Correlation of hemorrhage, axonal damage, and blood-tissue barrier disruption in brain and retina of Malawian children with fatal cerebral malaria.

BACKGROUND: The retinal and brain histopathological findings in children who died from cerebral malaria (CM) have been recently described. Similar changes occur in both structures, but the findings have not been directly compared in the same patients. In this study, we compared clinical retinal findings and retinal and cerebral histopathological changes in a series of patients in Blantyre, Malawi, who died of CM. METHODS: The features systematically compared in the same patient were: (1) clinical, gross and microscopic retinal hemorrhages with microscopic cerebral hemorrhages, (2) retinal and cerebral hemorrhage-associated and -unassociated axonal damage, and fibrinogen leakage, and (3) differences in the above features between the pathological categories of CM without microvascular pathology (CM1) and CM with microvascular pathology (CM2) in retina and brain. RESULTS: Forty-seven patients were included: seven CM1, 28 CM2, and 12 controls. In the 35 malaria cases retinal and cerebral pathology correlated in all features except for non-hemorrhage associated fibrinogen leakage. Regarding CM1 and CM2 cases, the only differences were in the proportion of patients with hemorrhage-associated cerebral pathology, and this was expected, based on the definitions of CM1 and CM2. The retina did not show this difference. Non-hemorrhage associated pathology was similar for the two groups. COMMENT: As postulated, histopathological features of hemorrhages, axonal damage and non-hemorrhage associated fibrinogen leakage correlated in the retina and brain of individual patients, although the difference in hemorrhages between the CM1 and CM2 groups was not consistently observed in the retina. These results help to underpin the utility of ophthalmoscopic examination and fundus findings to help in diagnosis and assessment of cerebral malaria patients, but may not help in distinguishing between CM1 and CM2 patients during life.

Hypoxia signaling regulates macrophage migration inhibitory factor (MIF) expression in stroke.

The macrophage migration inhibitory factor (MIF) is a multifaceted cytokine involved in many processes, including cellular responses to ischemia/reperfusion injury in the heart and brain. This study was undertaken to determine whether human MIF expression is induced following cerebral ischemia and its role therein. To examine whether the induction of MIF gene expression was mediated by its transcriptional upregulation, the human MIF gene promoter was cloned and a luciferase assay was used to determine the presence of a hypoxia-responsive region in the human MIF promoter. We found that human MIF promoter activity was significantly upregulated by hypoxia. A functional hypoxia-inducible factor 1α-binding site was identified using an electrophoretic mobility shift assay (EMSA). MIF has a protective effect on cortical neurons under oxygen-glucose deprivation (OGD) treatment. MIF significantly reduced OGD-induced cell death. To determine whether the expression of MIF in the human brain is altered following ischemia, brain sections from 10 stroke patients were examined with an antibody against MIF. Blood vessel endothelial cells in the peri-infarct region of ischemic brain displayed strong MIF immunoreactivity with no MIF immunoreactivity in control brains. Furthermore, we found that treatment of human brain endothelial cells with MIF had no effect on human monocyte adhesion to endothelium. Our study demonstrates that MIF gene expression is altered during stroke and dysregulation of the hypoxia signaling-induced MIF expression plays an important role in neuronal death in stroke.

Differential regulation of CD4+ T cell adhesion to cerebral microvascular endothelium by the ß-chemokines CCL2 and CCL3.

In Multiple sclerosis (MS), circulating lymphocytes cross the blood-brain barrier (BBB) and accumulate at sites of antigenic challenge. This process depends on specific interactions between lymphocytes and cerebral microvascular endothelium that involve endothelial activation by cytokines and the presence of chemokines. Chemokines play a key role in the orchestration of immune responses, acting both as chemoattractants and activators of leukocyte subsets. In the present study, we investigated the effects of the beta-chemokines, CCL2 and CCL3, on the adhesion of CD4+ T cell subsets to human brain microvessel endothelial cells (HBMEC). Chemokines added to the lower compartment of a two-chamber chemotaxis system under confluent resting or cytokine-activated HBMEC, diffused through the culture substrate and bound to the basal surface of HBMEC. The low rate of adhesion of naïve, resting and memory CD4+ T cells to resting HBMEC was significantly upregulated following treatment of HBMEC with TNF-alpha and IFN-g. Recently activated CD4+ T cells readily adhered to resting monolayers. Concentration gradients of CCL2 upregulated the adhesion of activated CD4+ T cells to cytokine treated but not resting HBMEC. The presence of CCL3 in the lower chamber increased the adhesion of memory T cells to both unstimulated and cytokine-treated HBMEC. These findings emphasize the importance of brain endothelial cell activation and the role of CCL2 and CCL3 in regulating the adhesion of CD4+ T cell subsets to BBB endothelium, thus contributing to the specificity of immune responses in MS.

The neuropathology of fatal cerebral malaria in malawian children.

We examined the brains of 50 Malawian children who satisfied the clinical definition of cerebral malaria (CM) during life; 37 children had sequestration of infected red blood cells (iRBCs) and no other cause of death, and 13 had a nonmalarial cause of death with no cerebral sequestration. For comparison, 18 patients with coma and no parasitemia were included. We subdivided the 37 CM cases into two groups based on the cerebral microvasculature pathology: iRBC sequestration only (CM1) or sequestration with intravascular and perivascular pathology (CM2). We characterized and quantified the axonal and myelin damage, blood-brain barrier (BBB) disruption, and cellular immune responses and correlated these changes with iRBC sequestration and microvascular pathology. Axonal and myelin damage was associated with ring hemorrhages and vascular thrombosis in the cerebral and cerebellar white matter and brainstem of the CM2 cases. Diffuse axonal and myelin damage were present in CM1 and CM2 cases in areas of prominent iRBC sequestration. Disruption of the BBB was associated with ring hemorrhages and vascular thrombosis in CM2 cases and with sequestration in both CM1 and CM2 groups. Monocytes with phagocytosed hemozoin accumulated within microvessels containing iRBCs in CM2 cases but were not present in the adjacent neuropil. These findings are consistent with a link between iRBC sequestration and intravascular and perivascular pathology in fatal pediatric CM, resulting in myelin damage, axonal injury, and breakdown of the BBB.

Epstein-Barr virus infection of human brain microvessel endothelial cells: a novel role in multiple sclerosis.

Multiple sclerosis (MS) is an inflammatory neurological disease that is widely regarded as the outcome of complex interactions between a genetic predisposition and an environmental trigger. Epstein-Barr virus (EBV) has recently been associated with the onset of MS, yet understanding how it elicits autoimmunity remains elusive. Neuroinflammation, including the entry of autoreactive T cells, likely follows a breach of the blood-brain barrier (BBB) leading to CNS lesions in MS. We show that EBV can infect human BBB cells leading to increased production of pro-inflammatory mediators that result in immune cell adherence thus modeling a key step in MS pathogenesis.

Regulation of CCL2 and CCL3 expression in human brain endothelial cells by cytokines and lipopolysaccharide.

BACKGROUND: Chemokines are emerging as important mediators of CNS inflammation capable of activating leukocyte integrins and directing the migration of leukocyte subsets to sites of antigenic challenge. In this study we investigated the expression, release and binding of CCL2 (MCP-1) and CCL3 (MIP-1alpha) in an in vitro model of the human blood-brain barrier. METHODS: The kinetics of expression and cytokine upregulation and release of the beta-chemokines CCL2 and CCL3 were studied by immunocytochemistry and enzyme-linked immunosorbent assay in primary cultures of human brain microvessel endothelial cells (HBMEC). In addition, the differential binding of these chemokines to the basal and apical endothelial cell surfaces was assessed by immunoelectron microscopy. RESULTS: Untreated HBMEC synthesize and release low levels of CCL2. CCL3 is minimally expressed, but not released by resting HBMEC. Treatment with TNF-alpha, IL-1beta, LPS and a combination of TNF-alpha and IFN-gamma, but not IFN-gamma alone, significantly upregulated the expression and release of both chemokines in a time-dependent manner. The released CCL2 and CCL3 bound to the apical and basal endothelial surfaces, respectively. This distribution was reversed in cytokine-activated HBMEC resulting in a predominantly basal localization of CCL2 and apical distribution of CCL3. CONCLUSIONS: Since cerebral endothelial cells are the first resident CNS cells to contact circulating leukocytes, expression, release and presentation of CCL2 and CCL3 on cerebral endothelium suggests an important role for these chemokines in regulating the trafficking of inflammatory cells across the BBB in CNS inflammation.

Regulation of CXCL12 and CXCR4 expression by human brain endothelial cells and their role in CD4+ and CD8+ T cell adhesion and transendothelial migration.

Chemokines have emerged as important mediators of leukocyte recruitment to the CNS across the normally restrictive blood-brain barrier (BBB). In the present study we investigated the regulation of CXCL12 and its receptor, CXCR4, expression in human brain microvessel endothelial cells (HBMEC) and the effects of CXCL12 on the adhesion and migration of CD4+ and CD8+ T lymphocytes across HBMEC monolayers. Resting HBMEC constitutively expressed CXCL12 and CXCR4. Treatment with TNF-alpha, IFN-gamma, IL-1beta and LPS downregulated CXCL12 and CXCR4 expression and CXCL12 ligation induced internalization of CXCR4. The minimal adhesion and migration of CD4+ and CD8+ T lymphocytes across resting HBMEC were increased following cytokine treatment of HBMEC. CXCL12 gradients further enhanced adhesion of both T cell subsets to activated HBMEC and migration across resting monolayers. A greater number of CD8+ T lymphocytes adhered and migrated across activated HBMEC compared to CD4+ T cells. These studies provide insight into the regulation of CXCL12 and CXCR4 expression in cerebral EC and indicate an important role for CXCL12 in T cell subset recruitment across the BBB in CNS inflammation.

Dendritic cell adhesion to cerebral endothelium: role of endothelial cell adhesion molecules and their ligands.

Dendritic cells (DCs) have been increasingly implicated in the pathogenesis of neuroinflammation, and there is evidence that they are recruited to the brain across the blood-brain barrier. The molecular mechanisms mediating DC trafficking to the central nervous system are poorly understood. This study used an in vitro model of the human blood-brain barrier and monocyte-derived DCs to investigate the role of endothelial cell (EC) adhesion molecules and their ligands in the adhesion of immature and mature DCs to cerebral microvascular ECs. Adhesion of DCs to resting brain ECs was minimal, but activation of ECs with tumor necrosis factor significantly upregulated adhesion. Immature DCs adhered to activated ECs more avidly than mature DCs; this correlated with differences in the expression of adhesion molecule ligands between the mature and immature DCs. Blocking studies indicated that adhesion to cytokine-activated blood-brain barrier endothelium is mediated by intercellular adhesion molecule (ICAM)-1, ICAM-2, platelet-EC adhesion molecule (PECAM)-1, vascular cell adhesion molecule 1, CD18, and DC-specific ICAM-3-grabbing nonintegrin (DC-SIGN) for immature DCs and ICAM-1, CD18, DC-SIGN, and PECAM-1 for mature DCs. These results suggest that DC adhesion to cerebral ECs depends on the maturation state of DCs and the activation state of the endothelium, and that it is regulated by specific receptor-ligand interactions. This study thus further highlights the active role of human brain microvascular ECs in neuroinflammation.

Histopathologic features of multiple myeloma involving the optic nerves.

We report a case of optic nerve involvement by multiple myeloma in which progressive visual loss heralded leukemic transformation and intracranial involvement. Imaging showed enhancing nodules in the intracranial segments of both optic nerves posterior to the optic canals and in the anterior optic tract, optic chiasm, and basal leptomeninges. Postmortem histopathologic examination disclosed malignant plasma cells in the subarachnoid spaces around the optic nerves and in the optic nerves. Infarctions were present in both optic nerves near their junction with the globes. Microscopic examination also showed malignant plasma cell infiltration of the leptomeninges of the cerebrum, brain stem, optic chiasm, pituitary gland, cranial bone marrow, and subarachnoid blood vessels. This is the first reported histopathologic examination in conjunction with MRI of multiple myeloma involving the anterior visual pathway. The mechanism of optic neuropathy in this case is probably related to infiltration of the optic nerve meninges by malignant plasma cells and impaired vascular supply caused by aggregated intraluminal plasma cells and monoclonal hypergammaglobulinemia.

Adhesion and migration of polymorphonuclear leukocytes across human brain microvessel endothelial cells are differentially regulated by endothelial cell adhesion molecules and modulate monolayer permeability.

The mechanisms by which polymorphonuclear leukocytes (PMN) cross the human blood-brain barrier have not been fully elucidated. Using a well characterized in vitro model of the human BBB, we examined the role of endothelial cell adhesion molecules on the adhesion and transendothelial migration of PMN across primary cultures of human brain microvessel endothelial cells (HBMEC). A small number of PMN (0.06%) adhered to unstimulated HBMEC, and the basal adhesion was not affected by anti-adhesion molecule antibodies. Treatment of HBMEC with tumor necrosis factor (TNF)-alpha resulted in increased PMN adhesion that was significantly inhibited by blocking antibodies to E-selectin and ICAM-1, but not VCAM-1 or PECAM-1. A very small number of adherent PMN migrated across unstimulated HBMEC monolayers. Migration increased 2 to 20 fold following stimulation of HBMEC with TNF-alpha. Monoclonal antibody blocking studies showed that PMN used ICAM-1, but not VCAM-1, E-selectin or PECAM-1 to move across activated monolayers. Anti-adhesion molecule antibodies did not diminish the basal PMN migration. Ultrastructurally, PMN often aggregated on top and between adjacent endothelial cells and adhered by first extending pseudopodia along the apical endothelial surface. They then flattened and inserted themselves between endothelial cells in order to migrate across the monolayers. At the end of the migration period, the cultures resumed their continuity with no evidence of disruption. Transendothelial migration of PMN decreased the transendothelial electrical resistance and increased the permeability to horseradish peroxidase, which penetrated alongside the migrating leukocytes. A blocking antibody to ICAM-1 that greatly decreased migration, had no effect on the permeability changes. These studies provide insights into the mechanisms that regulate the entry of PMN into the brain and the increased permeability of the BBB in CNS inflammation.

Midline cerebellar medulloblastoma in a seventy-one-year-old patient.

BACKGROUND: Medulloblastoma is the most common malignant central nervous system tumour in children but, in contrast, quite rare in adults. Hemispheric, rather than midline, cerebellar medulloblastomas are more common in older children and adults. We present the unusual case of a 71-year-old man who presented with a fourth ventricular mass that proved to be a medulloblastoma. METHODS: A 71-year-old man presented with progressive balance problems, slurred speech and double vision. A CT scan of the brain revealed a hyperattenuating, partially calcified, avidly enhancing mass within the fourth ventricle. Diffusion weighted MRI showed restricted diffusion within the mass. The patient underwent a midline suboccipital craniotomy and a subtotal resection was achieved. RESULTS: Histological examination showed a densely cellular neoplasm composed of small cells with a tendency towards neuroblastic rosette formation. Most cells were strongly positive for neuron-specific enolase and synaptophysin. Ultrastructurally, tumour cells showed evidence of neuronal differentiation. These findings were consistent with a classical medulloblastoma. CONCLUSION: Adult medulloblastoma should be considered in the differential diagnosis of a partially calcified hyperattenuating mass within the fourth ventricle.

Severe vascular disturbance in a case of familial brain calcinosis.

Here we present the first neuropathological study of a case of autosomal dominant brain calcinosis in a family followed through five generations. The 71-year-old female who came to autopsy had unusually severe and extensive bilateral brain calcifications. The process appeared to start with deposition of minute calcium-positive spheroids of less than 1 mum in diameter in capillaries that otherwise appeared normal. These could be observed extending to areas distant from the main pathology. In more advanced stages, larger spheroids completely covered some capillaries while sparing others. In heavily affected regions, ghost capillaries were observed where only calcium spheroids remained after endothelial cells and basement membranes had disappeared. Vessels of all sizes were affected, and large accretions were observed in the basal ganglia, thalamus and cerebellum. Combined scanning electron microscopy and X-ray spectrometry of these large deposits revealed a dominant presence of calcium and phosphorous, plus carbon and oxygen indicative of organic material, and small amounts of sodium, potassium, sulfur, and magnesium. Reactive astrocytes and reactive microglia accumulated around the calcified deposits, indicating a mild ongoing inflammatory process. The results suggest that severe vascular impairment and mild inflammation contribute to the slow but inexorable progression of hereditary brain calcinosis.

Nitric oxide reduces T lymphocyte adhesion to human brain microvessel endothelial cells via a cGMP-dependent pathway.

The entry of lymphocytes into the brain is normally limited by the blood-brain barrier, however, during inflammation prominent lymphocytic infiltration occurs. In this study, we investigated the effects of nitric oxide (NO) on the adhesion of T cells to cultured human brain microvessel endothelial cells. T cell adhesion to unstimulated or tumor necrosis factor-alpha (TNF-alpha)-treated cells was quantified by counting the number of lymphocytes bound to the monolayer by light microscopy. TNF-alpha increased T cell adhesion in a time-dependent manner. Incubation of monolayers with NO donors decreased adhesion. This effect was blocked by a guanylyl cyclase inhibitor and mimicked by a cGMP agonist, and was thus dependent on the generation of cGMP. NO did not modulate adhesion molecule expression in the endothelial cells, suggesting an action on the T cells. Pre-treatment of T cells with NO or a cGMP agonist decreased binding to recombinant endothelial adhesion molecules. These findings suggest that NO can modulate the adhesion of T cells to human brain microvessel endothelial cells via a cGMP-dependent mechanism, and may thus regulate lymphocyte traffic during central nervous system inflammation.

Cytokines, nitric oxide, and cGMP modulate the permeability of an in vitro model of the human blood-brain barrier.

The endothelial cells (EC) of the microvasculature in the brain form the anatomical basis of the blood-brain barrier (BBB). In the present study, the effects of agents that modify the permeability of a well-established in vitro model of the human BBB were studied. The monolayers formed by confluent human brain microvessel endothelial cell (HBMEC) cultures are impermeable to the macromolecule tracer horseradish peroxidase (HRP) and have high electrical resistance. Exposure of HBMEC to various cytokines including TNF-alpha, IL-1beta, interferon gamma (IFN-gamma), or lipopolysaccharide (LPS) decreased transendothelial electrical resistance (TEER) mainly by increasing the permeability of the tight junctions. Primary cultures of HBMEC express endothelial nitric oxide synthase (eNOS) and produce low levels of NO. Treatment with the NO donors sodium nitroprusside (SNP) and DETA NONOate or the cGMP agonist 8-Br-cGMP significantly increased monolayer resistance. Conversely, inhibition of soluble guanylyl cyclase with ODQ rapidly decreased the resistance, and pretreatment of HBMEC with Rp-8-CPT-cGMPS, an inhibitor of cGMP-dependent protein kinase, partially prevented the 8-Br-cGMP-induced increase in resistance. Furthermore, NO donors and 8-Br-cGMP could also reverse the increased permeability of the monolayers induced by IL-1beta, IFN-gamma, and LPS. These results indicate that NO can decrease the permeability of the human BBB through a mechanism at least partly dependent on cGMP production and cGMP-dependent protein kinase activation.

Nitric oxide regulates interactions of PMN with human brain microvessel endothelial cells.

The hypothesis that the NO/cGMP pathway modulates PMN adhesion to human brain microvessel endothelial cells (HBMEC) was examined. Human PMN were incubated with resting or TNF-alpha-treated endothelial monolayers, and adhesion was quantified by light microscopy. TNF-alpha upregulated PMN adhesion in a time-dependent manner. Treatment of HBMEC with the NO donors SNP and DETA NONOate for 4 or 24 h decreased PMN adhesion. This was completely reversed by the guanylyl cyclase inhibitor ODQ, while addition of a cGMP agonist (8-Br-cGMP) decreased PMN adhesion. NO donors did not affect the levels of E-selectin or ICAM-1 in HBMEC. However, pre-treatment of PMN with NO donors or 8-Br-cGMP decreased their adhesion to recombinant E-selectin and ICAM-1, suggesting an effect of NO on PMN. These findings indicate that NO modulates PMN-HBMEC interactions through cGMP and decreases the binding of PMN to the adhesion molecules E-selectin and ICAM-1.

The beta chemokines CCL4 and CCL5 enhance adhesion of specific CD4+ T cell subsets to human brain endothelial cells.

Chemokines are key mediators of inflammation, acting as subset-specific chemoattractants and activators of leukocytes. In the present study we investigated the effects of chemokine concentration gradients on CD4+ T cell (TC4) adhesion to human brain microvessel endothelial cells (HBMECs) in vitro. CCL4 or CCL5 were placed in a double chamber chemotaxis system beneath confluent resting HBMEC monolayers or cultures co-incubated with TNF-alpha and IFN-gamma to mimic an inflammatory milieu. Chemokines readily diffused across activated HBMEC monolayers while binding to the sub-endothelial regions, establishing a chemotactic and haptotactic gradient. Naïve or resting TC4 adhered poorly to resting HBMECs compared to memory or recently activated TC4, but all subsets adhered more readily to cytokine-treated HBMECs. Chemokine gradients (10-100 ng/ml) of both CCL4 and CCL5 significantly enhanced the adhesion of memory and recently activated TC4 to cytokine-treated HBMECs, as much as doubling adhesion in a manner that correlated with chemokine receptor expression. Neither chemokine influenced adhesion to resting HBMEC monolayers nor the adhesion of resting or naïve TC4. These findings emphasize the role and importance of CNS-derived beta-chemokines in regulating the traffic of recently activated TC subsets (those previously localized to the CNS in vivo) across cytokine-activated cerebral endothelium in inflammatory diseases.

Notch activation results in phenotypic and functional changes consistent with endothelial-to-mesenchymal transformation.

Various studies have identified a critical role for Notch signaling in cardiovascular development. In this and other systems, Notch receptors and ligands are expressed in regions that undergo epithelial-to-mesenchymal transformation. However, there is no direct evidence that Notch activation can induce mesenchymal transdifferentiation. In this study we show that Notch activation in endothelial cells results in morphological, phenotypic, and functional changes consistent with mesenchymal transformation. These changes include downregulation of endothelial markers (vascular endothelial [VE]-cadherin, Tie1, Tie2, platelet-endothelial cell adhesion molecule-1, and endothelial NO synthase), upregulation of mesenchymal markers (alpha-smooth muscle actin, fibronectin, and platelet-derived growth factor receptors), and migration toward platelet-derived growth factor-BB. Notch-induced endothelial-to-mesenchymal transformation does not seem to require external regulation and is restricted to cells expressing activated Notch. Jagged1 stimulation of endothelial cells induces a similar mesenchymal transformation, and Jagged1, Notch1, and Notch4 are expressed in the ventricular outflow tract during stages of endocardial cushion formation. This is the first evidence that Jagged1-Notch interactions induce endothelial-to-mesenchymal transformation, and our findings suggest that Notch signaling may be required for proper endocardial cushion differentiation and/or vascular smooth muscle cell development.

Induction of beta-chemokine secretion by human brain microvessel endothelial cells via CD40/CD40L interactions.

beta-chemokines play an important role during the course of central nervous system (CNS) inflammation. Using primary cultures of human cerebral microvascular endothelial cells, we detected increased monocyte chemoattractant protein-1 (MCP-1) and regulated upon activation normal T cell expressed and secreted (RANTES) production following incubation with soluble CD40L. These results suggest a potential mechanism by which activated CD40L positive T cells may enhance beta-chemokine expression and thus influence the recruitment of mononuclear cells across the human blood-brain barrier.