Cerebral edema complicates the management of a wide range of afflictions of the central nervous system; indeed, our efforts to limit its damaging effects often supersede treatment of the underlying pathophysiology. While the commonly used treatment regimens of osmotic diuresis are well-described, and other options like decompressive hemicraniectomy in extreme cases continue to be debated, what's clear is that there is significant room for additional weaponry in our therapeutic arsenal. In April's Nature Medicine (12:433–40, 2006) Simard et al. give us a glimpse of how we may attack this pathologic entity in the coming years, extending their previous body of work in which they have characterized the nonselective NCCa-ATP channel (J Neurosci. 23:8568–8577, 2003), so named as it requires Ca2+ for opening and is activated by depletion of intracellular ATP; SUR1 forms its regulatory subunit and confers sensitivity to sulfonylurea inhibitors such as glibenclamide. Having demonstrated that opening of NCCa-ATP channels causes depolarization and membrane blebbing characteristic of cytotoxic edema, the authors hypothesized that newly-expressed NCCa-ATP channels could constitute a mechanism for Na+ flux required for edema formation. The NCCa-ATP channel was first discovered in hypoxic gliotic tissues; this, coupled with its activation by low intracellular AT P, suggested that other causes of hypoxia may trigger channel expression. As such, the authors investigated NCCa-ATP and SUR1 expression in a rat model of middle cerebral artery occlusion (MCAO), showing first that SUR1 is upregulated in the infarct core and later in the peri-infarct regions (Figure 1) in astrocytes, neurons, and endothelial cells; moreover, NCCa-ATP channels were upregulated in astrocytes and neurons, while KATP channels—with which SUR1 is also associated—were not, suggesting a specificity for NCCa-ATP channels in ischemia. They then showed that inhibiting the channel with glibenclamide reduced ion flow through this channel and prevented cell death. Lastly, they demonstrated the efficacy of subcutaneously- delivered glibenclamide at reducing brain water and infarct volume after stroke and extending animal survival in their rodent MCAO model (Figure 2). Taken together, they show increased expression of the NCCa-ATP channel and its regulatory subunit after stroke; that glibenclamide blocks conductance through this channel; and that blocking the channel in vivo after stroke limits the extent of cerebral edema, reduces infarct volume and spares the cortical ribbon, and improves animal survival.Figure 1: Increased SUR1 expression after middle cerebral artery occlusion.Figure 2: Reduced infarct volume in glib enclamide-treated animal (right) compared to control (left). Note cortical sparing.The therapeutic implications of this work are clear, particularly since glibenclamide has been used safely for decades in the treatment of NIDDM. Limiting cerebral edema by targeting the NCCa-ATP channel will have benefit not only in stroke but also in trauma and in a range of other conditions in which cerebral edema contributes to morbidity and mortality. IAN F. DUNN, M.D. ROBERT M. FRIEDLANDER, M.D., M.A. BASIC SCIENCE RESEARCH
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