Targeting gene-modified hematopoietic cells to the central nervous system: use of green fluorescent protein uncovers microglial engraftment.

Gene therapy in the central nervous system (CNS) is hindered by the presence of the blood-brain barrier, which restricts access of serum constituents and peripheral cells to the brain parenchyma. Expression of exogenously administered genes in the CNS has been achieved in vivo using highly invasive routes, or ex vivo relying on the direct implantation of genetically modified cells into the brain. Here we provide evidence for a novel, noninvasive approach for targeting potential therapeutic factors to the CNS. Genetically-modified hematopoietic cells enter the CNS and differentiate into microglia after bone-marrow transplantation. Up to a quarter of the regional microglial population is donor-derived by four months after transplantation. Microglial engraftment is enhanced by neuropathology, and gene-modified myeloid cells are specifically attracted to the sites of neuronal damage. Thus, microglia may serve as vehicles for gene delivery to the nervous system.

Stroke-induced immunodepression and post-stroke infections: lessons from the preventive antibacterial therapy in stroke trial.

UNLABELLED: Infections are a leading cause of death in patients with acute CNS injury such as stroke. Recent experimental evidence indicated that stroke leads to suppression of innate and adaptive peripheral immune responses which predisposes to infection. However, less is known on phenotypic and functional immune alterations in correlation with the occurrence of infectious complications in patients with acute stroke. EXPERIMENTAL PROCEDURES: In the recently completed randomized, double blind, placebo-controlled Preventive Antibacterial Therapy in Stroke (PANTHERIS) trial on the efficacy of short-term antibacterial therapy to prevent the development of post-stroke infections, we assessed longitudinal changes in lymphocyte subpopulations and mitogen-induced lymphocytic interferon gamma (IFN)-gamma production using flow cytometry in 80 patients with acute severe stroke at days 1, 3, 8, 90 and 180 after clinical onset. Plasma interleukin (IL)-6 and IL-10 concentration as well as urinary levels of norepinephrine and cortisol was assessed within the first 8 days after stroke. Patients of the placebo and verum (moxifloxacin) treatment groups who did or did not develop infections within 11 days after stroke were compared to identify immunological changes associated with the occurrence of post-stroke infections. RESULTS: Rapid T-lymphopenia and long-lasting suppression of lymphocytic IFN-gamma production were observed in all stroke patients. Patients of the placebo group who developed infections showed a trend toward greater decline of CD4+ Th cell counts and higher urinary levels of norepinephrine early after stroke than patients without infections. Onset of infections was accompanied with higher plasma IL-6 levels in the placebo group but not in the moxifloxacin group. In addition, an early rise in plasma IL-10 was detected in patients who developed infections despite preventive antibacterial treatment. CONCLUSION: A rapid loss and functional deactivation of T cells are common changes in stroke patients consistent with immunodepression after brain ischemia. A stronger decrease in cellular immune responses and an increased sympathetic activity after stroke are associated with a higher risk of infections. Increased plasma levels of the anti-inflammatory cytokine IL-10 early after stroke may identify patients who will not respond to preventive antibacterial therapy with moxifloxacin.

DNA methyltransferase contributes to delayed ischemic brain injury.

DNA methylation is important for controlling the profile of gene expression and is catalyzed by DNA methyltransferase (MTase), an enzyme that is abundant in brain. Because significant DNA damage and alterations in gene expression develop as a consequence of cerebral ischemia, we measured MTase activity in vitro and DNA methylation in vivo after mild focal brain ischemia. After 30 min middle cerebral artery occlusion (MCAo) and reperfusion, MTase catalytic activity and the 190 kDa band on immunoblot did not change over time. However, [(3)H]methyl-group incorporation into DNA increased significantly in wild-type mice after reperfusion, but not in mutant mice heterozygous for a DNA methyltransferase gene deletion (Dnmt(S/+)). Dnmt(S/+) mice were resistant to mild ischemic damage, suggesting that increased DNA methylation is associated with augmented brain injury after MCA occlusion. Consistent with this formulation, treatment with the MTase inhibitor 5-aza-2'-deoxycytidine and the deacetylation inhibitor trichostatin A conferred stroke protection in wild-type mice. In contrast to mild stroke, however, DNA methylation was not enhanced, and reduced dnmt gene expression was not protective in an ischemia model of excitotoxic/necrotic cell death. In conclusion, our results demonstrate that MTase activity contributes to poor tissue outcome after mild ischemic brain injury.

Distinct physiologic properties of microglia and blood-borne cells in rat brain slices after permanent middle cerebral artery occlusion.

The authors investigated the time course of leukocyte infiltration compared with microglial activation in adult rat brain slices after permanent middle cerebral artery occlusion (MCAO). To distinguish peripheral leukocytes from microglia, the blood cells were prelabeled in vivo with Rhodamine 6G (Rhod6G) i.v. before induction of ischemia. At specific times after infarct, invading leukocytes, microglia, and endothelial cells were labeled in situ with isolectin (IL)B4-FITC (ILB4). Six hours after MCAO only a few of the ILB4+ cells were colabeled by Rhod6G. These cells expressed the voltage-gated inwardly and outwardly rectifying K+ currents characteristic of macrophages. The majority of the ILB4+ cells were Rhod6G- and expressed a lack of voltage-gated channels, recently described for ramified microglial cells in brain slices, or exhibited only an inward rectifier current, a unique marker for cultured (but unstimulated) microglia. Forty-eight hours after MCAO, all blood-borne and the majority of Rhod6G- cells expressed outward and inward currents indicating that the intrinsic microglial population exhibited physiologic features of stimulated, cultured microglia. The ILB4+/Rhod6G- intrinsic microglial population was more abundant in the border zone of the infarct and their morphology changed from radial to ameboid. Within this zone, the authors observed rapidly migrating cells and recorded this movement by time-lapse microscopy. The current findings indicate that microglial cells acquire physiologic features of leukocytes at a later time point after MCAO.

Reduced skilfulness of arm motor behaviour among motor stroke patients with good clinical recovery: does it indicate reduced automaticity? Can it be improved by unilateral or bilateral training? A kinematic motion analysis study.

Functional cortical reorganisation had been demonstrated to accompany recovery from motor stroke. In agreement with a previous study, quantitative kinematic analysis of aimed movements in 14 almost completely recovered hemiparetic stroke patients and 14 healthy control subjects indicated a reduced skilfulness of both the more ballistic initial movement phase and the more feedback-guided late homing-in phase of aimed movements. By means of two dual motor tasks it was further investigated whether the reduced skilfulness of patients was due to an increased attentional demand and thus a reduced automaticity of motor control. Interference effects by dual tasks, however, were similar for patients and control subjects. Thus, the notion of reduced automaticity could not be supported empirically, and reduced skilfulness seemed rather related to residual pyramidal motor deficits. By means of a repetitive daily training for 1 week based on the Arm Ability Training approach, patients were able to reduce their performance deficits in both movement phases significantly. Whether patients practised with the affected arm or simultaneously with both the affected and non-affected arm only marginally modified outcome, unilateral training being slightly more efficacious. These findings demonstrate that even clinically minor residual motor deficits can be improved by a structured training for the affected arm.

Distinct influence of the group III metabotropic glutamate receptor agonist (R,S)-4-phosphonophenylglycine [(R,S)-PPG] on different forms of neuronal damage.

With this study we evaluated the influence of (R, S)-4-phosphonophenylglycine [(R,S)-PPG], a selective group III metabotropic glutamate receptor agonist, on excitotoxic, hypoxic/hypoglycaemic and ischaemic cerebral damage in rodents. Consistent with previous data showing neuroprotective and anticonvulsive effects (Gasparini, F., Bruno, V., Battaglia, G., Lukic, S., Leonhardt, T., Inderbitzin, W., et al., 1999. (R, S)-4-Phosphonophenylglycine, a potent and selective group III metabotropic glutamate receptor agonist, is anticonvulsive and neuroprotective in vivo. Journal of Pharmacology and Experimental Therapeutics 290, 1678-1687), we found pronounced neuroprotective effects with (R,S)-PPG (300 nmol) in a model of excitotoxicity, i.e. quinolinic acid-induced striatal lesions in rats. However, neither in focal cerebral ischaemia in mice nor in global cerebral ischaemia in gerbils or rats did (R,S)-PPG have any significant influence on the extent of neuronal damage. In a model of hypoxia/hypoglycaemia in acutely isolated hippocampal slices, however, (R,S)-PPG led to an improved recovery of population spike amplitude. As acutely isolated hippocampal slices are only viable for a few hours, these electrophysiological recordings can only be performed in a limited time window after the challenge-when most probably excitotoxicity is still the predominant influence in hypoxic pathophysiology. From this we conclude that group III mGluR agonists might be promising drugs against damage mediated mainly by excitotoxicity, but less likely against development of neuronal death due to ischaemia.

Glutamate antagonists in therapy of stroke.

It is well established that excitotoxicity is a key mechanism of tissue destruction in focal cerebral ischemia (stroke). Very soon after onset of a critical perfusion deficit energy failure leads to neuronal depolarization and release of excitatory amino acids, most notably glutamate. At the same time, energy dependent reuptake of excitatory amino acids is impede. Overstimulation of glutamate receptors (NMDA, AMPA/kainate, metabotropic) induces dramatically increased intracellular Ca2+ concentrations, release of K+ into the extracellular space, and cell swelling due to the passive movement of water with Na+ influx. The massively increased intracellular second messenger Ca2+ triggers numerous deleterious processes, including free radial formation and membrane degradation, mitochondrial dysfunction, inflammation, DNA-damage and apoptosis. A plethora of experimental studies have convincingly demonstrated the relevance of excitotoxicity in focal cerebral ischemia, and pointed to very effective experimental treatment strategies, many of which involve the blockade of glutamate receptors. Unfortunately, large clinical studies were so far unable to replicate the animal data in human stroke patients. This article, by reviewing excitotoxic damage of focal cerebral ischemia in the context of a complex pathophysiological cascade, aims at explaining this failure and stimulating further efforts in drug design and clinical evaluation to establish the first neuroprotective therapy of human stroke.

Acute treatment of hypertension increases infarct sizes in spontaneously hypertensive rats.

We studied the effect of dihydralazine treatment of hypertension in spontaneously hypertensive stroke-prone rats in a model of permanent focal cerebral ischemia (stroke). After occlusion of the middle cerebral artery systemic arterial pressure (SAP) was lowered with a computer controlled infusion device from 163 to 135 or 117 mm Hg for 24h. In the control group SAP was not manipulated. Reduction of SAP to normotension (117 mm Hg) significantly worsened outcome and increased infarct volume measured 7 days after induction of ischemia, whereas a mild reduction of SAP (to 137 mm Hg) had no statistically significant effect on outcome or infarct volume. We conclude that pharmacological treatment of hypertension may negatively affect neurological outcome and infarct volume in a rat stroke model.

Hyperbaric oxygenation induced tolerance against focal cerebral ischemia in mice is strain dependent.

SV129 or C57BL/6 mice were exposed to hyperbaric oxygenation (HBO, 5 days, 1 h every day, 100% O(2) at 3 atm absolute). One day after the 5th HBO session focal cerebral ischemia was induced. In SV129 mice, HBO induced tolerance against permanent focal cerebral ischemia (n=42, mean infarct volume reduction 27%, P=0.001), but not against transient (30 or 60 min) focal cerebral ischemia. In the C57BL/6 strain of mice, HBO did not induce tolerance against focal cerebral ischemia, even when the duration of ischemia or the HBO protocol were modified. For the first time we demonstrate that HBO can induce tolerance to focal cerebral ischemia, but this effect is strain dependent.

Improved selective, simple, and contrast staining of acidophilic neurons with vanadium acid fuchsin.

Acidophilia is one of the hallmarks of acute neuronal damage and death in brain ischemia, excitotoxic and traumatic lesions and epileptic seizures. We here describe a novel and simple method for visualizing acidophilic neurons on paraffin sections, using vanadium acid fuchsin (VAF) staining and toluidine blue or hematoxylin counterstaining. Paraffin sections of the brain fixed in ethanol-formalin-acetic acid mixture are stained in 0.1% acid fuchsin containing 0.125% of ammonium metavanadate and 1% of glacial acetic acid, differentiated if overstained in 0.01% of borax solution, and counterstained with 0.05-0.025% of toluidine blue in acetate buffer (pH 3.3) or Gill's II hematoxylin. The sections are dehydrated, cleared in xylene and mounted in Canada balsam or any synthetic mounting media for light microscopy. VAF combined with toluidine blue or hematoxylin results in highly selective and reproducible color contrast staining of acidophilic neurons as well as glial nuclei and hyperchromatic neurons. As a progressive method, acid fuchsin staining usually does not require differentiation. The red acidophilic neurons are clearly visible on the background of non-damaged cells, which significantly facilitates the identification, and localization of damaged neurons, even at low magnification under the light microscope.

A flow sensitive alternating inversion recovery (FAIR)-MRI protocol to measure hemispheric cerebral blood flow in a mouse stroke model.

Blood flow imaging is an important tool in cerebrovascular research. Mice are of special interest because of the potential of genetic engineering. Magnetic resonance imaging (MRI) provides three-dimensional noninvasive quantitative methods of cerebral blood flow (CBF) imaging, but these MRI techniques have not yet been validated for mice. The authors compared CBF imaging using flow sensitive alternating inversion recovery (FAIR)-MRI and (14)C-Iodoantipyrine (IAP)-autoradiography in a mouse model of acute stroke. Twenty-nine male 129S6/SvEv mice were subjected to filamentous left middle cerebral artery occlusion (MCAo). CBF imaging was performed with (14)C-IAP autoradiography and FAIR-MRI using two different anesthesia protocols, namely intravenous infusion of etomidate or inhalation of isoflurane, which differentially affect perfusion. Using (14)C-IAP autoradiography, the average CBF in ml/(100 g*min) was 160+/-34 (isoflurane, n=5) vs. and 59+/-21 (etomidate, n=7) in the intact hemisphere and 43+/-12 (isoflurane, n=5) vs. 36+/-12 (etomidate, n=7) in the MCAo hemisphere. Using FAIR-MRI, the corresponding average CBFs were 208+/-56 (isoflurane, intact hemisphere, n=7), 84+/-9 (etomidate, intact hemisphere, n=7), 72+/-22 (isoflurane, MCAo hemisphere, n=7) and 48+/-13 (etomidate, MCAo hemisphere, n=7). Regression analysis showed a strong linear correlation between CBF measured with FAIR-MRI and (14)C-IAP autoradiography, and FAIR-MRI overestimated CBF compared to autoradiography. FAIR-MRI provides repetitive quantitative measurements of hemispheric CBF in a mouse model of stroke.

[Immunotherapy of chronic inflammatory demyelinating polyneuropathy]. / Immuntherapie der chronisch inflammatorischen demyelinisierenden Polyneuropathie.

Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired immune-mediated disease of the peripheral nervous system with an estimated prevalence of 1-2/100,000. The clinical presentation is heterogeneous, but the most common form causes symmetrical progressive or relapsing weakness affecting proximal and distal muscles. CIDP is among the most treatable peripheral nerve disorders and corticosteroids, plasmapheresis and intravenous immunoglobulin have been shown to be effective in short-term prospective, randomized controlled trials. Data however indicate that approximately one-third of patients do not respond to these treatment modalities, nor do they provide equivalent evidence for a durable clinical response. There is a lack of good quality controlled trials of any other immunosuppressive agent, but cyclophosphamide and cyclosporin may be of value in patients with poor response to first-line modalities. Alternatively, the use of combination therapy may increase the efficacy in unresponsive patients. This review highlights the current status of CIDP treatment trials and discusses the significance of any therapeutic option in terms of efficacy, tolerability and cost-effects.

Testing a motor performance series and a kinematic motion analysis as measures of performance in high-functioning stroke patients: reliability, validity, and responsiveness to therapeutic intervention.

OBJECTIVE: To assess measurement properties of motor performance tests when used with high-functioning stroke patients. DESIGN: Test-retest reliability study with an interval of 2 days; responsiveness study with assessment before and after training; validity study assessing the tests' ability to discriminate between the high-functioning stroke patients and healthy subjects. SETTING: Referral center for neurorehabilitation. PARTICIPANTS: Twenty-nine high motor-functioning stroke patients and 20 healthy control subjects. INTERVENTION: Two special training sessions per day on 5 consecutive days, plus regular therapy. OUTCOME MEASURES: Scores on the motor performance series, a two-dimensional tracking test, and a kinematic task analysis. RESULTS: All tests (except the bimanual test) were able to document performance deficits with these patients and showed a moderately high to high test-retest reliability without systematic trend from test to retest (intraclass correlation coefficients for main variables, .61 to .89). The kinematic task especially demonstrated changes after training (standardized response means for timing variables, .53 to .66). A subset of variables indicated a modifying effect of limb side, age, and gender. CONCLUSION: All tests (except the bimanual test) can be used for both cross-sectional and follow-up group studies with high-functioning stroke patients. Measurement properties and the lack of comprehensive normative data limit their use with individual patients.

[Ischemia tolerance; model for research, hope for clinical practice?]. / Ischämietoleranz. Modell für die Forschung, Hoffnung für die Klinik?

A brief episode of ischemia renders the brain resistant against subsequent, longer ischemic events. This ischemic tolerance has been shown in numerous experimental models of cerebral ischemia. After global cerebral ischemia, ischemic tolerance may protect up to 90% of hippocampal CA1 neurons. In focal ischemia, this phenomenon reduces infarct volume by 20-60%. However, the basic molecular mechanisms of ischemic tolerance are largely unknown. During the induction phase, N-methyl-d-aspartate (NMDA) and adenosine receptors and, possibly, oxygen free radicals and conservation of energy metabolism are required. Protein kinases, transcription factors, and immediate early genes appear to transduce the signal into a tolerant response. Ischemic tolerance can be observed in different phases. The early phase lasts for several hours after the preconditioning stimulus and adenosine receptors and ATP-dependent potassium channels play a role similar to that in cardiac ischemic tolerance. The delayed protection, retained for a maximum of 2-4 days, currently is best explained by genetic remodeling with expression or repression of multiple genes. Several candidates have been identified to date, among them heat-shock proteins, cytokines, and antioxidant enzymes. Several studies have shown that angina pectoris before myocardial infarction represents a clinical correlate of experimental preconditioning protocols. Accordingly, evidence for a possible protective effect of transient ischemic attacks (TIAs) occurring before stroke are accumulating.

Adult-onset Leukoencephalopathy with vanishing white matter presenting with dementia.

We report on a case of dementia and extensive cerebral white matter abnormalities seen on magnetic resonance-images which meet the criteria for leukoencephalopathy with vanishing white matter. This is an inherited condition that was first thought to occur only in children. Our patient shows that vanishing white matter should be considered in adult patients with early-onset dementia and extensive white matter changes seen on magnetic resonance images.