Reduction Of Cerebral Edema Research Articles

The Effect of Early Beta-Blockade with Esmolol on Therapy Intensity Level in Adults with Severe Traumatic Brain Injury.

Following severe traumatic brain injury (TBI), elevated catecholamine levels are associated with worsened secondary brain injury and poorer clinical outcomes. The mechanisms are uncertain but may include cerebral ischemia and blood-brain barrier disruption, with consequent cerebral edema manifesting as intracranial hypertension. Early beta-blockade (EBB) may mitigate these detrimental hyperadrenergic effects. Therapy Intensity Level (TIL) is a validated score that quantifies intracranial pressure (ICP)-lowering interventions, with higher TIL being a surrogate for more severe intracranial hypertension. In this post hoc secondary analysis of a dose-finding study of EBB with esmolol in adults with TBI, we compared summary TIL (TIL24) and domain TIL between patients who received esmolol and those who did not. The primary outcome was TIL24 for each 24-h epoch of the esmolol intervention period of 96 h. Baseline characteristics were comparable in the esmolol (E) and non-esmolol (NE) groups. Mean TIL24 was similar in both groups up to 48 h but then diverged. The mean (standard deviation) TIL24 score between 48 and 72 h was 4.8 (1.5) in group E versus 6.6 (5.4) in group NE and at 72-96 h 4.5 (1.5) in group E versus 7.0 (4.0) in group NE. TIL domain scores were lower in group E for hyperosmolar therapy, targeted temperature management, and surgical management (cerebrospinal fluid drainage, evacuation, or decompressive craniectomy). The association between esmolol use after TBI and the reduction in ICP-directed interventions is consistent with an effect of beta-blockade on reduction of cerebral edema. Further research is necessary to determine causality and mechanism.

NK1 tachykinin receptor antagonist treatment reduces cerebral edema and intracranial pressure in an ovine model of ischemic stroke

Following ischemic stroke, substance P (SP)-mediated neurogenic inflammation is associated with profound blood-brain barrier (BBB) dysfunction, cerebral edema, and elevated intracranial pressure (ICP). SP elicits its effects by binding the neurokinin 1 tachykinin receptor (NK1-R), with administration of an NK1-R antagonist shown to ameliorate BBB dysfunction and cerebral edema in rodent and permanent ovine stroke models. Given the importance of reperfusion in clinical stroke, this study examined the efficacy of NK1-R antagonist treatment in reducing cerebral edema and ICP in an ovine model of transient middle cerebral artery occlusion (tMCAo). Anesthetized sheep (n = 24) were subject to 2-hours tMCAo and randomized (n = 6/group) to receive early NK1-R treatment (days 1–3 post-stroke), delayed NK1-R treatment (day 5 post-stroke), or saline vehicle. At 6-days post-stroke animals were re-anaesthetized and ICP measured, followed by MRI to evaluate infarction, edema and BBB dysfunction. Following both early and delayed NK1-R antagonist administration, ICP was significantly reduced on day 6 compared to vehicle animals (p < 0.05), accompanied by a reduction in cerebral edema, midline shift and BBB dysfunction (p < 0.05). This study demonstrates that NK1-R antagonist treatment is an effective novel therapy for cerebral edema and elevated ICP following stroke in an ovine model, warranting future clinical evaluation.

Application and mechanisms of Sanhua Decoction in the treatment of cerebral ischemia-reperfusion injury.

Cerebral ischemia-reperfusion is a process in which the blood supply to the brain is temporarily interrupted and subsequently restored. However, it is highly likely to lead to further aggravation of pathological damage to ischemic tissues or the nervous system., and has accordingly been a focus of extensive clinical research. As a traditional Chinese medicinal formulation, Sanhua Decoction has gradually gained importance in the treatment of cerebrovascular diseases. Its main constituents include Citrus aurantium, Magnolia officinalis, rhubarb, and Qiangwu, which are primarily used to regulate qi. In the treatment of neurological diseases, the therapeutic effects of the Sanhua Decoction are mediated via different pathways, including antioxidant, anti-inflammatory, and neurotransmitter regulatory pathways, as well as through the protection of nerve cells and a reduction in cerebral edema. Among the studies conducted to date, many have found that the application of Sanhua Decoction in the treatment of neurological diseases has clear therapeutic effects. In addition, as a natural treatment, the Sanhua Decoction has received widespread attention, given that it is safer and more effective than traditional Western medicines. Consequently, research on the mechanisms of action and efficacy of the Sanhua Decoctions in the treatment of cerebral ischemia-reperfusion injury is of considerable significance. In this paper, we describe the pathogenesis of cerebral ischemia-reperfusion injury and review the current status of its treatment to examine the therapeutic mechanisms of action of the Sanhua Decoction. We hope that the findings of the research presented herein will contribute to a better understanding of the efficacy of this formulation in the treatment of cerebral ischemia-reperfusion, and provide a scientific basis for its application in clinical practice.

(S)-roscovitine, a CDK inhibitor, decreases cerebral edema and modulates AQP4 and α1-syntrophin interaction on a pre-clinical model of acute ischemic stroke.

Cerebral edema is one of the deadliest complications of ischemic stroke for which there is currently no pharmaceutical treatment. Aquaporin-4 (AQP4), a water-channel polarized at the astrocyte endfoot, is known to be highly implicated in cerebral edema. We previously showed in randomized studies that (S)-roscovitine, a cyclin-dependent kinase inhibitor, reduced cerebral edema 48 h after induction of focal transient ischemia, but its mechanisms of action were unclear. In our recent blind randomized study, we confirmed that (S)-roscovitine was able to reduce cerebral edema by 65% at 24 h post-stroke (t test, p = .006). Immunofluorescence analysis of AQP4 distribution in astrocytes revealed that (S)-roscovitine decreased the non-perivascular pool of AQP4 by 53% and drastically increased AQP4 clusters in astrocyte perivascular end-feet (671%, t test p = .005) compared to vehicle. Non-perivascular and clustered AQP4 compartments were negatively correlated (R = -0.78; p < .0001), suggesting a communicating vessels effect between the two compartments. α1-syntrophin, AQP4 anchoring protein, was colocalized with AQP4 in astrocyte endfeet, and this colocalization was maintained in ischemic area as observed on confocal microscopy. Moreover, (S)-roscovitine increased AQP4/α1-syntrophin interaction (40%, MW p = .0083) as quantified by proximity ligation assay. The quantified interaction was negatively correlated with brain edema in both treated and placebo groups (R = -.57; p = .0074). We showed for the first time, that a kinase inhibitor modulated AQP4/α1-syntrophin interaction, and was implicated in the reduction of cerebral edema. These findings suggest that (S)-roscovitine may hold promise as a potential treatment for cerebral edema in ischemic stroke and as modulator of AQP4 function in other neurological diseases.

Combination of Baicalin and Gardenoside Mitigates Brain Damage by Lowering AQP-4 Expression Levels in Rat Model of Cerebral Ischemia/Reperfusion

This study focused on the effects of the combination of baicalin (BC) and gardenoside (GD) (7:3) on blood-brain barrier (BBB) permeability, brain tissue water content, and aquaporin-4 (AQP-4) expression in rats with cerebral ischemia-reperfusion (I/R) injury. The previous research conducted by the investigators demonstrated that the combination of BC and GD (7:3) has anti-ischemic properties. Further research was conducted to determine the mechanism underlying the reduction in cerebral edema.

Neuroprotective mechanisms of erythropoietin in a rat stroke model.

ObjectiveThis study was designed to investigate the indirect neuroprotective properties of recombinant human erythropoietin (rhEPO) pretreatment in a rat model of transient middle cerebral artery occlusion (MCAO).MethodsOne hundred and ten male Wistar rats were randomly assigned to four groups receiving either 5,000 IU/kg rhEPO intravenously or saline 15 minutes prior to MCAO and bilateral craniectomy or sham craniectomy. Bilateral craniectomy aimed at elimination of the space-consuming effect of postischemic edema. Diagnostic workup included neurological examination, assessment of infarct size and cerebral edema by magnetic resonance imaging, wet–dry technique, and quantification of hemispheric and local cerebral blood flow (CBF) by flat-panel volumetric computed tomography.ResultsIn the absence of craniectomy, EPO pretreatment led to a significant reduction in infarct volume (34.83 ± 9.84% vs. 25.28 ± 7.03%; p = 0.022) and midline shift (0.114 ± 0.023 cm vs. 0.083 ± 0.027 cm; p = 0.013). We observed a significant increase in regional CBF in cortical areas of the ischemic infarct (72.29 ± 24.00% vs. 105.53 ± 33.10%; p = 0.043) but not the whole hemispheres. Infarct size-independent parameters could not demonstrate a statistically significant reduction in cerebral edema with EPO treatment.ConclusionsSingle-dose pretreatment with rhEPO 5,000 IU/kg significantly reduces ischemic lesion volume and increases local CBF in penumbral areas of ischemia 24 h after transient MCAO in rats. Data suggest indirect neuroprotection from edema and the resultant pressure-reducing and blood flow-increasing effects mediated by EPO.

Abstract 103: Rewarming Speed Affects Cardiopulmonary and Neurological Functions After Deep Hypothermic Cardiac Arrest

Introduction: The optimal rewarming rate from accidental or induced deep hypothermia is still unknown. Fast extracorporeal rewarming by extracorporeal circulation has been associated with cardiac dysfunction, pulmonary edema and poor neurologic outcome. Hypothesis: This study investigates whether the speed of rewarming after deep hypothermic cardiac arrest has neurological and cardiopulmonary effects. Methods: Thirty male Sprague-Dawley adult rats (450-550g) were rapidly cooled (ice packs) until 15°C core body temperature. Deep hypothermic cardiac arrest was maintained for 60 min. Thereafter rats were randomised to receive slow (90 minutes) or fast (30 minutes) rewarming by cardiopulmonary bypass to a target temperature of 35°C. After 90 minutes of reperfusion all animals underwent hemodynamic assessment by biventricular pressure-volume analysis, brain MRI and heart, lungs and brain were collected. Results: Slow rewarming preserved cardiac systolic and diastolic functions, ventricular arterial coupling and endothelium dependent relaxation. Lung edema was attenuated after slow rewarming. Cardimyocytes pro-survival kinases ERK and Akt activation were significantly higher in the slow rewarming group. MRI demonstrated enhancement of cerebral blood flow and reduction of cerebral edema after slow rewarming. Neurologic inflammatory response measured by IL-6, ICAM-1, CCL5 and TNF-α expression was significantly decreased in the slow rewarming group. Oxidative stress assessed by malondialdehyde was significantly reduced after slow rewarming. Conclusion: Slow rewarming by extracorporeal circulation after deep hypothermic cardiac arrest might improve systolic and diastolic function, preserve ventricular-arterial coupling, attenuate cerebral perfusion impairment and reduce neuronal damage.

Protective Effect of Diphenhydramine against Traumatic Brain Injury in Rats via Modulation of Oxidative Stress and Inflammation

Background: Traumatic brain injury (TBI) is considered a major burden across the globe affecting both individuals and their families. Therefore, the present study was conducted to determine the protective effect of diphenhydramine (DPM) against TBI in experimental rats. Methods: The effect of DPM was evaluated on the cerebral edema (CE) and neuronal degeneration after the induction of experimental brain injury in rats. The effect of DPM was also investigated on the inflammatory cytokines, for example, tumor necrosis factor-α and interleukin 1β and oxidative stress markers, such as malondialdehyde, superoxide dismutase, and glutathione peroxidase. Western blot analysis was used to investigate the effect of DPM on B-cell lymphoma 2 (Bcl-2), Bcl-2-associated X protein (Bax) and cleaved caspase-3. Results: Results of the study suggest that DPM causes reduction in CE and prevents neuronal degeneration. It also causes reduction in inflammation and oxidative stress in a dose-dependent manner. The level of Bax was found to be elevated, together with reduction in the Bcl-2 level in the DPM-treated group. Conclusion: DPM exerts a neuroprotective effect after TBI via the attenuation of oxidative stress, inflammation, and mitochondrial apoptosis pathways.

GM-CSF Blockade during Chimeric Antigen Receptor T-Cell (CART) Therapy Reduces Cytokine Release Syndrome and Neurotoxicity and May Enhance CART Effector Functions

Chimeric antigen receptor T-cell therapy (CART) is limited by the development of cytokine release syndrome (CRS) and neurotoxicity (NT). CRS is related to extreme elevation of cytokines and massive T cell expansion. Preliminary studies suggest that NT might be mediated by myeloid cells that cross the blood brain barrier. This is supported by correlative analysis from CART19 pivotal trials where CD14+ cell numbers were increased in the cerebrospinal fluid of patients that developed severe NT (Locke et al, ASH 2017). Thus, we aimed to investigate the role of GM-CSF neutralization in preventing CRS and NT after CART cell therapy via monocyte control. The human GM-CSF neutralizing antibody lenzilumab (Humanigen, Burlingame, California), which has been shown to be safe in phase II clinical trials, does not impair CART cell function in vitro (10 ug/mL) when CART19 cells are stimulated with the CD19+ Luciferase+ acute lymphoblastic leukemia (ALL) cell line NALM6. Lenzilumab results in enhanced CART cell antigen specific proliferation in the presence of monocytes. In vivo, NOD-SCID-g−/− mice were engrafted with high disease burdens of NALM6 and treated with low doses of CART19 or control T cells, in combination with lenzilumab or isotype control antibody. The combination of CART19 and lenzilumab does not impair CART cell activity in vivo (Fig 1A). The impact of GM-CSF neutralization on CART toxicities in a novel patient derived xenograft model was explored. NOD-SCID-g−/− mice were engrafted with primary ALL blasts (1-3 × 106 cells). Mice were treated with high doses of CART19 cells (2-5 × 106 iv) and developed CART cell related toxicities. The combination of CART19, lenzilumab (to neutralize human GM-CSF), and murine GM-CSF blocking antibody (to neutralize mouse GM-CSF) resulted in prevention of weight loss (Fig 1B), decrease in critical myeloid cytokines (Fig 1C-D), reduction of cerebral edema (Fig 1E), enhanced leukemic disease control in the brain (Fig 1F), and reduction in brain macrophages (Fig 1G). As CRISPR/Cas9 gene editing of the GM-CSF gene during the process of CART cell manufacturing would result in CART cells with innately reduced secretion of GM-CSF, we designed guide RNA targeting exon 3 of the GM-CSF gene to generate GM-CSFk/o CART19 cells. These CARTs produce significantly less GM-CSF upon activation but other T cell cytokine production is not inhibited (Fig 1H). Using the NALM6 high tumor burden relapse xenograft model as described above, GM-CSFk/o CART19 cells resulted in slightly enhanced disease control compared to CART19 cells (Fig 1I). These studies illuminate a novel approach to abrogate NT and CRS through GM-CSF blockade that also potentially enhances CART cell functions. Based on these results, we have designed a phase II clinical trial using lenzilumab as a modality to prevent CART related toxicities in patients with diffuse large B cell lymphoma.

GM-CSF Blockade during Chimeric Antigen Receptor T Cell Therapy Reduces Cytokine Release Syndrome and Neurotoxicity and May Enhance Their Effector Functions

▪Despite its efficacy, chimeric antigen receptor T-cell therapy (CART) is limited by the development of cytokine release syndrome (CRS) and neurotoxicity (NT). While CRS is related to extreme elevation of cytokines and massive T cell expansion, the exact mechanisms for NT have not yet been elucidated. Preliminary studies suggest that NT might be mediated by myeloid cells that cross the blood brain barrier. This is supported by correlative analysis from CART19 pivotal trials where CD14+ cell numbers were increased in the cerebrospinal fluid of patients that developed severe NT (Locke et al, ASH 2017). Therefore, we aimed to investigate the role of GM-CSF neutralization in preventing CRS and NT after CART cell therapy via monocyte control.First, we investigated the effect of GM-CSF blockade on CART cell effector functions. Here, we used the human GM-CSF neutralizing antibody (lenzilumab, Humanigen, Burlingame, California) that has been shown to be safe in phase II clinical trials. Lenzilumab (10 ug/kg) neutralizes GM-CSF when CART19 cells are stimulated with the CD19+ Luciferase+ acute lymphoblastic leukemia (ALL) cell line NALM6, but does not impair CART cell function in vitro. We have found that malignancy associated macrophages reduce CART proliferation. GM-CSF neutralization with lenzilumab results in enhanced CART cell antigen specific proliferation in the presence of monocytes. To confirm this in vivo, NOD-SCID-g-/- mice were engrafted with high disease burdens of NALM6 and treated with low doses of CART19 or control T cells (to induce tumor relapse), in combination with lenzilumab or isotype control antibody. The combination of CART19 and lenzilumab resulted in significant anti-tumor activity and overall survival benefit compared to control T cells (Fig 1A), similar to mice treated with CART19 combined with isotype control antibody, indicating that GM-CSF neutralization does not impair CART cell activity in vivo. This anti-tumor activity was validated in an ALL patient derived xenograft model.Next, we explored the impact of GM-CSF neutralization on CART cell related toxicities in a novel patient derived xenograft model. Here, NOD-SCID-g-/- mice were engrafted with leukemic blasts (1-3x106 cells) derived from patients with high risk ALL. Mice were then treated with high doses of CART19 cells (2-5x106 intravenously). Five days after CART19 treatment, mice began to develop progressive motor weakness, hunched bodies, and weight loss that correlated with massive elevation of circulating human cytokine levels. Magnetic Resonance Imaging (MRI) of the brain during this syndrome showed diffuse enhancement and edema, associated with central nervous system (CNS) infiltration of CART cells and murine activated myeloid cells. This is similar to what has been reported in CART19 clinical trials in patients with severe NT. The combination of CART19, lenzilumab (to neutralize human GM-CSF) and murine GM-CSF blocking antibody (to neutralize mouse GM-CSF) resulted in prevention of weight loss (Fig 1B), decrease in critical myeloid cytokines (Fig 1C-D), reduction of cerebral edema (Fig 1E), enhanced leukemic disease control in the brain (Fig 1F), and reduction in brain macrophages (Fig 1G).Finally, we hypothesized that disrupting GM-CSF through CRISPR/Cas9 gene editing during the process of CART cell manufacturing would result in functional CART cells with reduced secretion of GM-CSF. We designed guide RNA targeting exon 3 of the GM-CSF gene and generated GM-CSFk/o CART19 cells. Our preliminary data suggest that these CARTs produce significantly less GM-CSF upon activation but continue to exhibit similar production of other cytokines and exhibit normal effector functions in vitro (Fig 1H). Using the NALM6 high tumor burden relapse xenograft model as described above, GM-CSFk/o CART19 cells resulted in slightly enhanced disease control compared to CART19 cells (Fig 1I).Thus, modulating myeloid cell behavior through GM-CSF blockade can help control CART mediated toxicities and may reduce their immunosuppressive features to improve leukemic control. These studies illuminate a novel approach to abrogate NT and CRS through GM-CSF neutralization that also potentially enhances CART cell functions. Based on these results, we have designed a phase II clinical trial using lenzilumab as a modality to prevent CART related toxicities in patients with diffuse large B cell lymphoma. DisclosuresAhmed:Humanigen: Employment. Sahmoud:Humanigen: Employment. Durrant:Humanigen: Employment. Russell:Vyriad: Equity Ownership. Kay:Morpho-sys: Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Tolero Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Membership on an entity's Board of Directors or advisory committees; Agios Pharm: Membership on an entity's Board of Directors or advisory committees; Cytomx Therapeutics: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees; Infinity Pharm: Membership on an entity's Board of Directors or advisory committees; Acerta: Research Funding. Kenderian:Novartis: Patents & Royalties; Tolero Pharmaceuticals: Research Funding; Humanigen: Research Funding.

METABOLIC CORRECTION OF CEREBRAL DISORDERS IN ACUTE OBSTRUCTIVE CHOLESTASIS (EXPERIMENTAL STUDY)

Aim. To research cerebral functional and structural disorders in acute obstructive cholestasis and possibilities of their metabolic correction. Material and Methods. Acute obstructive cholestasis was simulated by common bile duct compression in 26 anesthetized dogs which were divided into three series. The first group included cholestasis dogs without treatment. In the second group common bile duct (CBD) was decompressed in 3 days postoperatively and 0.9% sodium chloride solution (20 ml / kg) was administered for 5 days. In the 3 rd group Mexidol® (6.5 mg / kg) and Cortexin® (10 mg / kg) were injected additionally after CBD decompression. In blood plasma and cerebral homogenate malondialdehyde (MDA) and catalase levels were determined. Brain tissue histological investigation was performed with 200x and 400x magnification. Results. In the 1 st series on the 10 th day MDA and catalase levels in cerebral homogenate were 4.1 times higher and 4.3 times lower than those in control animals. Structural changes were presented by perivascular and pericellular edema, reduction of capillary volume, vacuolization and atrophy of neurons. In the 2 nd series there were 2.15-fold and 1.2-fold decrease of MDA in systemic circulation and in cerebral tissue respectively. Catalase activity was increased up to 1.36 and 1.22 times (p &gt; 0.05) accordingly. Cerebral structural disorders were the same. In the 3rd series there were 2.91-fold and 3.77-fold decrease of MDA in systemic circulation and in cerebral homogenate respectively in 10 days postoperatively. Catalase activity was increased up to 1.57 and 4.76 times (p &lt; 0.001) accordingly. Structural normalization was accompanied by increase of microcirculatory volume, elimination of vacuolization and atrophy of neurons, reduction of cerebral edema. Conclusion. Mexidol® and Cortexin® reduce significantly the processes of free-radical oxidation in the brain and contributes to normalization of structural disorders.

Delayed Administration of BQ788, an ETB Antagonist, after Experimental Traumatic Brain Injury Promotes Recovery of Blood-Brain Barrier Function and a Reduction of Cerebral Edema in Mice.

Traumatic brain injury (TBI) is induced by immediate physical disruption of brain tissue, and causes death and disability. Studies on experimental TBI animal models show that disruption of the blood-brain barrier (BBB) underlies brain edema and neuroinflammation during the delayed phase of TBI. In neurological disorders, endothelin-1 (ET-1) is involved in BBB dysfunction and brain edema. In this study, the effect of ET antagonists on BBB dysfunction and brain edema were examined in a mouse focal TBI model using lateral fluid percussion injury (FPI). ET-1 and ETB receptors were increased at 2-7 days after FPI, which was accompanied by extravasation of Evans blue (EB) and brain edema. Repeated intracerebroventricular administration of BQ788 (15 nmol/day), an ETB antagonist, from 2 days after FPI promoted recovery of EB extravasation and brain edema, while FR 139317, an ETA antagonist, had no effect. Delayed intravenous administration of BQ788 also promoted recovery from FPI-induced EB extravasation and brain edema. While FPI caused decreases in claudin-5, occludin, and zonula occludens-1 proteins, BQ788 reversed FPI-induced reductions of them. Immunohistochemical observation of the cerebrum after FPI showed that ETB receptors are predominantly expressed in glial fibrillary acidic protein (GFAP)-positive astrocytes. BQ788 reduced FPI-induced increases in GFAP-positive astrocytes. GFAP-positive astrocytes produced vascular endothelial growth factor-A (VEGF-A) and matrix metalloproteinase-9 (MMP9). FPI-induced increases in VEGF-A and MMP-9 production were reversed by BQ788. These results suggest that ETB receptor antagonism during the delayed phase of focal TBI promotes recovery of BBB function and reduction of brain edema.

Thrombospondin‐1 Contributes to Hepatic Pathology and Systemic Complications in the Acetaminophen and Azoxymethane Mouse Models of Acute Liver Failure

IntroductionAcute liver failure results from a significant loss of liver function and has few effective treatments and poor clinical outcomes. Numerous systemic complications can occur following acute liver failure though the development of neurological complications, a disease state called hepatic encephalopathy, greatly increases mortality. Previously we have demonstrated that transforming growth factor beta 1 (TGFβ1) is upregulated during acute liver failure and promotes disease progression. TGFβ1 requires interactions with other proteins, such as thrombospondin‐1 (TSP‐1), to become activated and be capable of binding its receptors. Therefore, we hypothesize that TSP‐1 contributes to acute liver failure disease progression through its activation of TGFβ1.MethodsMale C57Bl/6 mice or TSP‐1 knockout mice were injected with acetaminophen (APAP; 300 and 600 mg/kg) to generate acute liver injury or azoxymethane, (AOM; 100 mg/kg) to induce acute liver failure and hepatic encephalopathy. APAP‐treated mice had serum and liver collected at 6 hours and 24 hours post injection while AOM‐treated mice had serum, liver and brain collected once at coma. Liver pathology was assessed in both models by H&amp;E staining, cytokine ELISAs and reactive oxygen species (ROS), reactive nitrogen species (RNS), nitrotyrosine and transaminase assessments. Hepatic glutathione concentrations were assessed in APAP‐treated mice using a fluorometic assay. TGFβ1 and TSP‐1 expression was assessed by immunoblotting, immunohistochemistry, ELISA and/or real‐time PCR in both models. In AOM‐treated mice, cognitive impairment was monitored by assessment of reflex responses and ataxia and cerebral edema, microglia activation and neuroinflammation via cytokine ELISAs.ResultsMice injected with AOM or APAP had elevated hepatic TGFβ1 and TSP‐1 levels, which colocalized primarily to hepatocytes. AOM and APAP‐treated mice with genetic knockout of TSP‐1 had reduced hepatocyte necrosis, injury and oxidative stress compared to wildtype controls as assessed by H&amp;E staining, ROS, RNS and serum transaminase concentrations. Levels of hepatic and circulating proinflammatory cytokines were also reduced in both models in TSP‐1 knockout mice compared to wildtype controls. APAP‐treated mice had reduced glutathione concentrations that were increased in TSP‐1 knockout mice. AOM‐treated TSP‐1 knockout mice also had delayed development of hepatic encephalopathy as indicated by a delay in the time to coma, a reduction in cerebral edema, attenuated microglia activation, and reduced neuroinflammation compared to wildtype controls.ConclusionsStrategies employed to reduce TSP‐1 signaling in APAP‐treated mice reduced liver damage and pathology while AOM‐treated mice had reduced liver damage, neuroinflammation and improved neurological outcomes. Therefore, targeting TSP‐1 signaling may be a novel therapeutic target for the management of acute liver failure and/or hepatic encephalopathy.Support or Funding InformationThe study was funded by a VA Career Development Award‐2 (BX003486‐01) from the United States Department of Veterans Affairs Biomedical Laboratory Research and Development Service (BLR&amp;D) to Dr. McMillin, an NIH R01 award (DK082435) to Dr. DeMorrow and a VA Merit award (BX002638‐01) from the United States Department of Veterans Affairs BLR&amp;D to Dr. DeMorrow. This material is the result of work supported with resources and the use of facilities at the Central Texas Veterans Health Care System, Temple, Texas. The views are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

29 Trans Sodium Crocetinate: A Novel Kosmotropic Molecule that Enhances Oxygen Diffusion in the Treatment of Hypoxia-Driven Medical Emergencies

Tissue-hypoxia directly contributes to underlying morbidity and mortality of the top 5 leading causes of death in the US which include heart disease, cancer, chronic lower respiratory diseases, accidents (unintentional injuries) and cerebrovascular accidents. These conditions frequently present as medical emergencies requiring urgent intervention which occurs either at home, site of an accident, in an ambulance or in the emergency department. Currently, aside from oxygen therapy, there are no effective therapies approved available to reverse hypoxia and its potentially catastrophic consequences. Trans sodium crocetinate (TSC) is a kosmotrope that was developed to treat oxygen deficits in emergency cases. TSC is based on a novel mechanism of action, that of increasing the diffusion of oxygen from the erythrocytes through the plasma to the vascular wall, thereby increasing the gradient for oxygen diffusion to hypoxic tissues. The increase in the diffusion rate is caused by the influence of the intermolecular forces of the TSC molecule on the water molecules: it increases the numbers of hydrogen bonds among them. The initial investigation of TSC was part of the Battlefield Casualty Program of the US Office of Naval Research and was further developed by Diffusion Pharmaceuticals Inc. To assess the effect of treating hypoxic emergency, TSC was evaluated preclinically in animal models of three common medical emergencies; namely hemorrhagic shock, myocardial infarction and stroke. The results are summarized below: Hemorrhagic shock resulting from severe blood loss. After inducing 60% loss in estimated blood volumes in rats, studies showed that treatment with TSC; a) increased whole body oxygen consumption, b) increased blood pressure, c) preserved organ function as reflected by liver enzymes and d) resulted in 100% survival at 24 hours compared to 15% in saline treated controls. Myocardial infarction. Studies of coronary artery ligation in a swine model showed that treatment with TSC conferred a 90% survival at 4 hours compared to 33% in controls. Stroke. Studies in both rats (3 vessel occlusion: two carotids and left middle cerebral arteries) and rabbits (injection of blood clots) showed improved neuronal preservation in animals treated with TSC compared to controls in ischemic stroke. Further, studies in rats injected with collagenase to induce hemorrhagic stroke showed an increase in live neurons and a reduction in cerebral edema in TSC treated animals compared to controls. To date, about 150 patients have received TSC in clinical trials without any serious side effects attributed to TSC. TSC is currently being developed to treat hypoxia in patients with cancer. TSC appears to be a safe and potentially beneficial treatment for hypoxia related conditions. Furthermore, compelling preclinical data call for urgent clinical investigation of TSC in hypoxia related medical emergencies.

Reduction of Cerebral Edema via an Osmotic Transport Device Improves Functional Outcome after Traumatic Brain Injury in Mice.

Traumatic brain injury (TBI), the foremost cause of morbidity and mortality in persons under 45 years of age worldwide, leads to about 200,000 victims requiring hospitalization and approximately 52,000 deaths per year in the United States. TBI is characterized by cerebral edema leading to raised intracranial pressure, brain herniation, and subsequent death. Current therapies for TBI treatment are often ineffective, thus novel therapies are needed. Recent studies have shown that an osmotic transport device (OTD) is capable of reducing brain water content and improving survival in mice with severe cerebral edema. Here we compare the effects of a craniectomy and an OTD plus craniectomy on neurological function in mice after TBI. Animals treated with a craniectomy plus an OTD had significantly better neurological function 2 days after TBI compared with those treated with craniectomy only. This study suggests that an OTD for severe brain swelling may improve patient functional outcome. Future studies include a more comprehensive neurological examination, including long-term memory tests.

Radiosurgery for brain metastases and cerebral edema

The objective of this study was to assess reduction in cerebral edema following linear accelerator radiosurgery (LINAC) as first line therapy for brain metastasis. We reviewed the medical records of all patients who underwent LINAC radiosurgery for brain metastasis at our institution during 2010–2012, and who had not previously undergone either surgery or whole brain radiotherapy. Data were analyzed for 55 brain metastases from 46 patients (24 males), mean age 59.9years. During the 2months following LINAC radiosurgery, the mean steroid dose decreased from 4.8 to 2.6mg/day, the mean metastasis volume decreased from 3.79±4.12cc to 2.8±4.48cc (p=0.001), and the mean edema volume decreased from 16.91±30.15cc to 12.85±24.47cc (p=0.23). The 17 patients with reductions of more than 50% in brain edema volume had single metastases. Edema volume in the nine patients with two brain metastases remained stable in five patients (volume change <10%, 0–2cc) and increased in four patients (by >10%, 2–14cc). In a subanalysis of eight metastases with baseline edema volume greater than 40cc, edema volume decreased from 77.27±37.21cc to 24.84±35.6cc (p=0.034). Reductions in brain edema were greater in metastases for which non-small-cell lung carcinoma and breast cancers were the primary diseases. Overall, symptoms improved in most patients. No patients who were without symptoms or who had no signs of increased intracranial pressure at baseline developed signs of intracranial pressure following LINAC radiosurgery. In this series, LINAC stereotactic radiosurgery for metastatic brain lesions resulted in early reduction in brain edema volume in single metastasis patients and those with large edema volumes, and reduced the need for steroids.

Reduction of cerebral edema after traumatic brain injury using an osmotic transport device.

Traumatic brain injury (TBI) is significant, from a public health standpoint, because it is a major cause of the morbidity and mortality of young people. Cerebral edema after a TBI, if untreated, can lead to devastating damage of the remaining tissue. The current therapies of severe TBI (sTBI), as outlined by the Brain Trauma Foundation, are often ineffective, thus a new method for the treatment of sTBI is necessary. Herein, the reduction of cerebral edema, after TBI, using an osmotic transport device (OTD) was evaluated. Controlled cortical impact (CCI) was performed on adult female CD-1 mice, and cerebral edema was allowed to form for 3 h, followed by 2 h of treatment. The treatment groups were craniectomy only, craniectomy with a hydrogel, OTD without bovine serum albumin (BSA), and OTD. After CCI, brain water content was significantly higher for animals treated with a craniectomy only, craniectomy with a hydrogel, and OTD without BSA, compared to that of control animals. However, when TBI animals were treated with an OTD, brain water content was not significantly higher than that of controls. Further, brain water content of TBI animals treated with an OTD was significantly reduced, compared to that of untreated TBI animals, TBI animals treated with a craniectomy and a hydrogel, and TBI animals treated with an OTD without BSA. Here, we demonstrate the successful reduction of cerebral edema, as determined by brain water content, after TBI using an OTD. These results demonstrate proof of principle for direct water extraction from edematous brain tissue by direct osmotherapy using an OTD.

Cerebroprotective effect of Eclipta alba against global model of cerebral ischemia induced oxidative stress in rats

Oxidative stress is believed to contribute to neuronal damage induced by cerebral ischemia/reperfusion (I/R) injury. The present study was undertaken to evaluate the possible cerebroprotective and antioxidant effect of hydroalcoholic extract of Eclipta alba against global cerebral ischemia in the rat. Adult Wistar albino rats were treated with extract of Eclipta alba (250 and 500mg/kg/day, p.o.) for 10 days. The global cerebral ischemia–reperfusion injury was induced by occluding bilateral common carotid arteries (BCCA) for 30min, followed by 4h reperfusion. Quercetin (20mg/kg, i.p.) was used for the reference compound. After that, animals were sacrificed by decapitation, brain was removed, various biochemical estimations, cerebral edema, assessment of cerebral infarct size, and histopathological examinations were carried out. BCCA caused significant depletion in superoxide dismutase (SOD), glutathione peroxidase (GPx), reduced glutathione (GSH), catalase (CAT), glutahione-S-transferase (GST), glutathione ruductase (GR) and significant increase in malondialdehyde (MDA) in brain. Pretreatment with hydroalcoholic extract of Eclipta alba significantly reversed the levels of biochemical parameters and significantly reduced the edema and cerebral infarct size as compared to the ischemic control group. Eclipta alba at higher dose markedly reduced ischemia-induced neuronal loss of the brain. Reduction of cerebral edema, an early symptom of ischemia, is one of the most important remedies for reducing subsequent chronic neural damage in stroke. The results of the study show that Eclipta alba pretreatment ameliorates cerebral ischemia/reperfusion injury and enhances the antioxidant defense against BCCA occlusion induced I/R in rats; so it exhibits cerebroprotective property. HPLC fingerprint of hydroalcoholic extract of Eclipta alba was performed for conforming the coumestan present in the plant extract.

TT-301 Inhibits Microglial Activation and Improves Outcome after Central Nervous System Injury in Adult Mice

Microglial inhibition may reduce secondary tissue injury and improve functional outcome following acute brain injury. Utilizing clinically relevant murine models of traumatic brain injury and intracerebral hemorrhage, neuroinflammatory responses and functional outcome were examined in the presence of a potential microglial inhibitor, TT-301. TT-301 or saline was administered following traumatic brain injury or intracerebral hemorrhage, and then for four subsequent days. The effect of TT-301 on neuroinflammatory responses and neuronal viability was assessed, as well as short-term vestibulomotor deficit (Rotorod) and long-term neurocognitive impairment (Morris water maze). Finally differential gene expression profiles of mice treated with TT-301 were compared with those of vehicle. Reduction in F4/80+ staining was demonstrated at 1 and 10 days, but not 28 days, after injury in mice treated with TT-301 (n = 6). These histologic findings were associated with improved neurologic function as assessed by Rotorod, which improved by 52.7% in the treated group by day 7, and Morris water maze latencies, which improved by 232.5% as a function of treatment (n = 12; P < 0.05). Similar benefit was demonstrated following intracerebral hemorrhage, in which treatment with TT-301 was associated with functional neurologic improvement of 39.6% improvement in Rotorod and a reduction in cerebral edema that was independent of hematoma volume (n = 12; P < 0.05). Differential gene expression was evaluated following treatment with TT-301, and hierarchical cluster analysis implicated involvement of the Janus kinase-Signal Transducer and Activator of Transcription pathway after administration of TT-301 (n = 3/group). Modulation of neuroinflammatory responses through TT-301 administration improved histologic and functional parameters in murine models of acute neurologic injury.

Hypothermia after aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is a common and frequently devastating condition, accounting for 1 to 7% of all strokes with an incidence of 9.1 per 100,000 [1]. Major advances in SAH management over the past three decades have decreased case fatality by 0.8% per year, but it is still 40% and many survivors have long-term disabilities [2]. The most important and potentially treatable complication is development of delayed cerebral ischemia (DCI), which can progress to cerebral infarction associated with poor outcome. The pathogenesis of DCI is multifactorial and assumed to be initiated in the early phase of SAH [3]. The onset of SAH is characterized by a short-lasting and cerebral perfusion pressure (CPP)-dependent decrease in cerebral blood flow (CBF) leading to global cerebral ischemia [4]. Elevated intracranial pressure (ICP) and acute cerebral ischemia are the main factors for early disruption of the blood-brain barrier as well as impairment of autoregulation associated with brain edema and brain swelling. Important pathogenic mechanisms of CPP-independent hypoperfusion include acute vasoconstriction, cortical spreading ischemia, and activation of the inflammatory response. The release of oxyhemoglobin and endothelin-1 (ET-1) are the key factors for cortical spreading ischemia, reduced nitric oxide (NO) availability, and secondary cytotoxic edema formation. Cerebral vasospasm (CVS) is a delayed morphological narrowing of cerebral arteries, occurring 4 to 10 days after SAH. Although CVS have been associated with DCI, it is generally accepted that CVS is not solely responsible for DCI [5]. In fact, DCI may occur in the absence of CVS and vice versa and the distribution of CVS may fail to reliably predict the subsequent pattern of cerebral infarction [6]. Neuroprotective strategies to prevent DCI have been mainly focused on treatment of CVS, but despite extensive research, effective and/or causative prophylaxis and treatment are not available [7]. So far, oral nimodipine is the only drug that can reduce the incidence of DCI and poor outcome, but there is no beneficial effect on CVS [8]. Hypothermia (HT) treatment exerting numerous protective effects such as a decrease in cerebral metabolism [9], stabilization of the blood-brain barrier [10], reduction of cerebral edema [11], suppression of excitatory neurotransmitter concentrations [12] and inflammatory reactions [13] seems to be well suited as a neuroprotective strategy. In the following, the clinical application of HT after SAH is presented by reviewing the existing literature.