneurysms

To analyze the effectiveness of intravascular hypothermia in patients with ischemic cerebrovascular accidents in early postoperative period after microsurgical clipping of complex MCA aneurysms. We present four patients with cerebral ischemia after microsurgical treatment of complex MCA aneurysms. In all cases, ischemic disorders developed immediately after surgery. We induced intravascular hypothermia 32-34 °C in all patients. CT-based volumetry of ischemia and edema foci was performed to objectively assess the dynamics of ischemic disorders. We carried out volumetry using segmentation of edema and ischemia foci (range 5-33 Hounsfield units). According to brain CT data, all four patients had enlargement of postoperative ischemic brain damage. Nevertheless, ICP was stable that made it possible to avoid decompressive craniotomy. Early hypothermia for acute ischemic injury after surgery for complex MCA aneurysms can reduce ischemic perifocal edema. This approach effectively reduces ICP and can exclude the need for decompressive craniotomy in some cases. No side effects of hypothermia justifies further research in this field.