Increased nitric oxide synthesis is not involved in delayed cerebral energy failure following focal hypoxic-ischemic injury to the developing brain.

This study addressed the hypothesis that the delayed impairment in cerebral energy metabolism that develops 10-24 h after transient hypoxia-ischemia in the developing brain is mediated by induction of increased nitric oxide synthesis. Four groups of 14-d-old Wistar rat pups were studied. Group 1 was subjected to unilateral carotid artery ligation and hypoxia followed immediately by treatment with the nitric oxide synthase (NOS) inhibitor, Nomega-nitro-L-arginine methyl ester (L-NAME, 30 mg/kg). Group 2 underwent hypoxia-ischemia but received saline vehicle. Group 3 received L-NAME without hypoxia-ischemia, and group 4, saline vehicle alone. At defined times after insult, the expression of neuronal and inducible NOS were determined and calcium-dependent and -independent NOS activities measured. Cerebral energy metabolism was observed using 31P magnetic resonance spectroscopy. At 48 h after insult, the expression of inducible NOS increased, whereas neuronal NOS at 24 h decreased on the infarcted side. Calcium-dependent NOS activity was higher than calcium-independent NOS activity, but did not increase within 36 h after insult, and was significantly inhibited by the administration of L-NAME. However, L-NAME did not prevent delayed impairment of cerebral energy metabolism or ameliorate infarct size. These results suggest that the delayed decline in cerebral energy metabolism after hypoxia-ischemia in the 14-d-old rat brain is not mediated by increased nitric oxide synthesis.     

神经节苷脂治疗新生大鼠缺血缺氧性脑损伤的研究

目的：观察神经节苷脂(GM1)对缺氧缺血(HI)新生大鼠的治疗作用及对凋亡相关基因Bax/Bcl-2表达的影响。方法：应用生后第7天的SD大鼠,制备缺血缺氧性脑病(HIE)模型。用TUNEL法检测细胞凋亡,用免疫组织化学SABC法检测Bax/Bcl-2的表达。结果：新生大鼠HI后脑细胞存在凋亡。GM1治疗能减少细胞凋亡。治疗组皮质凋亡细胞数为55.75±6.71,较HI组75.25±4.94下降(P<0.01);治疗组海马凋亡细胞数较对照组也有下降(47.25±6.6 vs 32.14±4.88),P<0.01。各组Bax和Bcl-2表达皆为阳性,但在HI对照组,Bax表达更强,而Bcl-2表达较弱。结论：应用GM1治疗HI脑损伤可减少脑细胞凋亡,GM1治疗对凋亡相关基因Bax/Bcl-2表达有一定的影响,HI脑损伤后细胞凋亡可能与这两种基因相关。     

Neuronal apoptosis in sudden infant death syndrome

Although evidence shows that victims of sudden infant death syndrome (SIDS) suffer repetitive episodes of hypoxemia, only subtle abnormalities have been found in their brains by light microscopy. The aim of the present study was to determine whether apoptosis, a form of cell death that can be triggered by hypoxemia and that leaves no scarring detectable by light microscopy, would be present in hypoxia-sensitive brain regions of SIDS victims. We looked for the presence of apoptosis with an in situ end-labeling method that detects DNA fragmentation. We studied 29 SIDS victims who were age-matched to nine control cases. We found significant neuronal apoptosis in 79% of the SIDS cases: 55% of the cases positive in the hippocampus and 96% positive in the brainstem. Whereas the distribution of apoptosis in the hippocampus was in hypoxia-sensitive subregions, the distribution in the brainstem was mostly in dorsal nuclei, including those involved with sensation in the face and position of the head (nucleus of the spinal trigeminal tract and vestibular nuclei). The control cases showed no significant apoptosis in the hippocampus and a mild degree in the brainstem in three cases. Our results indicate the occurrence of an acute insult at least several hours before death, an insult from which the infants had apparently recuperated. This suggests that SIDS victims suffered repeated apoptosis resulting in significant neuronal damage and, thus, functional loss in key brain regions. The involvement of specific nuclei in the brainstem may be linked to the fact that prone sleeping is a significant risk factor for SIDS. Enhanced neuronal death by apoptosis may thus have major implications for understanding the sequence of events leading to SIDS.     

Neurobiology of hypoxic-ischemic injury in the developing brain

Hypoxic ischemia is a common cause of damage to the fetal and neonatal brain. Although systemic and cerebrovascular physiologic factors play an important role in the initial phases of hypoxic-ischemic injuries, the intrinsic vulnerability of specific cell types and systems in the developing brain may be more important in determining the final pattern of damage and functional disability. Excitotoxicity, a term applied to the death of neurons and certain other cells caused by overstimulation of excitatory, mainly glutamate, neurotransmitter receptors, plays a critical role in these processes. Selected neuronal circuits as well as certain populations of glia such as immature periventricular oligodendroglia may die from excitotoxicity triggered by hypoxic ischemia. These patterns of neuropathologic vulnerability are associated with clinical syndromes of neurologic disability such as the extrapyramidal and spastic diplegia forms of cerebral palsy. The cascade of biochemical and histopathologic events triggered by hypoxic ischemia can extend for days to weeks after the insult is triggered, creating the potential for therapeutic interventions.     

Keeping a cool head, post-hypoxic hypothermia–an old idea revisited

Hypoxia-ischaemia produces permanent brain damage by processes that continue for many hours after reoxygenation/reperfusion. This provides a window of opportunity for therapy aimed at preventing further loss of brain cells. Reducing brain temperature by 2–6°C for 3–72 h after reoxygenation/reperfusion has been shown to reduce brain damage by 25–80% in controlled trials with six different neonatal animal models of hypoxia-ischaemia. No adverse effects from mild hypothermia have been documented. The mechanisms of protection are unknown but may include a reduction in extracellular excitotoxic amino acids, reduced nitric oxide synthesis and inhibition of apoptosis. Mild hypothermia is currently the most promising clinically feasible neural rescue therapy for full-term infants at risk of developing hypoxic-ischaemic encephalopathy, but clinical use must be restricted to approved trial protocols.     

促红细胞生成素对缺氧缺血性脑病的神经保护作用

研究表明,促红细胞生成素(EPO)对新生儿缺氧缺血性脑病具有神经保护作用,EPO能明显抑制脑缺血诱导的神经细胞凋亡,对缺氧缺血导致损伤的神经元有一定的保护作用.其机制可能包括抑制NO过度合成、抗谷氨酸兴奋毒性等.     

缺氧缺血性脑病新生鼠胃壁内一氧化氮的改变

目的探讨缺氧缺血性脑病新生鼠胃壁局部一氧化氮（ＮＯ）的改变及窒息对消化系统的影响。方法采用二氢硫辛酰胺脱氢酶ＮＡＤＰＨ组织化学方法，检测２４只正常或缺氧新生鼠胃壁各层一氧化氮合成酶（ＮＯＳ）的分布变化。结果急性缺氧组与正常对照组相比，ＮＯＳ阳性产物无论在分布、染色深浅、纤维密度及ＮＯＳ阳性胞体数目上，差异均无显著意义（Ｐ＞０．０５）。但在缺氧缺血性脑病组，其肌层的ＮＯＳ阳性纤维无论是密度还是染色深浅，均明显强于正常对照组，ＮＯＳ阳性胞体亦明显多于正常对照组，其差异有非常显著意义（Ｐ＜０．０１）；而粘膜和粘膜下层的ＮＯＳ分布与正常对照组相比，差异无显著意义（Ｐ＞０．０５）。结论窒息时胃动力降低及胃粘膜病变与一氧化氮在胃壁内的改变有关     

Animal models of neonatal stroke.

Neonatal stroke occurs in approximately 1 in 4,000 to 1 in 10,000 newborns, and more than 80% involve the vascular territory supplied by the middle cerebral artery. Neonatal stroke is associated with many acquired and genetic prothrombotic factors, and follow-up studies indicate that as many as two thirds of neonates develop neurologic deficits. In the past two decades unilateral carotid occlusion with 8% hypoxia has been used to study focal and global ischemia in the newborn, and recently a filament model of middle cerebral artery occlusion has been developed. This review describes the results of studies in these two newborn models covering aspects of the injury cascade that occurs after focal ischemia. A likely requirement is that therapeutic efforts be directed less at using thrombolytic therapy and more toward treatment of events associated with reperfusion injury, the inflammatory cascade, and apoptosis. Additional areas of research that have received attention in the past year include inhibition of nitric oxide and free-radical formation, use of iron chelating agents, the potential role of hypoxia-inducible factors and mediators of caspase activity, use of growth factors, hypothermia, and administration of magnesium sulfate.     

Time for a cool head-neuroprotection becomes a reality

Studies in encephalopathic infants have demonstrated a brief phase of normal cerebral energetics following hypoxia-ischaemia prior to development of delayed energy failure. In experimental models, mild hypothermia has shown a consistent neuroprotective action, although its efficacy is critically dependent on the severity of the primary insult, the delay in initiating cooling, and the duration and depth of hypothermia. Early electroencephalographic assessment of encephalopathic infants has the potential to provide objective information about the preceding insult, aiding the selection of infants for enrollment to clinical trials. Preliminary results from a large randomised trial of selective head cooling suggest that early intervention can lead to significantly improved outcome in a subgroup of encephalopathic infants with intermediate electroencephalographic abnormalities. Further research in established experimental models is essential to improve the identification of suitable infants for treatment, to investigate the importance of variations in regional brain temperature, and to examine the therapeutic potential of hypothermia combined with other neuroprotective agents.     

Effect of intrauterine ischemia-hypoxia on endothelial nitric oxide synthase in fetal brain in rats

Nitric oxide (NO) plays important roles in the regulation of cerebral blood flow (CBF) in the perinatal period. The present study was undertaken to investigate the influence of intrauterine ischemia-hypoxia (IH) on the expression of endothelial NO synthase (eNOS) in fetal brains in rats. To induce intrauterine IH insult, bilateral uterine arteries were ligated on day 17 of pregnancy. Activities and mRNA levels in the brain of the fetuses were examined on days 17-21 of pregnancy. The IH insult caused the increase in both activities and mRNA levels of eNOS on day 21 of pregnancy, whereas there were no significant changes in neuronal NOS mRNA levels. Endothelial NOS expression in the fetal brains was increased by intrauterine IH insult, suggesting that eNOS may contribute to the maintenance of CBF against ischemia or hypoxia conditions in the fetal rats.     

Inflammatory mediators and neonatal brain damage

Inflammatory mediators are multifunctional cytokines that play important roles both in normal central nervous system (CNS) development and in the response of the brain to diverse forms of injury. Interleukin (IL)-1beta, tumor necrosis factor-alpha and IL-6 are among the best-characterized early-response cytokines. Recent data suggest that they may be synthesized and secreted by several CNS cell types, including microglia, astrocytes and neurons. Biological effects of these cytokines that could influence the progression of injury in the brain include stimulating the synthesis of other cytokines and neuronal injury mediators such as nitric oxide synthase, inducing leukocyte infiltration and the expression of adhesion molecules, influencing glial gene expression and damaging oligodendrocytes. In the immature brain, proinflammatory cytokines might lead to white matter damage during prenatal intrauterine infection and contribute to progressive neuronal damage in acute brain injury evoked by cerebral hypoxia-ischemia. Interrupting the proinflammatory cascade might limit the extent of irreversible injury.     

新生大鼠脑缺氧缺血后迟发性细胞死亡的研究

目的　探讨新生动物脑缺氧缺血 (HI)后迟发性细胞死亡是否存在细胞凋亡 ;分析不同检测手段的敏感性与特异性。方法　在建立新生大鼠脑HI损伤标准动物模型基础上,采用脑组织病理学HE染色光镜观察、透射电镜、原位末端标记 (ISEL)及DNA电泳等分别对HI后不同时间点的实验侧脑皮质、海马回中凋亡细胞的形态、特点等进行观察和比较。结果　光镜、电镜下显示实验侧脑皮质及海马神经元皱缩、染色质凝集并出现凋亡小体,ISEL及DNA电泳证实有裂解DNA存在。且发现脑皮质及海马回凋亡性细胞死亡通常自HI后 6～12h开始,2 4h达高峰。结论　缺氧缺血可引起新生动物脑细胞凋亡。在脑HI迟发性损伤中不仅存在坏死,而且存在着复杂的细胞凋亡过程。不同的检测手段均具有一定的局限性 ,只有结合多种方法进行检测 ,才能正确判定凋亡细胞的存在。     

Fetal intestinal obstruction induces alteration of enteric nervous system development in human intestinal atresia

Intestinal motility disorders are a major cause of morbidity after surgical repair of intestinal atresia of unknown mechanism. We hypothesized that interruption of antenatal peristalsis may disturb the normal development of the enteric nervous system. Using a series of neuronal (synaptophysin, neuronal nitric oxide synthase, neurofilaments) and nonneuronal markers (glial acidic fibrillary protein and c-Kit) and immunohistochemistry, we have defined developmental steps of the enteric nervous system in normal intestine (12 fetuses, 15 children, and 4 adults) and their alterations above and below the obstacle in 22 human intestinal atresia compared with age-matched controls. Antisynaptophysin antibody revealed the progressive conversion of the myenteric plexus from a continuous belt into regularly spaced ganglions during normal fetal gut development and, by contrast, the significantly delayed appearance of individual neuronal ganglions in the distal segments of atresia (p < 0.05). Staging using three other markers for neuronal (neurofilaments and neuronal nitric oxide synthase) and nonneuronal cells (glial acidic fibrillary protein) confirmed that maturation of the myenteric plexus was significantly delayed below atresia (p < 0.01). These results indicate that intestinal atresia impairs the development of the enteric nervous system and provide an anatomical substrate for the motility disorders observed after surgical repair. They point to the role of peristalsis in normal gut development and suggest that stimulation of peristalsis might be used to accelerate recovery.     

Hypoxic ischaemic encephalopathy

Over the past several years, basic and clinical research has improved our understanding of critical cellular and molecular events which eventually lead to brain damage following perinatal hypoxia-ischaemia. The knowledge that perinatal hypoxia-ischaemia is a process that evolves over hours to days provides a “window of opportunity” for intervention. This review briefly covers the biochemical and physiological changes that occur in the neonatal brain following hypoxia-ischaemia.     

Role of epigenetic regulatory mechanisms in neonatal hypoxic–ischemic brain injury

Background

DNA methylation and histone modifications are the most identified modifications that selectively activate or inactivate genes that control cell growth, proliferation, and apoptosis.

Aim

We hypothesized that alterations in gene expression due to hypoxic–ischemic brain damage was regulated by epigenetic mechanisms including DNA methylation and histone methylation.

Study design

To test this hypothesis, we established a rat model of HIE. Three groups were defined as hypoxic–ischemic, sham-operated, and control group.

Outcome measurements

The validity of the HIE model used in this study was confirmed by histological and immunohistochemical tests. Gene expressions related with apoptosis and angiogenesis were studied at 0.5, 3, 6 and 24 h after HI or sham operation. DNA and histone methylation status was studied in the genes showing significant change in expression.

Results and conclusions

Most of the genes related with apoptosis and angiogenesis (Epo, Epor, Hif 1α, Hif3α, VEGFa, VEGFc, Casp1, Casp9, and Casp8ap2) induced early after HI (30 min). All of these genes were unmethylated at the beginning of the insult and in the control group. DNA methylation percentage and histone methylation (H3K36) levels were not correlated with gen expression levels. To our knowledge this is the first study evaluating the role of epigenetic mechanisms in HIE model, therefore the absence of similar studies don't allow us to compare the present results. Further studies investigating different epigenetic mechanisms are needed.     

亚低温减轻新生大鼠缺氧缺血脑细胞凋亡的作用及机制研究

目的：细胞凋亡在新生儿缺氧缺血性脑病(HIE)的发病机制中起重要作用,亚低温治疗是HIE最有前途的治疗方法之一。通过观察缺氧缺血后凋亡通路上关键成分的变化,探讨亚低温减轻新生大鼠脑细胞凋亡的作用及机制。方法：采用7日龄SD清洁级大鼠, 建立新生大鼠HIBD标准模型。模型动物随机分为常温缺氧缺血组 (IN, 肛温=37℃)和亚低温缺氧缺血组 (IH,肛温=33℃)。采用TUNEL结合苏木素-伊红染色、神经元Nissl染色等方法检测脑细胞凋亡;Western blotting加免疫组织化学法观察线粒体及胞浆细胞色素C蛋白改变;分别用RT-PCR和显色底物法检测caspase-3 mRNA表达及其酶活性改变。结果：IN组海马CA1区TUNEL阳性锥体细胞明显增多,DNA电泳梯状条带明显;72 h亚低温治疗显著降低脑细胞凋亡发生率,与常温比较差异有显著性（6.4±1.7 vs 25.3±1.5,P<0.01）。IN组胞浆Cyt c水平6 h开始明显升高,72 h达高峰,而线粒体内Cyt c水平则出现相应的下降;亚低温治疗组胞浆Cyt c水平降低和对应线粒体Cyt c水平的升高,以24 h、48 h和72 h最为明显,与IN组比较差异有显著性（P＜0.05）。HIBD后24 h组结扎侧脑组织caspase-3 mRNA表达明显增加,亚低温治疗显著降低caspase-3 mRNA表达水平,以48 h、72 h 治疗组最明显（P＜0.05）,而caspase-3酶活性却在24 h达高峰,亚低温治疗可明显降低HIBD 后24 h 的caspase-3酶活性,与常温比较差异有显著性（2.42±0.5 RFU vs 34.7±3.2 RFU ,P＜ 0.01)。结论：亚低温治疗能够显著降低HIBD后细胞凋亡发生率,其机制可能作用于凋亡通路的多个部位：减少Cyt c释放,减轻或抑制caspase-3表达及其蛋白酶活性等。［中国当代儿科杂志,2007,9（1）：37-41］     

Use of the Ages and Stages Questionnaire to predict outcome after hypoxic‐ischaemic encephalopathy in the neonate

Background: Infants who suffer hypoxic‐ischaemic encephalopathy (HIE) at birth are at increased risk of developmental disability. In this at‐risk population, reliable, inexpensive and early identification of those children who are likely to require formal developmental assessment and intervention is needed. Aim: To evaluate the ability of the Ages and Stages Questionnaire (ASQ) to detect developmentally delayed children in an Australian population of infants who suffered HIE at birth. Methods: Fifty‐five children who survived HIE were followed until 12–14 months of age. Test characteristics were calculated to examine the ability of the ASQ to appropriately identify developmentally delayed infants against this study's ‘gold standard’: the Bayley Scales of Infant Development II. Results: Comparing the ASQ with the Bayley Scales of Infant Development II, the questionnaire had the following test characteristics: sensitivity 92%, specificity 95%, positive predictive value 92%, negative predictive value 95% when used to detect severe developmental delay; and sensitivity 67%, specificity 93%, positive predictive value 92%, negative predictive value 68% when used to detect both severe and mild developmental delay. However, the ASQ used at standard cut‐offs failed to detect any of the children with mild delay. Conclusions: The ASQ is extremely effective for the detection of severe developmental delay in children who have suffered HIE at birth. Its capacity to identify those with milder delay is limited. The ability of the test to detect only those with severe developmental delay means that the ASQ is of little value as a screening tool in this population.     

Alterations in antioxidant enzyme activities in cerebrospinal fluid related with severity of hypoxic ischemic encephalopathy in newborns

BACKGROUND: The antioxidant status of the tissue affected by ischemia-reperfusion is of great importance for the primary endogenous defense against the free-radical-induced injury. OBJECTIVE: In this study, we aimed to evaluate the relationship between the activities of antioxidant enzymes [superoxide dismutase (SOD), glutathione peroxidase (GPX), and catalase (CAT)] in cerebrospinal fluid (CSF) and severity of hypoxic-ischemic encephalopathy (HIE) in newborns. METHODS: Thirty full-term asphyxiated infants (gestational age >37 weeks) and 11 full-term infants (none of whom showed any signs of asphyxia) were included in this study. Activities of SOD, GPX, and CAT in CSF were measured within the first 72 h of life in infants with HIE and controls. RESULTS: Activity of SOD in CSF was significantly higher in infants with HIE compared with controls (p<0.05). GPX and CAT activities were higher in infants with HIE than they were in controls; however, the differences were not statistically significant (p > 0.05). The activities of GPX and CAT were significantly increased in severe HIE as compared with mild HIE and controls (p < 0.05). CONCLUSION: Both the duration of the hypoxic-ischemic insult and the severity of HIE modulate elevations of enzymatic activity as an adaptive response to excessive free radical production in CSF in newborn infants with HIE. The activities of antioxidant enzyme alterations in CSF correspond highly to the severity of HIE, and these patterns may be useful for diagnostic and prognostic purposes.     

New treatments for the mucopolysaccharidoses: from pathophysiology to therapy

Enzyme replacement therapy is currently considered the standard of care for the treatment of mucopolysaccharidoses (MPS) type I, II, VI, and IV. This approach has shown substantial efficacy mainly on somatic symptoms of the patients, but no benefit was found for other clinical manifestations, such as neurological involvement. New strategies are currently being tested to address these limitations, in particular to obtain sufficient therapeutic levels in the brain. Intrathecal delivery of recombinant enzymes or chimeric enzymes represent promising approaches in this respect. Further innovation will likely be introduced by the recent advancements in the knowledge of lysosomal biology and function. It is now clear that the clinical manifestations of MPS are not only the direct effects of storage, but also derive from a cascade of secondary events that lead to dysfunction of several cellular processes and pathways. Some of these pathways may represent novel therapeutic targets and allow for development of novel or adjunctive therapies for these disorders.