Gary S. Krause

Brain ischemia and reperfusion: molecular mechanisms of neuronal injury.

Brain ischemia and reperfusion engage multiple independently-fatal terminal pathways involving loss of membrane integrity in partitioning ions, progressive proteolysis, and inability to check these processes because of loss of general translation competence and reduced survival signal-transduction. Ischemia results in rapid loss of high-energy phosphate compounds and generalized depolarization, which induces release of glutamate and, in selectively vulnerable neurons (SVNs), opening of both voltage-dependent and glutamate-regulated calcium channels. This allows a large increase in cytosolic Ca(2+) associated with activation of mu-calpain, calcineurin, and phospholipases with consequent proteolysis of calpain substrates (including spectrin and eIF4G), activation of NOS and potentially of Bad, and accumulation of free arachidonic acid, which can induce depletion of Ca(2+) from the ER lumen. A kinase that shuts off translation initiation by phosphorylating the alpha-subunit of eukaryotic initiation factor-2 (eIF2alpha) is activated either by adenosine degradation products or depletion of ER lumenal Ca(2+). Early during reperfusion, oxidative metabolism of arachidonate causes a burst of excess oxygen radicals, iron is released from storage proteins by superoxide-mediated reduction, and NO is generated. These events result in peroxynitrite generation, inappropriate protein nitrosylation, and lipid peroxidation, which ultrastructurally appears to principally damage the plasmalemma of SVNs. The initial recovery of ATP supports very rapid eIF2alpha phosphorylation that in SVNs is prolonged and associated with a major reduction in protein synthesis. High catecholamine levels induced by the ischemic episode itself and/or drug administration down-regulate insulin secretion and induce inhibition of growth-factor receptor tyrosine kinase activity, effects associated with down-regulation of survival signal-transduction through the Ras pathway. Caspase activation occurs during the early hours of reperfusion following mitochondrial release of caspase 9 and cytochrome c. The SVNs find themselves with substantial membrane damage, calpain-mediated proteolytic degradation of eIF4G and cytoskeletal proteins, altered translation initiation mechanisms that substantially reduce total protein synthesis and impose major alterations in message selection, down-regulated survival signal-transduction, and caspase activation. This picture argues powerfully that, for therapy of brain ischemia and reperfusion, the concept of single drug intervention (which has characterized the approaches of basic research, the pharmaceutical industry, and clinical trials) cannot be effective. Although rigorous study of multi-drug protocols is very demanding, effective therapy is likely to require (1) peptide growth factors for early activation of survival-signaling pathways and recovery of translation competence, (2) inhibition of lipid peroxidation, (3) inhibition of calpain, and (4) caspase inhibition. Examination of such protocols will require not only characterization of functional and histopathologic outcome, but also study of biochemical markers of the injury processes to establish the role of each drug.

Brain ischemia and reperfusion activates the eukaryotic initiation factor 2α kinase, PERK

Reperfusion after global brain ischemia results initially in a widespread suppression of protein synthesis in neurons, which persists in vulnerable neurons, that is caused by the inhibition of translation initiation as a result of the phosphorylation of the α‐subunit of eukaryotic initiation factor 2 (eIF2α). To identify kinases responsible for eIF2α phosphorylation [eIF2α(P)] during brain reperfusion, we induced ischemia by bilateral carotid artery occlusion followed by post‐ischemic assessment of brain eIF2α(P) in mice with homozygous functional knockouts in the genes encoding the heme‐regulated eIF2α kinase (HRI), or the amino acid‐regulated eIF2α kinase (GCN2). A 10‐fold increase in eIF2α(P) was observed in reperfused wild‐type mice and in the HRI–/– or GCN2–/– mice. However, in all reperfused groups, the RNA‐dependent protein kinase (PKR)‐like endoplasmic reticulum eIF2α kinase (PERK) exhibited an isoform mobility shift on SDS–PAGE, consistent with the activation of the kinase. These data indicate that neither HRI nor GCN2 are required for the large increase in post‐ischemic brain eIF2α(P), and in conjunction with our previous report that eIF2α(P) is produced in the brain of reperfused PKR–/– mice, provides evidence that PERK is the kinase responsible for eIF2α phosphorylation in the early post‐ischemic brain.

Molecular pathways of protein synthesis inhibition during brain reperfusion: Implications for neuronal survival or death

Protein synthesis inhibition occurs in neurons immediately on reperfusion after ischemia and involves at least alterations in eukaryotic initiation factors 2 (eIF2) and 4 (eIF4). Phosphorylation of the α subunit of eIF2 [eIF2(αP)] by the endoplasmic reticulum transmembrane eIF2α kinase PERK occurs immediately on reperfusion and inhibits translation initiation. PERK activation, along with depletion of endoplasmic reticulum Ca2+ and inhibition of the endoplasmic reticulum Ca2+-ATPase, SERCA2b, indicate that an endoplasmic reticulum unfolded protein response occurs as a consequence of brain ischemia and reperfusion. In mammals, the upstream unfolded protein response components PERK, IRE1, and ATF6 activate prosurvivial mechanisms (e.g., transcription of GRP78, PDI, SERCA2b) and proapoptotic mechanisms (i.e., activation of Jun N-terminal kinases, caspase-12, and CHOP transcription). Sustained eIF2(αP) is proapoptotic by inducing the synthesis of ATF4, the CHOP transcription factor, through “bypass scanning” of 5‘ upstream open-reading frames in ATF4 messenger RNA; these upstream open-reading frames normally inhibit access to the ATF4 coding sequence. Brain ischemia and reperfusion also induce μ-calpain–mediated or caspase-3–mediated proteolysis of eIF4G, which shifts message selection to m7G-cap–independent translation initiation of messenger RNAs containing internal ribosome entry sites. This internal ribosome entry site–mediated translation initiation (i.e., for apoptosis-activating factor-1 and death-associated protein-5) can also promote apoptosis. Thus, alterations in eIF2 and eIF4 have major implications for which messenger RNAs are translated by residual protein synthesis in neurons during brain reperfusion, in turn constraining protein expression of changes in gene transcription induced by ischemia and reperfusion. Therefore, our current understanding shifts the focus from protein synthesis inhibition to the molecular pathways that underlie this inhibition, and the role that these pathways play in prosurvival and proapoptotic processes that may be differentially expressed in vulnerable and resistant regions of the reperfused brain.

Global brain ischemia and reperfusion : Modifications in eukaryotic initiation factors associated with inhibition of translation initiation

Abstract: We used in vitro translation and antibodies against phosphoserine and the eukaryotic initiation factors eIF‐4E, eIF‐4G, and eIF‐2α to examine the effects of global brain ischemia and reperfusion on translation initiation and its regulation in a rat model of 10 min of cardiac arrest followed by resuscitation and 90 min of reperfusion. Translation reactions were performed on postmitochondrial supernatants from brain homogenates with and without aurintricarboxylic acid to separate incorporation due to run‐off from incorporation due to peptide synthesis initiated in vitro. The rate of leucine incorporation due to in vitro‐initiated protein synthesis in normal forebrain homogenates was ∼0.4 fmol of leucine/min/µg of protein and was unaffected by 10 min of cardiac arrest, but 90 min of reperfusion reduced this rate 83%. Sodium dodecyl sulfate‐polyacrylamide gel electrophoresis and western blots of these homogenates showed that neither 10 min of global brain ischemia nor 90 min of reperfusion induced significant alterations in the quantity or serine phosphorylation of eIF‐4E. However, we observed in all 90‐min‐reperfused samples eIF‐4G fragments that also bound eIF‐4E. The amount of eIF‐2α was not altered by ischemia or reperfusion, and immunoblotting after isoelectric focusing did not detect serine‐phosphorylated eIF‐2α in normal samples or in those obtained after ischemia without reperfusion. However, serine‐phosphorylated eIF‐2α was uniformly present after 90 min of reperfusion and represented 24 ± 3% of the eIF‐2α in these samples. The serine phosphorylation of eIF‐2α and partial fragmentation of eIF‐4G observed after 90 min of reperfusion offer an explanation for the inhibition of protein synthesis.

Effect of Brain Ischemia and Reperfusion on the Localization of Phosphorylated Eukaryotic Initiation Factor 2α

Postischemic brain reperfusion is associated with a substantial and long-lasting reduction of protein synthesis in selectively vulnerable neurons. Because the overall translation initiation rate is typically regulated by altering the phosphorylation of serine 51 on the α-subunit of eukaryotic initiation factor 2 (eIF-2α), we used an antibody specific to phosphorylated eIF-2α [eIF-2(αP)] to study the regional and cellular distribution of eIF-2(αP) in normal, ischemic, and reperfused rat brains. Western blots of brain postmitochondrial supernatants revealed that ~1% of all eIF-2α is phosphorylated in controls, eIF-2(αP) is not reduced by up to 30 minutes of ischemia, and eIF-2(αP) is increased ~20-fold after 10 and 90 minutes of reperfusion. Immunohistochemistry shows localization of eIF-2(αP) to astrocytes in normal brains, a massive increase in eIF-2(αP) in the cytoplasm of neurons within the first 10 minutes of reperfusion, accumulation of eIF-2(αP) in the nuclei of selectively vulnerable neurons after 1 hour of reperfusion, and morphology suggesting pyknosis or apoptosis in neuronal nuclei that continue to display eIF-2(αP) after 4 hours of reperfusion. These observations, together with the fact that eIF-2(αP) inhibits translation initiation, make a compelling case that eIF-2(αP) is responsible for reperfusion-induced inhibition of protein synthesis in vulnerable neurons.

Dysfunction of the Unfolded Protein Response During Global Brain Ischemia and Reperfusion

A variety of endoplasmic reticulum (ER) stresses trigger the unfolded protein response (UPR), a compensatory response whose most proximal sensors are the ER membrane–bound proteins ATF6, IRE1α, and PERK. The authors simultaneously examined the activation of ATF6, IRE1α, and PERK, as well as components of downstream UPR pathways, in the rat brain after reperfusion after a 10-minute cardiac arrest. Although ATF6 was not activated, PERK was maximally activated at 10-minute reperfusion, which correlated with maximal eIF2α phosphorylation and protein synthesis inhibition. By 4-h reperfusion, there was 80% loss of PERK immunostaining in cortex and 50% loss in brain stem and hippocampus. PERK was degraded in vitro by μ-calpain. Although inactive IRE1α was maximally decreased by 90-minute reperfusion, there was no evidence that its substrate xbp-1 messenger RNA had been processed by removal of a 26-nt sequence. Similarly, there was no expression of the UPR effector proteins 55-kd XBP-1, CHOP, or ATF4. These data indicate that there is dysfunction in several key components of the UPR that abrogate the effects of ER stress. In other systems, failure to mount the UPR results in increased cell death. As other studies have shown evidence for ER stress after brain ischemia and reperfusion, the failure of the UPR may play a significant role in reperfusion neuronal death.

Incidence of cocaine-Associated rhabdomyolysis

STUDY HYPOTHESIS Rhabdomyolysis is a common complication of cocaine use, and muscle symptoms fail to predict its development. STUDY POPULATION A prospective, convenience sample of patients presenting to the emergency department of a large inner-city hospital with complaints related to cocaine use were eligible for inclusion. Patients were excluded if they had other potential causes of elevated creatine kinase (CK) levels or rhabdomyolysis. A control group comprised patients who were not cocaine users and satisfied the exclusion criteria. Sixty-eight patients were studied. METHODS Initial evaluation included determination of the presence of muscle pain or swelling and total CK levels. Patients with a CK level of more than 800 U/L had additional tests, including a urine myoglobin, urine drug screen, and serum phosphorus. Rhabdomyolysis was defined by a serum CK level of more than 1,000 U/L (more than fivefold that of normal). CK levels were compared by two-tailed Students t test. Muscle symptoms were compared with the development of rhabdomyolysis by Fishers exact test. RESULTS The CK level in the cocaine group was 931 +/- 1,785 U/L (mean +/- 1 SD). The CK level in the control group was 242 +/- 168 U/L (P = .028). Of the cocaine users, 24% (eight of 34) had rhabdomyolysis; one developed multiorgan failure and died. No patient in the control group had a CK level of more than 1,000 U/L. Only one cocaine user who developed rhabdomyolysis had muscle symptoms. Three cocaine users had muscle symptoms but did not develop rhabdomyolysis. No patient in the control group had muscle symptoms or developed rhabdomyolysis. Muscle symptoms did not predict the CK level (P = .55). CONCLUSION This study revealed that 24% of the cocaine users had rhabdomyolysis. Many of the cases of rhabdomyolysis were not predictable from history or physical examination, making laboratory evaluation essential.

Brain iron delocalization and lipid peroxidation following cardiac arrest

Brain injury after cardiac arrest and resuscitation may occur, in part, by oxygen radical mechanisms. The availability of a transition metal, such as iron, is essential for in vitro initiation of this type of reaction. The brain has significant stores of iron bound in large proteins. We conducted this study to determine whether iron availability is enhanced in the canine brain following resuscitation from 15 minutes of cardiac arrest, and whether this iron is associated with the appearance of products of radical-mediated lipid peroxidation (LP) after two hours of reperfusion. Examination of the data by the method of multivariate analysis revealed significant increases in the low molecular weight species (LMWS) iron (300% of nonischemic controls, P less than .01), malondialdehyde (MDA), a lipid peroxidation degradation product (145% of nonischemic controls, P less than .01), and conjugated dienes (CD) (204% of nonischemic controls, P = .07). Therapy with deferoxamine (50 mg/kg IV immediately post resuscitation) produced a reduction in MDA and CD to levels statistically indistinguishable from nonischemic controls. We conclude that brain tissue iron is delocalized from normal storage forms to a LMWS pool after two hours of reperfusion following resuscitation from a 15-minute cardiac arrest, and that this is associated with increased products of LP. The increase in LP products is blocked by treatment with deferoxamine.

Brain μ-Calpain Autolysis During Global Cerebral Ischemia

Abstract: Proteolytic degradation of numerous calpain substrates, including cytoskeletal and regulatory proteins, has been observed during brain ischemia and reperfusion. In addition, calpain inhibitors have been shown to decrease degradation of these proteins and decrease postischemic neuronal death. Although these observations support the inference of a role for μ‐calpain in the pathophysiology of ischemic neuronal injury, the evidence is indirect. A direct indicator of μ‐calpain proteolytic activity is autolysis of its 80‐kDa catalytic subunit, and therefore we examined the μ‐calpain catalytic subunit for evidence of autolysis during cerebral ischemia. Rabbit brain homogenates obtained after 0, 5, 10, and 20 min of cardiac arrest were electrophoresed and immunoblotted with a monoclonal antibody specific to the μ‐calpain catalytic subunit. In nonischemic brain homogenates the antibody identified an 80‐kDa band, which migrated identically with purified μ‐calpain, and faint 78‐ and 76‐kDa bands, which represent autolyzed forms of the 80‐kDa subunit. The average density of the 80‐kDa band decreased by 25 ± 4 (p = 0.008) and 28 ± 9% (p = 0.004) after 10 and 20 min of cardiac arrest, respectively, whereas the average density of the 78‐kDa band increased by 111 ± 50% (p = 0.02) after 20 min of cardiac arrest. No significant change in the density of the 76‐kDa band was detected. These results provide direct evidence for autolysis of brain μ‐calpain during cerebral ischemia. Further work is needed to characterize the extent, duration, and localization of μ‐calpain activity during brain ischemia and reperfusion as well as its role in the causal pathway of postischemic neuronal injury.

Early amelioration of neurologic deficit by lidoflazine after fifteen minutes of cardiopulmonary arrest in dogs

A prospective, controlled, blind study was done to test the effect of a calcium entry blocker on the neurologic integrity of dogs after cardiopulmonary arrest. Ten male mongrel dogs were anesthetized, prepared with sterile technique, and instrumented for pulmonary arterial (PA) and systematic arterial pressure monitoring. A left thoracotomy and pericardotomy were performed. Cardiac arrest was produced by injecting KCl (1 mEq/kg) through the PA line, and the respirator was stopped. Full arrest was maintained for 15 minutes. Thereafter, the dogs were resuscitated with ventilation, internal massage, fluids, bicarbonate, epinephrine, and internal defibrillation. All dogs were resuscitated within 6 to 10 minutes. Five control dogs received saline placebo, and five dogs were treated with lidoflazine (1 mg/kg) IV drip immediately post resuscitation. All dogs were scored neurologically every two hours by a deficit grading scale. All treated dogs had spontaneous ventilation, reactive pupils and corneals, voluntary movements, and responses to tactile stimulation at 12 hours post resuscitation. Four of five control dogs had maximum deficit scores without improvement. The difference in neurologic scores between the treated and control groups became increasingly divergent with time, and was statistically significant (P less than .05) by four hours post resuscitation. Thus the calcium antagonist lidoflazine produces improvement in neurologic recovery in the first 12 hours after cardiopulmonary arrest in dogs.