Brain Tolerance Research Articles

Brain Ischemic Tolerance Triggered by Preconditioning Involves Modulation of Tumor Necrosis Factor-α-Stimulated Gene 6 (TSG-6) in Mice Subjected to Transient Middle Cerebral Artery Occlusion.

Ischemic preconditioning (PC) induced by a sub-lethal cerebral insult triggers brain tolerance against a subsequent severe injury through diverse mechanisms, including the modulation of the immune system. Tumor necrosis factor (TNF)-α-stimulated gene 6 (TSG-6), a hyaluronate (HA)-binding protein, has recently been involved in the regulation of the neuroimmune response following ischemic stroke. Thus, we aimed at assessing whether the neuroprotective effects of ischemic PC involve the modulation of TSG-6 in a murine model of transient middle cerebral artery occlusion (MCAo). The expression of TSG-6 was significantly elevated in the ischemic cortex of mice subjected to 1 h MCAo followed by 24 h reperfusion, while this effect was further potentiated (p < 0.05 vs. MCAo) by pre-exposure to ischemic PC (i.e., 15 min MCAo) 72 h before. By immunofluorescence analysis, we detected TSG-6 expression mainly in astrocytes and myeloid cells populating the lesioned cerebral cortex, with a more intense signal in tissue from mice pre-exposed to ischemic PC. By contrast, levels of TSG-6 were reduced after 24 h of reperfusion in plasma (p < 0.05 vs. SHAM), but were dramatically elevated when severe ischemia (1 h MCAo) was preceded by ischemic PC (p < 0.001 vs. MCAo) that also resulted in significant neuroprotection. In conclusion, our data demonstrate that neuroprotection exerted by ischemic PC is associated with the elevation of TSG-6 protein levels both in the brain and in plasma, further underscoring the beneficial effects of this endogenous modulator of the immune system.

Preservatives for postmortem brain tissue in biomechanical testing: A pilot study.

Postmortem human subject (PMHS) studies are essential to brain injury research in motor vehicle safety. However, postmortem deterioration reduces the similarity between postmortem test results and invivo response in material testing of brain tissue and in biomechanical testing of the whole head. This pilot study explores the effect of potential preservatives on brain tissue breakdown to identify promising preservatives that warrant further investigation. To identify preservatives with potential to slow postmortem degradation, samples from an initial PMHS were refrigerated at 10°C to qualitatively compare tissue breakdown from 58 to 152 h postmortem after storage in candidate solutions. On brain tissue samples from a second PMHS, compressive stiffness was measured on six samples immediately after harvest for comparison to the stiffness of 23 samples that were stored at 10°C in candidate solutions for 24 h after harvest. The candidate solutions were artificial cerebrospinal fluid (ACSF) without preservatives; ACSF with a combination of antibiotics and antifungal agents; ACSF with added sodium bicarbonate; and ACSF with both the antibiotic/antifungal combination and sodium bicarbonate. Results were analyzed using multiple linear regression of specimen stiffness on harvest lobe and storage solution to investigate potential differences in tissue stiffness. Qualitative evaluation suggested that samples stored in a solution that contained both the antibiotic/antifungal combination and sodium bicarbonate exhibited less evidence of tissue breakdown than the samples stored without preservatives or with only one of those preservatives. In compression testing, samples tested immediately after harvest were significantly stiffer than samples tested after 24 h of storage at 10°C in ACSF (difference: -0.27 N/mm, 95% confidence interval (CI): -0.50, -0.05) or ACSF with antibiotics/antifungal agents (difference: -0.32 N/mm, 95% CI: -0.59, -0.04), controlling for harvest lobe. In contrast, the stiffness of samples tested after storage in either solution containing sodium bicarbonate was not significantly different from the stiffness of samples tested at harvest. There was no significant overall difference in the mean tissue stiffness between samples from the frontal and parietal lobes, controlling for storage solution. Given the importance of PMHS studies to brain injury research, any strategy that shows promise for helping to maintain invivo brain material properties has the potential to improve understanding of brain injury mechanisms and tolerance to head injury and warrants further investigation. These pilot study results suggest that sodium bicarbonate has the potential to reduce the deterioration of brain tissue in biomechanical testing. The results motivate further evaluation of sodium bicarbonate as a preservative for biomechanical testing using additional test subjects, more comprehensive material testing, and evaluation under a broader set of test conditions including in whole-head testing. The effect of antibiotics and antifungal agents on brain tissue stiffness was minimal but may have been limited by the cold storage conditions in this study. Further exploration of the potential for microbial agents to preserve tissue postmortem would benefit from evaluation of the effects of storage temperature.

Molecular Mechanisms of Neuroprotection after the Intermittent Exposures of Hypercapnic Hypoxia.

The review introduces the stages of formation and experimental confirmation of the hypothesis regarding the mutual potentiation of neuroprotective effects of hypoxia and hypercapnia during their combined influence (hypercapnic hypoxia). The main focus is on the mechanisms and signaling pathways involved in the formation of ischemic tolerance in the brain during intermittent hypercapnic hypoxia. Importantly, the combined effect of hypoxia and hypercapnia exerts a more pronounced neuroprotective effect compared to their separate application. Some signaling systems are associated with the predominance of the hypoxic stimulus (HIF-1α, A1 receptors), while others (NF-κB, antioxidant activity, inhibition of apoptosis, maintenance of selective blood-brain barrier permeability) are mainly modulated by hypercapnia. Most of the molecular and cellular mechanisms involved in the formation of brain tolerance to ischemia are due to the contribution of both excess carbon dioxide and oxygen deficiency (ATP-dependent potassium channels, chaperones, endoplasmic reticulum stress, mitochondrial metabolism reprogramming). Overall, experimental studies indicate the dominance of hypercapnia in the neuroprotective effect of its combined action with hypoxia. Recent clinical studies have demonstrated the effectiveness of hypercapnic-hypoxic training in the treatment of childhood cerebral palsy and diabetic polyneuropathy in children. Combining hypercapnic hypoxia with pharmacological modulators of neuro/cardio/cytoprotection signaling pathways is likely to be promising for translating experimental research into clinical medicine.

TMIC-75. SPATIALLY-RESOLVED TRANSCRIPTOME ANALYSIS OF BRAIN METASTATIC BREAST CANCER REVEAL KEY MEDIATORS OF BRAIN-TROPIC METASTATIC POTENTIAL

Abstract BACKGROUND In women with metastatic breast cancer, 30% (HER2+) to 50% (triple negative) develop brain metastases. Breast-to-brain metastasis carries a poor median survival of only 10 months and is accompanied by severe neurologic decline. Halting the progression of breast cancer brain metastases requires modulation of the tumor microenvironment (TME), yet little is known about how the primary breast TME affects brain tropism, or how, once there, metastatic cancer cells interact with normal brain cells (e.g., neurons, astrocytes, microglia). METHODS We constructed a large (n = 253 cores), diverse, clinically-annotated tissue microarray (TMA) of breast cancer brain metastases with surrounding brain (n = 127), associated primary breast tumors (n = 67, with 30 matched), normal brain (n = 23), and staining control (n = 18) tissue samples, from patients (n = 140) treated at Stanford Hospital between 2008 – 2018. We then leveraged a combination of genome-wide transcriptome analysis and high resolution spatial imaging (using GeoMx Digital Spatial Profiling) to interrogate the distinct, spatially-driven gene signatures of tumor, immune, and normal brain cells within the breast cancer brain metastasis TME. RESULTS We revealed novel gene regulatory programs that are associated with metastatic potential from the primary breast to the brain. We also identified not only diverging features of the breast and brain TMEs, but equivalent features which may contribute to preferential honing and outgrowth of metastatic breast cells in the brain microniche. Additionally, we uncovered significant cellular crosstalk between tumor, immune, and brain cell populations, including putative cell-cell interactions and intercellular signaling pathways. CONCLUSION These results served as a starting point for identifying key tumor-immune-brain interactions responsible for priming immune and brain tolerance of malignant cells, allowing outgrowth and progression of breast cancer brain metastases. Further investigation focused on tumor-brain crosstalk, specifically tumor-microglia interactions, will provide promising targets for therapeutic advancements.

Mitochondria drive hypoxia tolerance in naked mole rat brain.

Mitochondria drive hypoxia tolerance in naked mole rat brain.

Remote ischemic conditioning after stroke: Research progress in clinical study.

Stroke is a leading cause of global morbidity and mortality, indicating the necessity and urgency of effective prevention and treatment. Remote ischemic conditioning (RIC) is a convenient, simple, non-intrusive, and effective method that can be easily added to the treatment regime of stroke patients. Animal experiments and clinical trials have proved the neuroprotective effects of RIC on brain injury including (examples of neuroprotective effects). This neuroprotection is achieved by raising brain tolerance to ischemia, increasing local cerebral blood perfusion, promoting collateral circulations, neural regeneration, and reducing the incidence of hematomas in brain tissue. This current paper will summarize the studies within the last 2 years for the comprehensive understanding of the use of RIC in the treatment of stroke. This paper summarizes the clinical research progress of RIC on stroke (ischemic stroke and hemorrhagic stroke (HS)). This paper is a systematic review of research published on registered clinical trials using RIC in stroke from inception through November 2022. Four major databases (PUBMED, WEB OF SCIENCE, EMBASE, and ClinicalTrials.gov) were searched. Forty-eight studies were identified meeting our criteria. Of these studies, 14 were in patients with acute ischemic stroke with onset times ranging from 6 h to 14 days, seven were in patients with intravenous thrombolysis or endovascular thrombectomy, 10 were in patients with intracranial atherosclerotic stenosis, six on patients with vascular cognitive impairment, three on patients with moyamoya disease, and eight on patients with HS. Of the 48 studies, 42 were completed and six are ongoing. RIC is safe, feasible, and effective in the treatment of stroke. Large-scale research is still required to explore the optimal treatment options and mechanisms of RIC in the future to develop a breakthrough in stroke prevention and treatment.

GABAergic Mechanisms of the Brain Tolerance to Hypoxia in Lower Vertebrates

Hypoxic/ischemic brain injuries a major medical challenge. One of the approaches to the development of therapeutic interventions is to establish the pathways of survival for neurons in tolerant to O2 deficiency vertebrates, which could suggest the ways to mitigate hypoxic catastrophe for separate cells under oxygen starvation. Metabolic depression is considered to be a universal strategy for the survival of hypoxia tolerant animals; however, the details of the mechanism of brain metabolism limitation with a decrease in PO2 have not hitherto been established. Under oxygen starvation, an increase in the extracellular concentration of inhibitory neurotransmitters can be one of the significant links in the apparatus for suppression of electrical activity, which makes it possible to reduce energy demand. GABA (γ-aminobutyric acid) serves as a universal inhibitory neurotransmitter in the CNS of higher and lower vertebrates, the functioning of which is associated with the metabolism suppression and leveling the consequences of an energy failure. GABA is found in various taxonomic groups of vertebrates. This review considers strategies for GABA involvement in the mechanisms of ensuring a brain tolerance to oxygen starvation in representatives of various taxonomic groups of lower vertebrates (cyclostomes, cartilaginous and bony fish, amphibians, reptiles), which are distinguished by a most pronounced ability to survive under acute and chronic hypoxia/anoxia.

GABAergic Mechanisms of Brain Tolerance to Hypoxia in Lower Vertebrates

GABAergic Mechanisms of Brain Tolerance to Hypoxia in Lower Vertebrates

THE PLACE OF ANALGOSEDATION IN THE MANAGEMENT OF ACUTE ARTERIAL HYPERTENSION IN PATIENT WITH INTRACEREBRAL HEMORRHAGE (REFERENCES)

The aim of the study. Highlight the most well-founded knowledge that reflects the dependence of treatment and sedation options for patients in the treatment of intracerebral hemorrhage (ICH).&#x0D; Materials and methods. Literature sources related to the study of the annual number of registered stroke cases in the world were analyzed. The vast majority of patients remain permanently disabled, which leads to a decrease in the able-bodied population. An important factor in the development of complications and increased mortality is the high variability and persistent increase in blood pressure (BP). Traditional tactics have a number of disadvantages. At present, there are no clear recommendations for the use of certain antihypertensive drugs, and the optimal numbers to which BP should be lowered are debatable.&#x0D; The results. It has been established that sedation plays an important role in the treatment of intracerebral hemorrhage. In fact, it helps control pain, anxiety, agitation and synchronicity of the patient with the ventilator, and also reduces cerebral metabolic demands and improves the brain's tolerance to secondary damage. However, combinations of drugs for its implementation may differ even in units of the same hospital.&#x0D; Conclusions. Combination therapy of propofol with opioids or dexmedetomidine with opioids is most common. However, the heterogeneity of the data makes it impossible to qualitatively interpret the obtained results. In turn, due to the uncertainty of the unequivocal tactics of analgosedation, the question of the optimal dosage of drugs is open. Thus, the optimal treatment of acute hypertension in patients with VMC remains a therapeutic dilemma and an important part of scientific research. Adequate correction of the variability of systemic hemodynamics and cerebral perfusion with the help of analgosedation is a promising direction in the treatment of ICH.

Understanding transformation tolerant visual object representations in the human brain and convolutional neural networks

Forming transformation-tolerant object representations is critical to high-level primate vision. Despite its significance, many details of tolerance in the human brain remain unknown. Likewise, despite the ability of convolutional neural networks (CNNs) to exhibit human-like object categorization performance, whether CNNs form tolerance similar to that of the human brain is unknown. Here we provide the first comprehensive documentation and comparison of three tolerance measures in the human brain and CNNs. We measured fMRI responses from human ventral visual areas to real-world objects across both Euclidean and non-Euclidean feature changes. In single fMRI voxels in higher visual areas, we observed robust object response rank-order preservation across feature changes. This is indicative of functional smoothness in tolerance at the fMRI meso-scale level that has never been reported before. At the voxel population level, we found highly consistent object representational structure across feature changes towards the end of ventral processing. Rank-order preservation, consistency, and a third tolerance measure, cross-decoding success (i.e., a linear classifier's ability to generalize performance across feature changes) showed an overall tight coupling. These tolerance measures were in general lower for Euclidean than non-Euclidean feature changes in lower visual areas, but increased over the course of ventral processing for all feature changes. These characteristics of tolerance, however, were absent in eight CNNs pretrained with ImageNet images with varying network architecture, depth, the presence/absence of recurrent processing, or whether a network was pretrained with the original or stylized ImageNet images that encouraged shape processing. CNNs do not appear to develop the same kind of tolerance as the human brain over the course of visual processing.

Glutamatergic pathways in the brains of turtles: A comparative perspective among reptiles, birds, and mammals.

Glutamate acts as the main excitatory neurotransmitter in the brain and plays a vital role in physiological and pathological neuronal functions. In mammals, glutamate can cause detrimental excitotoxic effects under anoxic conditions. In contrast, Trachemys scripta, a freshwater turtle, is one of the most anoxia-tolerant animals, being able to survive up to months without oxygen. Therefore, turtles have been investigated to assess the molecular mechanisms of neuroprotective strategies used by them in anoxic conditions, such as maintaining low levels of glutamate, increasing adenosine and GABA, upregulating heat shock proteins, and downregulating KATP channels. These mechanisms of anoxia tolerance of the turtle brain may be applied to finding therapeutics for human glutamatergic neurological disorders such as brain injury or cerebral stroke due to ischemia. Despite the importance of glutamate as a neurotransmitter and of the turtle as an ideal research model, the glutamatergic circuits in the turtle brain remain less described whereas they have been well studied in mammalian and avian brains. In reptiles, particularly in the turtle brain, glutamatergic neurons have been identified by examining the expression of vesicular glutamate transporters (VGLUTs). In certain areas of the brain, some ionotropic glutamate receptors (GluRs) have been immunohistochemically studied, implying that there are glutamatergic target areas. Based on the expression patterns of these glutamate-related molecules and fiber connection data of the turtle brain that is available in the literature, many candidate glutamatergic circuits could be clarified, such as the olfactory circuit, hippocampal–septal pathway, corticostriatal pathway, visual pathway, auditory pathway, and granule cell–Purkinje cell pathway. This review summarizes the probable glutamatergic pathways and the distribution of glutamatergic neurons in the pallium of the turtle brain and compares them with those of avian and mammalian brains. The integrated knowledge of glutamatergic pathways serves as the fundamental basis for further functional studies in the turtle brain, which would provide insights on physiological and pathological mechanisms of glutamate regulation as well as neural circuits in different species.

Extreme Physiology Extreme Tolerance to Hypoxia, Hypercapnia, and Pain in the Naked Mole-Rat

Challenging environmental conditions can drive the evolution of extreme physiological traits. The naked mole-rat has evolved to survive and thrive in a low oxygen, high carbon dioxide environment that would be deadly to humans and most other mammals. The naked mole-rat’s lifestyle is unusual in that this species combines subterranean living and living in large, social groups of up to 300 + individuals. Many respiring animals in a closed environment can lead to depletion of oxygen (hypoxia) and accumulation of carbon dioxide (hypercapnia). Naked mole-rats display a variety of physiological traits that negate the adverse effects of living in this atmosphere. For hypoxia tolerance, naked mole-rats have a low resting metabolism, high affinity hemoglobin, intrinsic brain tolerance, the ability to use fructose for anaerobic glycolysis, and the ability to enter a low energy, suspended animation-like state. For hypercapnia tolerance, these animals have a mutation in a voltage gated sodium channel that effectively eliminates neuronal responses to tissue acidosis. In other mammals, acidosis from exposure to high concentrations of carbon dioxide induces pain and pulmonary edema. Understanding these mechanisms of extreme physiology is not only inherently interesting, but it may lead to biomedical breakthroughs in research on heart attacks, strokes, and pain pathologies.

Goldfish and crucian carp are natural models of anoxia tolerance in the retina

Vertebrates need oxygen to survive. The central nervous system has an especially high energy demand, so brain and retinal neurons quickly die in anoxia. But fish of the genus Carassius are exceptionally anoxia-tolerant: the crucian carp (C. carassius) can survive months without oxygen in ice-covered ponds, and the common goldfish (C. auratus) can withstand hours of anoxia at room temperature. These fish previously offered insights into anoxia tolerance in the brain, heart, and liver. Here, we advance Carassius spp. as models to study anoxia tolerance in the retina. Electroretinogram and evoked potential recordings show that crucian carp reversibly downregulate their visual systems in anoxia, probably to save ATP. Notably, Carassius suppress their visual systems nearly twice as much as anoxia-tolerant turtles, Trachemys and Chrysemys spp., which are often promoted as the champions of anoxia tolerance. We summarize what is known about anoxia tolerance in the goldfish and crucian carp retinas, including cellular pathways which may protect retinal neurons from excitotoxic cell death. We compare the Carassius retina with two relevant models: natural anoxia tolerance in the turtle brain, and ischemic preconditioning in the rat retina. All three models include mitochondria as oxygen sensors: mitochondria depolarize due to mitochondrial ATP-dependent K+ channels, possibly to trigger neuroprotective second messenger cascades. The Carassius retina is an accessible and inexpensive model, with over 70 fruitful years of history in vision research. As a model for anoxia tolerance, it may provide new insights into diseases of the eye (like diabetes, macular degeneration, and eye stroke).

Integrating Human and Nonhuman Primate Data to Estimate Human Tolerances for Traumatic Brain Injury.

Traumatic brain injury (TBI) contributes to a significant portion of the injuries resulting from motor vehicle crashes, falls, and sports collisions. The development of advanced countermeasures to mitigate these injuries requires a complete understanding of the tolerance of the human brain to injury. In this study, we developed a new method to establish human injury tolerance levels using an integrated database of reconstructed football impacts, subinjurious human volunteer data, and nonhuman primate data. The human tolerance levels were analyzed using tissue-level metrics determined using harmonized species-specific finite element (FE) brain models. Kinematics-based metrics involving complete characterization of angular motion (e.g., diffuse axonal multi-axial general evaluation (DAMAGE)) showed better power of predicting tissue-level deformation in a variety of impact conditions and were subsequently used to characterize injury tolerance. The proposed human brain tolerances for mild and severe TBI were estimated and presented in the form of injury risk curves based on selected tissue-level and kinematics-based injury metrics. The application of the estimated injury tolerances was finally demonstrated using real-world automotive crash data.

Abstract TP234: Delayed Administration Of A Repurposed Drug With Sigma 1 Receptor Activity Improves Stroke Outcomes In Male Rats

Sigma-1 receptor ligands including agonists and antagonists have been shown to improve outcomes from experimental stroke when administered at delayed time points. However, clinical trials for one such agonist, cutamesine, failed to demonstrate benefit. In the present study, we sought to identify approved drugs that could be repurposed for Sigma-1 activity and the delayed treatment of stroke. High-throughput screening was used to identify Sigma-1 receptor selective binding and stimulation of brain-derived neurotrophic factor (BDNF) release for several potential ligands that are already approved for other indications. Two lead compounds, promethazine (an antihistamine) and oxeladin (a cough suppressant), were advance to in vivo studies. Both compounds displayed favorable oral absorption into the brain and high dose tolerance in rats. Neither compound significantly altered thrombosis in an in vitro blood coagulation assay. Daily oral administration of oxeladin (3 doses) or vehicle was started 48 hours after 90-minute transient middle cerebral artery occlusion in adult male Sprague-Dawley rats (n=12/group) and continued for 10 days in a treatment-blind manner. Rats receiving the two highest doses showed significant (P&lt;0.05, 2-way ANOVA and Dunnett’s test) improvements in Bederson scores (0.4±0.1 vs 1.5±0.2), an 11 point Neurological assessment (1.2±0.1 vs 3.9±0.2) , and the elevated body swing test (60% vs 90% bias) 1, 4, and 10 days after dosing compared to vehicle controls. A subset of rats was administered BrdU (50 mg/kg ip) every other day. However, there were no significant differences among groups in BrdU incorporation observed in the subventricular zone at 14 days after stroke. Additional studies are being performed to assess the mechanisms of neuroprotection. These data suggest that repurposing of approved/safe drugs with Sigma-1 receptor activity is a promising avenue for the treatment of chronic stroke.

RADT-20. SINGLE INSTITUTION REVIEW OF LARGE VOLUME HIGH GRADE GLIOMA PATIENTS TREATED WITH RADIOTHERAPY

Abstract AIM Not uncommonly, we come across significantly large high grade glioma cases (HGGs). With standard delineation protocols, we end up irradiating a large volume of normal brain. Emami &amp; QUANTEC data define normal brain tolerance doses, however they are often of limited use in clinic practice. Thus, we reviewed our patients with significant tumor volumes to derive a safe dose/ volume level for brain. METHODOLOGY Patients with HGGs over the last 3 years were extracted from Mosaiq™ information system. The output was sorted with respect to clinical target volumes from lowest to highest. The top 25 percentile i.e. patients with a CTV of &amp;gt; 412cc (n=53) were identified for this study. Data was collected with respect to clinical, tumor characteristics and radiotherapy parameters. RESULTS Median age of population was 53 and majority (n=38) were males. Nine patients had multi-focal tumors while six had bilateral extension. Majority of the study group had Glioblastoma Multiforme (n=44), whereas 6 had Grade 3 tumors. Most of the patients could only have a biopsy (n=27). Molecular profile showed 42 were Isocitrate-Dehydrogenase negative and 26 were unmethylated tumors. Stupp’s &amp; Perry’s regimen were the commonly used protocols, however patients (n=7) with significant volumes near critical structures were treated with doses in the range of 50.4 – 55Gy in 30 fractions. The CTV volumes in the population ranged from 412 – 1223 cc while total brain volume range was 1112 – 1667 cc. Median of 43.5% of brain volume was covered in the PTV, while median of 5% of brain volume outside the PTV was treated to BED2 of 100Gy. Median survival was 12.4 months. CONCLUSION Our study shows reasonable tolerance of radiotherapy doses of &amp;gt; 50 Gy to larger volumes of brain. We propose a multi-center collaborative study to derive a new standardized dose volume tolerance.

Regulation and Intervention of Intracranial Pressure

Intracranial pressure is the total amount of pressure exerted by the brain, blood and cerebrocinal fluid in the rigid cranial space. Compliance is an indicator of the brain's tolerance for increased ICP, when compliance is exceeded, there will be a dramatic increase in the pressure/volume curve so that ICP will increase rapidly. In the injured brain, cerebral blood flow (CBF) is regulated to supply sufficient oxygen and substrates to the brain. Certain physiological factors such as hypercarbia, acidosis and hypoxemia cause vasodilation which causes an increase in CBF, seizure activity and fever will increase the level of brain metabolism and CBF. Cerebral edema is the most common cause of non-traumatic brain injury such as central nervous system infections, metabolic and systemic encephalopathy. Vasogenic brain edema occurs due to injury to the blood-brain barrier and increased capillary permeability in the area around the injury, or to inflammation, especially in CNS infections. Medical management of elevated intracranial pressure includes sedation, cerebrospinal fluid drainage, and osmotherapy with either mannitol or hypertonic salts.

Multicenter study: outcomes of carotid endarterectomy depending on configuration of circle of Willis

BACKGROUND: The circle of Willis (CW) is an important network of collaterals that provide compensatory redistribution of hemodynamic load. Several studies showed that the CW is open in approximately 50%90% of cases, and the number of missing segments correlates with low brain tolerance to ischemia in internal carotid artery (ICA) compression. Currently, studies dedicated to the relationship of different configurations of CW with the risk of ischemic brain damage.&#x0D; AIM: The analyze the immediate results of eversion carotid endarterectomy (CEA) in patients with different configurations of the structure of the CW.&#x0D; MATERIALS AND METHODS: We included 641 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA) in a study period from 2010 to 2020. All patients underwent multispiral computed tomography with angiography of the extracranial and CW arteries. Based on the structural variants of the CW, six groups of patients were studied: group 1 (64.9%, n = 416) closed posterior part (CPP) with the existence of posterior communicative artery (PCA) and P1 segment of the posterior cerebral artery (PCerA); group 2 (27%, n = 173) an intermediate structure of the posterior part (IPP) with hypoplasia of the PCA or PCerA; group 3 (8.1%, n = 52) open posterior part (OPP) with the absence of PCA or PCerA; group 4 (85.95%, n = 551) closed anterior part (CAP) with the presence of the anterior communicating artery (ACA) and A1 segment of the anterior cerebral artery (ACerA); group 5 (7.95%, n = 51) an intermediate structure of the anterior part (IAP) with hypoplasia of ACA or ACerA; group 6 (6.1%, n = 39) open anterior part (OAP) with the absence of ACA or ACerA. To assess the compensatory potentials of the brain, all patients underwent measurement of the retrograde pressure in the ICA and intraoperative cerebral oximetry.&#x0D; RESULTS: In the postoperative period, 1 death was recorded in group 4 (CAP) due to a hemorrhagic transformation in the zone of ischemic stroke, on the background development of hyperperfusion syndrome. The largest number of ischemic strokes of the cardioembolic subtype was diagnosed in the ACerA territory in the presence of an unstable atherosclerotic plaque: group 1 (CPP) 0%; group 2 (IPP) 0%; group 3 (OPP) 0.24%, n = 1; group 4 (CAP) 0.18%, n = 1; group 5 (IAP) 1.96%, n = 1; group 6 (OAP) 5.1%, n = 2; p 0.9999. The probable cause was embolization against the background increase in the arterial pressure before ICA clamping. In turn, the majority of ischemic strokes of the hemodynamic subtype developed in the territory of PCerA: group 1 (CPP) 0%; group 2 (IPP) 1.73%, n = 3; group 3 (OPP) 3.8%, n = 2; group 4 (CAP) 0.18%, n = 1; group 5 (IAP) 0%; group 6 (OAP) 2.56%, n = 1; p 0.9999. This pattern coincided with the largest number of patients with CW of the IPP and OPP types among all open variants of the structure.&#x0D; CONCLUSION: Parameters of retrograde pressure in the ICA and intraoperative cerebral oximetry do not always demonstrate the need for a temporary shunt (TS). Due to the opened structure of CW, the redistribution of blood flow occurs with the formation of zones of hypo- and hyperperfusion, causing ischemic alterations in the brain matter. Thus, in order to maintain adequate cerebral hemodynamics, to mitigate the effect of hypo- and hyperperfusion, and reduce the risk of ischemic stroke, the open variant of the CW structure should be considered as an indication for a TS.

The Slow-Releasing and Mitochondria-Targeted Hydrogen Sulfide (H2S) Delivery Molecule AP39 Induces Brain Tolerance to Ischemia.

Ischemic stroke is the third leading cause of death in the world, which accounts for almost 12% of the total deaths worldwide. Despite decades of research, the available and effective pharmacotherapy is limited. Some evidence underlines the beneficial properties of hydrogen sulfide (H2S) donors, such as NaSH, in an animal model of brain ischemia and in in vitro research; however, these data are ambiguous. This study was undertaken to verify the neuroprotective activity of AP39, a slow-releasing mitochondria-targeted H2S delivery molecule. We administered AP39 for 7 days prior to ischemia onset, and the potential to induce brain tolerance to ischemia was verified. To do this, we used the rat model of 90-min middle cerebral artery occlusion (MCAO) and used LC-MS/MS, RT-PCR, LuminexTM assays, Western blot and immunofluorescent double-staining to determine the absolute H2S levels, inflammatory markers, neurotrophic factor signaling pathways and apoptosis marker in the ipsilateral frontal cortex, hippocampus and in the dorsal striatum 24 h after ischemia onset. AP39 (50 nmol/kg) reduced the infarct volume, neurological deficit and reduced the microglia marker (Iba1) expression. AP39 also exerted prominent anti-inflammatory activity in reducing the release of Il-1β, Il-6 and TNFα in brain areas particularly affected by ischemia. Furthermore, AP39 enhanced the pro-survival pathways of neurotrophic factors BDNF-TrkB and NGF-TrkA and reduced the proapoptotic proNGF-p75NTR-sortilin pathway activity. These changes corresponded with reduced levels of cleaved caspase 3. Altogether, AP39 treatment induced adaptative changes within the brain and, by that, developed brain tolerance to ischemia.

Preconditioning-Activated AKT Controls Neuronal Tolerance to Ischemia through the MDM2-p53 Pathway.

One of the most important mechanisms of preconditioning-mediated neuroprotection is the attenuation of cell apoptosis, inducing brain tolerance after a subsequent injurious ischemia. In this context, the antiapoptotic PI3K/AKT signaling pathway plays a key role by regulating cell differentiation and survival. Active AKT is known to increase the expression of murine double minute-2 (MDM2), an E3-ubiquitin ligase that destabilizes p53 to promote the survival of cancer cells. In neurons, we recently showed that the MDM2–p53 interaction is potentiated by pharmacological preconditioning, based on subtoxic stimulation of NMDA glutamate receptor, which prevents ischemia-induced neuronal apoptosis. However, whether this mechanism contributes to the neuronal tolerance during ischemic preconditioning (IPC) is unknown. Here, we show that IPC induced PI3K-mediated phosphorylation of AKT at Ser473, which in turn phosphorylated MDM2 at Ser166. This phosphorylation triggered the nuclear stabilization of MDM2, leading to p53 destabilization, thus preventing neuronal apoptosis upon an ischemic insult. Inhibition of the PI3K/AKT pathway with wortmannin or by AKT silencing induced the accumulation of cytosolic MDM2, abrogating IPC-induced neuroprotection. Thus, IPC enhances the activation of PI3K/AKT signaling pathway and promotes neuronal tolerance by controlling the MDM2–p53 interaction. Our findings provide a new mechanistic pathway involved in IPC-induced neuroprotection via modulation of AKT signaling, suggesting that AKT is a potential therapeutic target against ischemic injury.