Short-term lack of cerebral perfusion with good outcome. Advantages of early intracranial pressure monitoring

A 21-year-old man was injured by a tailboard of a truck. He suffered a severe head injury with bilateral depressed skull fractures necessitating surgical decompression. On admission to the hospital the patient showed bending to pain stimuli (Glasgow Coma Score 5). Anisocoria was noticed from the beginning. Initial intracranial pressure (ICP), measured 3 hours after injury, was 30 mm Hg, and the cerebral perfusion pressure (CPP) was 70 mm Hg. During surgical elevation of the skull fracture on the right side an unexplainable rise of ICP to values of 100 mm Hg occurred, which corresponded to the mean arterial blood pressure (MAP). At the same time both pupils were dilated and fixed indicating a lack of cerebral perfusion. Due to immediate trephination of the opposite side, the ICP was lowered to values below 20 mm Hg, and sufficient cerebral perfusion (above 50 mm Hg) was regained. The patient showed a good recovery and was transferred to a rehabilitation center 5 weeks after injury.This case report emphasizes the importance of early and continuous intracranial pressure monitoring for adequate therapy in neurosurgical emergencies.     

Uptake of iodine-123-α-methyl tyrosine by gliomas and non-neoplastic brain lesions

Using single-photon emission tomography (SPET), the radiopharmaceuticall,-3-iodine-123--methyl tyrosine (IMT) has been applied to the imaging of amino acid transport into brain tumours. It was the aim of this study to investigate whether IMT SPET is capable of differentiating between high-grade gliomas, low-grade gliomas and non-neoplastic brain lesions. To this end, IMT uptake was determined in 53 patients using the triple-headed SPET camera MULTISPECT 3. Twenty-eight of these subjects suffered from high-grade gliomas (WHO grade III or IV), 12 from low-grade gliomas (WHO grade II), and 13 from non-neoplastic brain lesions, including lesions after effective therapy of a glioma (five cases), infarctions (four cases), inflammatory lesions (three cases) and traumatic haematoma (one case). IMT uptake was significantly higher in high-grade gliomas than in low-grade gliomas and non-neoplastic lesions. IMT uptake by low-grade gliomas was not significantly different from that by non-neoplastic lesions. Diagnostic sensitivity and specificity were 71% and 83% for differentiating high-grade from low-grade gliomas, 82% and 100% for distinguishing high-grade gliomas from non-neoplastic lesions, and 50% and 100% for discriminating low-grade gliomas from non-neoplastic lesions. Analogously to positron emission tomography with radioactively labelled amino acids and fluorine-18 deoxyglucose, IMT SPET may aid in differentiating high-grade gliomas from histologically benign brain tumours and non-neoplastic brain lesions; it is of only limited value in differentiating between non-neoplastic lesions and histologically benign brain tumours.     

Cerebral energy metabolism in patients with brain lesions at normo- and hyperbaric oxygen pressures

Summary The object of this study was to ascertain the oxygen tolerance limit and the oxygenation state of the injured brain in man. While breathing air, oxygen and hyperbaric oxygen at pressures of 1.5 and 2.0 atmospheres absolute (ATA), the cerebral arteriovenous differences (AVD) for O₂, glucose, lactate, pyruvate and blood gas pressures and pH values were measured. The balance of the cerebral glucose metabolism was calculated. The results showed that the injured brain did not tolerate the exposure to an oxygen pressure of 2.0 ATA for 10 to 15 min, but exposure to 1.5 ATA for 35–40 min was tolerated and had a favorable effect on the glucose or energy metabolism of the brain as well as on the clinical course. There was a distinctly increased cerebral glycolysis while breathing air indicating insufficient oxygen delivery to the brain. The change from breathing air to oxygen resulted in a distinct inhibition of cerebral glycolysis, which indicated improved cerebral oxygenation and energy production and gave evidence for a Pasteur effect regulating the glucose metabolism of the injured brain in man. At an inspiratory oxygen pressure of 1.5 ATA we had a nearly balanced cerebral glucose metabolism indicating an adequate cerebral oxygenation and energy formation. Further increase in inspiratory oxygen pressure to 2.0 ATA (performed only in group A) increased cerebral glycolysis considerably. This was assumed to be due to cerebral oxygen poisoning resulting in disturbed oxidative energy formation. Following this alteration an extreme reduction of the cerebral glucose uptake appeared, probably due to a disturbance of the specific glucose transport system. These metabolic alterations were not accompanied by seizures or any other clinical neurological manifestation. In group B, exposed to 1.5 ATA, such alterations of the cerebral glucose metabolism did not appear. A nearly balanced cerebral glucose metabolism was found at inspiratory oxygen pressures of 1.0 and particularly of 1.5 ATA, indicating an improved oxygenation and energy production of the affected brain. Finally, a renewed increase of the cerebral glycolysis occurred following the change from breathing oxygen to air. This again indicated an insufficient oxygen delivery to the affected brain.

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Zusammenfassung Ziel dieser Arbeit war es, die Wirkung verschiedener inspiratorischer O₂-Drucke auf den zerebralen Glukose- bzw. Energiestoffwechsel zu untersuchen. Dabei sollte insbesondere die Sauerstoff-Toleranzgrenze und der Zustand der Oxygenierung des geschädigten Hirns bestimmt werden. Unter Luft-, Sauerstoff und hyperbarer Sauerstoffatmung, d. h. bei Drucken von 1,5 und 2,0 Atmosphären, wurden die arterio-hirnvenösen Differenzen (AVD) für O₂, Glukose, Laktat, Pyruvat sowie die Blutgasdrucke und die pH-Werte gemessen. Die Bilanz des zerebralen Glukosestoffwechsels wurde bestimmt. Die Ergebnisse zeigten vor allem, daß das geschädigte Hirn eine Sauerstoffbelastung von 2,0 Atmosphären mit einer Expositionszeit von 10 bis 15 min nicht toleriert. Dagegen wurde eine Sauerstoffbelastung von 1,5 Atmosphären mit einer Expositionszeit von 35–40 min vertragen und hatte einen günstigen Einfluß auf den zerebralen Glukose- bzw. Energiestoffwechsel sowie auf den Krankheitsverlauf von traumatischen oder ischämischen Hirngewebsveränderungen. Während der Luftatmung fand sich eine erhebliche Steigerung der zerebralen Glykolyse, was auf eine mangelhafte O₂-Versorgung des Hirngewebes hinwies. Der Wechsel von Luft- auf Sauerstoffatmung führte zu einer deutlichen Hemmung der zerebralen Glykolyse. Dies zeigte eine Besserung der zerebralen Sauerstoffversorgung und Energieproduktion an und wies auf einen Pasteur Effekt bei der Regulation des Glukosestoffwechsels des geschädigten Hirns hin. Bei einem inspiratorischen Sauerstoffdruck von 1,5 Atmosphären war eine praktisch ausgeglichene Bilanz des zerebralen Glukosestoffwechsels nachweisbar, was für eine ausreichende Sauerstoffversorgung und Energiebildung des Hirns sprach. Der weitere Anstieg des inspiratorischen Sauerstoffdruckes auf 2,0 Atmosphären, der nur in Gruppe A durchgeführt wurde, bewirkte jedoch eine erhebliche Steigerung der zerebralen Glykolyse. Es ist anzunehmen, daß diese Stoffwechseländerung durch eine zerebrale Sauerstoffvergiftung hervorgerufen wurde, die vor allem zu einer Störung der oxydativen Energiegewinnung führte. Anschließend trat eine extreme Reduzierung der zerebralen Glukoseaufnahme auf, die am ehesten durch eine Störung des spezifischen Glukosetransportsystems des Hirns bedingt war. Diese Stoffwechselstörungen gingen nicht mit epileptischen Anfällen oder sonstigen klinisch-neurologischen Veränderungen einher. Bei den Patienten der Gruppe B, die nur mit einem Sauerstoffdruck von 1,5 Atmosphären belastet wurden, traten derartige Veränderungen des zerebralen Glukosestoffwechsels nicht auf. Eine praktisch ausgeglichene Bilanz des zerebralen Glukosestoffwechsels wurde bei inspiratorischen Sauerstoffdrucken von 1,0 und vor allem von 1,5 Atmosphären nachgewiesen und zeigte eine Besserung der Sauerstoffversorgung und Energiebildung des geschädigten Hirns an. Schließlich beobachteten wir nach dem Wechsel von Sauerstoff- auf Luftatmung einen erneuten Anstieg der zerebralen Glykose, was wiederum auf eine insuffiziente Sauerstoffversorgung des Hirns hinwies.

     

Effect of nimodipine in treatment of experimental focal cerebral ischaemia

Abstract

Despite the voluminous current literature the potential of nimodipine to modify the outcome in experimental cerebral ischaemia remains a controversial matter. The authors have evaluated in controlled double blind experiments the influence of a continuous i.v. infusion of the drug (1 ¼g kg^-1 min^-1) upon infarct size, histopathology and neurological outcome in rats with permanent middle cerebral artery (MCA) occlusion. The infusion was started 20 min before induction of ischaemia and continued 4 hours thereafter. The nimodipine treated animals were subdivided into hypotensive (MABP lower than 85 mmHg for more than 5 min after arterial occlusion) and normotensive groups. Infarction size, documented by TTC, H&E and Nissl staining was significantly smaller (p < 0.001) in nimodipine normotonic rats than the lesions in placebo and saline treated ratsas well compared with hypotonic nimodipine animals (largest infarction). These differences were found to be entirely at the expense of the cortical (frontoparietal) component of the lesion, suggesting ‘penumbra’ action of the drug. Moreover, nimodipine normotonic rats displayed lower cortical neuronal injury in the periinfarct zone. These findings were corroborated by corresponding better neurological scores. Our results indicate that nimodipine is effective in reducing focal cerebral ischaemia, provided the MABP is maintained higher than 85 mmHg.     

Distinct CD11b-monocyte subsets accelerate endothelial cell recovery after acute and chronic endothelial cell damage

Background

Endothelial cell recovery requires replenishment of primary cells from the endothelial lineage. However, recent evidence suggests that cells of the innate immune system enhance endothelial regeneration.

Methods and results

Focusing on mature CD11b⁺-monocytes, we analyzed the fate and the effect of transfused CD11b⁺-monocytes after endothelial injury in vivo. CD11b-diphtheria-toxin-receptor-mice – a mouse model in which administration of diphtheria toxin selectively eliminates endogenous monocytes and macrophages – were treated with WT-derived CD11b⁺-monocytes from age-matched mice. CD11b⁺-monocytes improved endothelium-dependent vasoreactivity after 7 days while transfusion of WT-derived CD11b⁻-cells had no beneficial effect on endothelial function. In ApoE^−/−-CD11b-DTR-mice with a hypercholesterolemia-induced chronic endothelial injury transfusion of WT-derived CD11b⁺-monocytes stimulated by interferon-γ (IFNγ) decreased endothelial function, whereas interleukin-4-stimulated (IL4) monocytes had no detectable effect on vascular function. Bioluminescent imaging revealed restriction of transfused CD11b⁺-monocytes to the endothelial injury site in CD11b-DTR-mice depleted of endogenous monocytes. In vitro co-culture experiments revealed significantly enhanced regeneration properties of human endothelial outgrowth cells (EOCs) when cultured with preconditioned-media (PCM) or monocytes of IL4-stimulated-subsets compared to the effects of IFNγ-stimulated monocytes.

Conclusion

CD11b⁺-monocytes play an important role in endothelial cell recovery after endothelial injury by homing to the site of vascular injury, enhancing reendothelialization and improving endothelial function. In vitro experiments suggest that IL4-stimulated monocytes enhance EOC regeneration properties most likely by paracrine induction of proliferation and cellular promotion of differentiation. These results underline novel insights in the biology of endothelial regeneration and provide additional information for the treatment of vascular dysfunction.     

Repetitive hypoxic exposure of brain slices and electrophysiological responses as an experimental model for investigation of cerebroprotective measurements

Abstract

An in vitro hippocampal (CA-1 region, guinea pig) slice technique using repeated hypoxia was employed to model electrophysiological changes (DC-potentials and evoked potentials (EP) by stimulation of Schaffer- collaterals) occurring in the hypoxic CA1 pyramidal layer. A standardized neuronal response under repeated hypoxic conditions was observed in this model, consisting of disappearance of EP and a trend towards partially reversible, but progressive synaptic failure subsequent anoxic depolarisation (AD). Slices treated with the calcium antagonist nimodipine showed a prolongation of AD latency between the first and following hypoxias. So it seems possible to simulate hypoxic lesions of the brain tissue by using this in vitro slice model. [Neurol Res 1996; 18: 367-369]     

Presence of the BCR-ABL mutation Glu255Lys prior to STI571 (imatinib) treatment in patients with Ph+ acute lymphoblastic leukemia

The tyrosine kinase inhibitor STI571 (imatinib) binds competitively to the adenosine triphosphate (ATP) binding site of the ABL kinase, thereby inhibiting auto- and substrate phosphorylation of the oncogenic protein BCR-ABL and preventing the activation of downstream signaling pathways. Comparative studies on leukemic cell samples obtained from chronic myelogenous leukemia (CML) and Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) patients before and after treatment with STI571 reported point mutations in resistant samples after a short time of therapy. The aim of this study was to determine whether patients with Ph+ ALL in whom resistance developed as a consequence of the Glu255Lys mutation already harbored this subclone prior to STI571 treatment. First, the migration pattern of cDNAs from 30 bone marrow samples from patients with Ph+ ALL was analyzed by polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP). Thereafter, detailed mutational analysis using genomic DNA was performed on initial STI571-naive bone marrow samples of 4 individuals with Ph+ ALL, for whom the mutation Glu255Lys in association with STI571 treatment had been shown. A 166-bp PCR fragment spanning from nucleotide (nt) 862 to nt 1027 was cloned, and 108 clones per sample were analyzed by direct sequencing. This more sensitive technique revealed the presence of the Glu255Lys mutation in 2 initial samples, one clone each. We identified for the first time the mutation Glu255Lys in STI571-naive leukemic samples of Ph+ ALL patients. The findings suggest that the mutation exists in a very small subpopulation of leukemic cells at the beginning of STI571 therapy.     

Bioelectrical behaviour of hypoxic human neocortical tissue under the influence of nimodipine and dimethyl sulfoxide

Nimodipine and dimethyl sulfoxide (DMSO) have been shown to affect electrophysiological responses in rodent brain tissue in an vitro model of hypoxia. In the present study, the same agents were now examined for their effects on human neocortical brain slices under repeated hypoxic conditions. DMSO (0.4%), with and without addition of nimodipine (40 micromol/l), did not increase the latency of anoxic depolarization (AD). This finding is not in line with our previous observations of DMSO effects, with and without nimodipine, on brain slices of guinea pigs. AD latency was significantly longer in human neocortical brain slices compared with hippocampal slices of rodents even without any pharmacological influence. A possible acute effect of DMSO-nimodipine may therefore be masked by an interspecies difference of hypoxia resistance.     

Noninvasive grading of untreated gliomas: a comparative study of MR imaging and 3-(iodine 123)-L-alpha-methyltyrosine SPECT

PURPOSE: To compare the accuracy of magnetic resonance (MR) imaging scores with that of 3-(iodine 123)-L-alpha-methyltyrosine ((123)I-IMT) single photon emission computed tomography (SPECT) in the noninvasive grading of untreated gliomas. MATERIALS AND METHODS: The study comprised 15 patients with low-grade gliomas (grades I-II, according to World Health Organization criteria) and 33 patients with high-grade gliomas (grades III-IV). The lesions were evaluated by using an MR imaging score based on nine criteria. The (123)I-IMT uptake was quantified as the ratio between the amino acid uptake in the tumor and that in the contralateral hemisphere. To test for potentially significant differences in diagnostic performance between contrast material-enhanced MR imaging and (123)I-IMT SPECT, binormal receiver operating characteristic curves were fitted to the data and compared by using the area test. RESULTS: The accuracy of MR imaging in the noninvasive grading of untreated gliomas was higher than that of (123)I-IMT SPECT (88% vs 79%). However, the difference in diagnostic performance was not significant on the basis of findings at receiver operating characteristic analysis (P >.2). Neither MR imaging nor (123)I-IMT SPECT allowed differentiation between high-grade gliomas (grades III and IV). CONCLUSION: Although (123)I-IMT uptake is significantly higher in high-grade gliomas than in low-grade gliomas, the performance of (123)I-IMT SPECT adds little to the accuracy of determining tumor grade when MR imaging is performed.