Judith Sonn

Effects of brain oxygenation on metabolic, hemodynamic, ionic and electrical responses to spreading depression in the rat.

The effect of cortical spreading depression (CSD) on oxygen demand (extracellular K(+)), oxygen supply (cerebral blood flow - CBF) and oxygen balance (mitochondrial NADH) was studied by a special multiprobe assembly (MPA), during hypoxia and partial ischemia. The MPA was constructed and applied to monitor the CSD wave from its front line until complete recovery, continuously and simultaneously. CSD under hypoxia or partial ischemia led to an initial increase in NADH levels and a further decrease in CBF during the first phase of the CSD wave, indicating a decrease of tissue capability to compensate for an increase in oxygen demand. Furthermore, the special design of the MPA enabled identifying the close interrelation between oxygen demand, supply and balance during CSD propagation. In conclusion, brain oxygenation was shown to have a clear effect on tissue responses to CSD.

Relationship between Intracranial Pressure and Cortical Spreading Depression following Fluid Percussion Brain Injury in Rats

Traumatic brain injury (TBI) is known to be accompanied by an increase in intracranial pressure (ICP) and in some cases, by spontaneous generation of cortical spreading depression (CSD) cycles. However, the role of CSD in the pathophysiology of cerebral contusion is still unknown. A multiparametric monitoring assembly was placed on the right hemisphere of the rat brain to evaluate ICP, DC potential, extracellular K(+), cerebral blood flow (CBF), and electrocorticogram in 27 rats during 5 h. Fluid percussion brain injury (FPBI) with the magnitude of the impact 2.9, 3.3, 4.1, and 5.0 atmospheres was induced to the left parietal cortex in animal groups A, B, C, and D, respectively. A slow increase in ICP was evident, and was pronounced in group C and especially in group D, where four of nine animals died during the monitoring. At the end of the 5 h experiment, the mean ICP levels were 6.75 +/- 2.87, 8.40 +/- 2.70, 12.75 +/- 4.03, 29.56 +/- 9.25, and the mean total number of CSD cycles was 2.00 +/- 1.41, 4.29 +/- 4.23, 11.71 +/- 13.29, and 20.11 +/- 19.26 in groups A, B, C, and D, respectively. The maximal level of intensity of CSD cycle generation after FPBI was obtained in group D, where almost constant activity was maintained until the end of the experiment. A significant coefficient of correlation between ICP level and total number of CSD cycles was found for all ICP measurements (r = 0.47-0.63, p < 0.05, n = 27), however more significant (p < 0.001) was the coefficient during the period of monitoring between 2 and 4 h after FPBI. Our results suggest that numerous repeating CSD cycles are typical phenomena in moderate and especially severe forms of FPBI. The rising number of CSD cycles under condition of an ICP level >/=20 mm Hg may demonstrate, with high probability, the unfavorable development of TBI, caused by growing secondary hypoxic insult.

Effect of hyperbaric oxygenation on brain hemodynamics, hemoglobin oxygenation and mitochondrial NADH

To determine the HbO(2) oxygenation level at the microcirculation, we used the hyperbaric chamber. The effects of hyperbaric oxygenation (HBO) were tested on vitality parameters in the brain at various pressures. Microcirculatory hemoglobin oxygen saturation (HbO(2)), cerebral blood flow (CBF) and mitochondrial NADH redox state were assessed in the brain of awake restrained rats using a fiber optic probe. The hypothesis was that HBO may lead to maximal level in microcirculatory HbO(2) due to the amount of the dissolved O(2) to provide the O(2) consumed by the brain, and therefore no O(2) will be dissociated from the HbO(2). Awake rats were exposed progressively to 15 min normobaric hyperoxia, 100% O(2) (NH) and to 90 min hyperbaric hyperoxia (HH) from 1.75 to 6.0 absolute atmospheres (ATA). NH and HH gradually decreased the blood volume measured by tissue reflectance and NADH but increased HbO(2) in relation to pO(2) in the chamber up to a nearly maximum effect at 2.5 ATA. Two possible approximations were found to describe the relationship between NADH and HbO(2): linear or logarithmic. These findings show that the increase in brain microcirculatory HbO(2) is due to an increase in O(2) supply by dissolved O(2), reaching a maximum at 2.5 ATA. NADH is oxidized (decreased signal) in parallel to the HbO(2) increase, showing maximal tissue oxygenation and cellular mitochondrial NADH oxidation at 2.5 ATA. In conclusion, in the normoxic brain, the level of microcirculatory HbO(2) is about 50% as compared to the maximal level recorded at 2.5 ATA and the minimal level measured during anoxia.

The effect of ethanol on metabolic, hemodynamic and electrical responses to cortical spreading depression

Alcohol induces a decrease in cerebral blood flow (CBF) and metabolic rate, mitochondrial damage and other impairments in brain function and structure. Cortical spreading depression (CSD) is a phenomenon causing changes in ion homeostasis and raises energy demand, mitochondrial activity and CBF. It is of great interest to study the effect of ethanol on brain response under a challenge of increasing oxygen demand by inducing CSD. A special multisite assembly (MSA) was constructed to evaluate metabolic (mitochondrial NADH), hemodynamic (reflectance) and electrical (DC potential) activities from four parasagittally adjacently arranged areas of the cerebral cortex, continuously and simultaneously in vivo. Three CSD cycles were initiated every 30 min before and after ethanol or saline infusion over 4.5 h. During CSD amplitude changes of reflectance, NADH and DC potential as well as propagation rates and wave frequency were calculated. After ethanol infusion CSD showed a decrease in the negative shift of the DC potential, and alterations in the biphasic responses in reflectance, which may indicate alteration in blood volume: unclear responses in the initial vasoconstriction phase and a significant increase in the subsequent vasodilatation phase. The reduction in the amplitude of the NADH oxidation cycle may depict a decrease in energy production, which could also be indicated by a decline in wave frequency (prolonging the recovery phase of the CSD). The decrease in propagation rate indicates a decline in tissue excitability and in the CSD initiation mechanism induced by ethanol treatment.

Multiparametric monitoring of brain oxygen balance under experimental and clinical conditions.

In order to evaluate the relationship between brain oxygen supply and demand (O2 balance) in real time, it is necessary to use a multiparametric monitoring approach. Cerebral blood flow (CBF) is a representative parameter of O2 supply. The extracellular level of K+ is a reliable indicator of O2 demand since more than 60% of the energy consumed by the brain is utilized by active transport processes. Mitochondrial NADH redox state can represent the balance between O2 supply and demand. In order to monitor the brain of experimental animals or patients, we constructed the multiparametric assembly (MPA) and the following parameters were monitored simultaneously and in real time: CBF, CBV, NADH redox state, extracellular K+, DC potential, EEG, tissue temperature and ICP. Animals were exposed to hypoxia, ischemia, hypercapnia, hyperoxia and spreading depression (SD) and the relative changes in CBF and NADH were calculated and found to be significant indicators of brain energy state. Monitoring these two parameters increases the possibility of differentiating between various pathophysiological states. Each added parameter increases the power of diagnosis and determination of the functional state of the brain. Preliminary results obtained in patients monitored in the ICU or in the OR show that the responses to hypercapnia, spreading depression or ischemia are similar to those measured in experimental animals.

Effects of anesthesia on the responses to cortical spreading depression in the rat brain in vivo

Abstract Objectives: The aim of this study was to evaluate the effect of cortical spreading depression (CSD) on the metabolic, hemodynamic, electrical and ionic properties during anesthesia as compared with the awake state. Methods: The mitochondrial NADH redox state, reflected light, direct current (DC) potential, electrocorticography (ECoG), cerebral blood flow (CBF) and volume (CBV), and extracellular K+ concentrations ([K+]e), were measured continuously and simultaneously in real time using two unique monitoring systems that evaluate brain function. Three consecutive CSD waves were initiated using a KCl solution in both awake and anesthetized rats. Results and discussion: CSD caused typical amplitude changes: biphasic waves in reflectance, oxidation cycles in NADH, an increase in CBF, CBV and in [K+]e, a negative shift in DC potential and depression in ECoG. Anesthesia by equithesin decreased significantly the baseline levels of CBF and [K+]e, showing a reduction in oxygen supply and demand. After anesthesia, CSD significantly decreased [K+]e and NADH oxidation cycles, indicating a reduction in oxygen demand and in oxygen balance, respectively. Furthermore, anesthesia reduced CSD wave frequencies by slowing the recovery period, showing a decline in energy production during brain activation, or by changing electrophysiological properties of the tissue. No changes were found in the propagation rate and in the initiation period of CSD, which may indicate that equithesin does not block CSD initiation. In addition, we found that the whole cerebral cortex reacts homogenously to CSD and that equithesin may reduce oxygen demand and energy production, which may have a protective effect on the brain exposed to pathophysiological conditions.

Real-Time Assessment of Organ Vitality During the Transplantation Procedure

Although organ transplantation has become well established as a treatment modality for many patients with organ failure, little attention has been given to the evaluation of organ quality during its various steps. A critical factor in the success of the actual engraftment procedure is the integrity of energy metabolism and oxygen balance (supply/demand) at the microvasculature and intracellular mitochondrial level. The supply of oxygen to the cells is dependent on the saturation of hemoglobin (HbO2), tissue blood flow, and tissue oxygen partial pressure. The mitochondrial reduced nicotinamide adenine dinucleotide redox state represents oxygen balance in the tissue. Although these parameters can be monitored in all tissues of the body, demand for oxygen may be organ-specific. The various steps surrounding transplantation may require different techniques for the evaluation of tissue vitality. Assessment of blood flow or HbO2 is not possible during preservation of the organ. On the other hand, because extracellular levels of potassium may represent the energy demand processes in many organs, monitoring of extracellular potassium as an indicator of ionic homeostasis may provide important information regarding the quality of the preservation techniques. Although a large number of relevant studies have been performed in small laboratory animals, real-time monitoring in patients needs more practical tools. We present here the principles of multiparametric monitoring by which tissue vitality may be measured in both experimental and clinical situations. Much of the relevant literature on the subject is limited to the monitoring of kidney and liver. There are also some data on the monitoring of skin flaps. We have reviewed the major published reports in which organ and tissue vitality and quality were assessed in real time and will describe tissue and organ oxygen balance, vitality principles, technologic features of the various monitoring techniques, the clinical or experimental tools available and the conceptual and technologic aspects of the multiparametric monitoring concept. We will also discuss both experimental results and preliminary clinical observations by using multiparametric monitoring.

Effect of isoproterenol on regional myocardial segment work, O2 consumption, and oxygen balance

SummaryWe tested the hypothesis that positive inotropic stimulation by isoproterenol alters the relationship between regional segment work and regional myocardial oxygen consumption. Regional parameters were compared with external cardiac work and global LV oxygen consumption. In anesthetized openchest dogs, regional myocardial segment length (ultrasonic dimension crystals) and force development (miniature force transducer) were measured. The integrated multiples of myocardial shortening by corresponding force during an averaged beat expressed segment work (area under the systolic portion of the length-force loop). External cardiac work was calculated from aortic blood pressure and cardiac output. Global and regional myocardial MVO2 were evaluated at baseline and during intravenous infusion of isoproterenol (0.5 and 1.0 μg/kg per min). Regional coronary blood flow was measured with radioactive microspheres, and microspectrophotometry of frozen myocardial biopsies was used to evaluate O2 saturation in small arteries and veins. These parameters were used to calculate regional MVO2. Arterial and coronary sinus O2 saturation was used to calculate global LV O2 consumption. Regional myocardial O2 balance was estimated by measurement of NADH redox level using surface fluorometry. It was found that 0.5 μg/kg per min isoproterenol increased regional segment work/minute from 4650±495 to 6750±750 mm·g/min. Corresponding regional oxygen consumption was disproportionately increased from 5.43±0.61 to 15.24±1.37 ml/min per 100 g. External cardiac work was found to decrease from 728±13 to 562±25 mmHg·1/min (due to decreased aortic blood pressure), whereas global myocardial O2 consumption increased. Regional myocardial O2 extraction and NADH fluorescence were elevated, indicating impaired tissue oxygenation. Regional MVO2 was increased by 153±56%, but regional work by only 45.3±33% (P<0.05). These results indicate that regional contraction efficiency was markedly reduced by isoproterenol.

Differential effects of various inotropic agents on the intracellular NADH redox level in the in vivo dog heart.

A similar inotropic response was elicited by either increasing heart rate or infusing noradrenaline or ouabain in the open-chest dog preparation. Changes in local coronary blood supply and intracellular NADH redox level produced by these inotropic interactions were examined. Contractile tension was measured using a strain gauge arch; coronary flow, using a thermistor probe; and NADH redox level, by surface fluorometry. For each inotropic agent, isometric tension increased by about 40%. However, the mean increase in coronary flow was 80 ± 9.7% for adrenaline, 67 ± 18% for tachycardia, and 1 ± 10.8% for ouabain. The mean changes in intracellular NADH redox level were −17 ± 4.4%, 49 ± 8.4%, and −6 ± 6.4% for noradrenaline, tachycardia, and ouabain, respectively. The time course of changes in the various parameters was different following the onset of each inotropic stimulus. Furthermore, inducing tachycardia while the heart was under the influence of the various inotropic agents caused a reduction in contractility at different rates. These results indicate a large variation in the oxygen cost of contraction produced by these inotropic interventions, and also demonstrate notable variations in the intracellular oxygen balance. The possible relation between the intracellular NADH level and the “mechanical reserve” of cardiac muscle is discussed.

Real Time Monitoring of Intraoperative Allograft Vitality

URING the transplantation procedure, the organ preserved under low temperature is shifted toward the normothermic range. This temperature change shifts the mitochondria toward a more oxidized state and the mitochondria will depend on adequate tissue oxygenation. The successful rate of organ transplantation depends on adequate microcirculatory blood flow (O2 supply) and recovery of mitochondrial function to the normal range. Attempts to monitor kidney microcirculatory blood flow or mitochondrial NADH redox state were published. Based on the early studies, Thornilley et al applied the NADH fluorometry technique to study the kidney and liver during transplantation. 1 In parallel, Lu et al applied the laser Doppler flowmetry to study kidney blood flow under various physiological conditions. 2 As seen, those attempts to monitor the kidney during transplantation suggest the need as well as the value of the results in evaluating the kidney for its viability. In this report we are presenting for the first time preliminary results of a new device that enables the real time simultaneous monitoring of kidney microcirculatory blood flow and the mitochondrial NADH redox state in experimental animals as well as during human kidney transplantation. It is assumed, according to the published material and our preliminary studies, 3 that the monitoring of the microcirculatory blood flow and volume together with the mitochondrial NADH redox state will provide real time information on the viability of the transplanted kidney.