Pathophysiology 20 (2013) 513

Hypothermic protection in traumatic brain injury

Paul McCarthy a, , L. Keith Scott b , Chaitanya V. Ganta c , Alireza Minagar d
b a LSU Health-Shreveport, Ochsner Medical Center, New Orleans, LA, United States LSU Health, Emergency Medicine, Medicine, Pediatrics and Bioinformatics & Computational Biology, Shreveport, LA, United States c LSU Health, Molecular & Cellular Physiology, Shreveport, LA, United States d LSU Health, Neurology, Shreveport, LA, United States

Accepted 30 November 2011

1. Introduction Traumatic brain injury (TBI) remains a major cause of morbidity and mortality in North America for individuals below the age of 45 [70], in the US there are about 1.41.7 million cases of TBI leading to 300,000 hospital admissions, 50,000 deaths and over 80,000 patients with signicant disability each year [35,46]. Moderate or mild hypothermia (dened as a reduction in core temperature to 3234 C), administered prior to, during, or following induction of several forms of brain injury (including TBI) protects against development of brain injury in both animal and human studies and improves survival [95]. In stroke [7,69] and post cardiac arrest brain injury [72], hypothermia has been well documented to improve neurologic outcomes. Therapeutic hypothermia (TH) is currently recommended by American Heart Association for treatment of the post patient for neuroprotection cardiac arrest [65,2]. While the potential benecial effects of TH in the treatment of traumatic brain injury have been reported in the literature since the mid-1940s [30,47], and TH has often been shown to improve survival and outcomes in animal models of TBI [21,23] the clinical benets of TH in TBI are still under debate. TH is theoretically indicated for TBI-associated complications like intracranial pressure (ICP) >20 mm Hg and status epilepticus [41], but is not currently considered a rst-line treatment for TBI in the USA. TH is, however, in use for TBI in 47% of neurotrauma centers in Japan [87]. Because recent ndings [22] suggest that earlier (e.g. pre-hospital) applications of TH in the 34 h early window of opportunity may lead to improved outcomes in TBI, there has been widespread and renewed

interest and application of TH in TBI treatment [5]. TH may induce neuroprotection and minimize vascular injury in TBI by decreasing the release and response to excitotoxic neurotransmitters [54], diminishing reactive oxygen and nitrogen species, preserving mitochondrial energy homeostasis, and by preventing apoptosis/necrosis. The potential benets of therapeutic hypothermia in TBI therefore reect the suppression of several parallel, but not necessarily related pathways. Currently, standardized clinical policy decisions on if, when, and how TH should be administered in TBI depend on several factors which are discussed below.

2. Effects of TH on TBI pathophysiology Initially it was thought that hypothermia produced benet solely through temperature-dependent reductions in neuronal metabolism, to decrease overall demands for oxygen and glucose in the brain and decrease formation/accumulation of toxic metabolites. Early strategies for inducing hypothermia largely relied on surface-cooling techniques such as placing ice packs on the patient; these too often led to extreme variations in core temperature control; not only between different patients, but in individuals. Therapeutic hypothermia was frequently performed on general wards and was instituted in non-uniform manners. Currently, cooling is accomplished by administration of cold uids, by intra-arterial or intravenous cooling catheters, and surface-cooling systems. Therefore despite widely varying early clinical applications of TH, research on applying TH [8,93,63] has continued in animal, human and cell-based therapies. Neuronal destruction begins within minutes to several hours following an initial traumatic injury to the central nervous system (CNS); in TBI this may reect

Corresponding author. E-mail address: pbluesmd@yahoo.com (P. McCarthy).

0928-4680/$ see front matter 2012 Published by Elsevier Ireland Ltd. doi:10.1016/j.pathophys.2012.03.002

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(5) decreased excitotoxicity and (6) suppression of epileptic activity (Fig. 1).

3. Decreased cerebral metabolism induced by TH Cerebral metabolism decreases up to 10% for each C reduction in body temperature during cooling [56,62]. This nding drove early research to attempt lowering metabolism as far as possible by using deep hypothermia (<30 C). It is now understood that although reduced tissue metabolism is central to hypothermias protective effects, excessive hypothermia (and too rapid re-warming) carries signicant risk. When core body temperature drops to 32 C, basal metabolism decreases at least 50% and both oxygen consumption, CO2 production decreases to a similar degree. Hypothermia causes hypotension and bradycardia, with a greater reduction in heart rate than pressure. Hypothermia depresses (usually reversibly) cardiovascular reexes (e.g. baroceptors, renal sympathetic nerve activity)[71] and hypotensive, (but not hypercapnic) vasodilatation [40]. If controlled ventilator settings are not adjusted for changes in metabolism, this may lead to hyperventilation and metabolic alkalosis, leading to consequences such as cerebral vasoconstriction [25,24]. Decreased O2 consumption can increase blood oxygen levels, increasing the potential risk for oxidantmediated reperfusion injury [51]. Other metabolic changes associated with hypothermia include increased metabolism of fat, increased plasma levels of glycerol, free fatty acids, ketoacids, and lactic acid. These can provoke a mild metabolic acidosis [4]. Disturbances in acid/base balance, the failure of Na/K ATPase pumps, membrane depolarization, progressive mitochondrial dysfunction contribute to increased acidosis, a state that powerfully intensies many destructive processes [27,59]. At least part of the benet of TH in TBI may be preservation of tissue and cell pH which maintains Ca2+ homeostasis [45]. Glucose metabolism is affected by ischemiareperfusion [16] and similar observations have been made in severe TBI. Animal and clinical studies suggest that an initial increase in cerebral glucose metabolism in the hours following brain trauma is followed by a deep and persistent decrease in metabolic rate, with a depression of mitochondrial oxidative phosphorylation and glucose utilization (reecting a switch to anaerobic glycolysis) that can last for several weeks. Induced hypothermia applied during or after reperfusion increases the speed of metabolic recovery, with a better preservation of high-energy phosphates and reduced accumulation of toxic metabolites [83].

Fig. 1. Therapeutic hypothermia (TH) in brain injury. TH preserves cerebral and cerebrovascular integrity and suppresses inammatory/destructive cascades. Right side (blue arrow) shows suppressed signals and pathways, left side (red arrow) shows features and functions which are conserved through TH treatment. (For interpretation of the references to colour in this gure legend, the reader is referred to the web version of this article.)

direct physical trauma or delayed mechanisms reecting ischemia/reperfusion or progression of death pathways (Fig. 1). Cerebral ischemia may be induced by obstruction of a blood vessel, or edema, or vasospastic/constrictor mechanisms. The events in neuronal injury are similar regardless of the cause, although differences in injury reect both severity and duration. These processes which have been collectively described as secondary brain injury may continue for hours to days after the initial injury and can be re-initiated or aggravated by additional rounds of ischemia [65]. Neurologic destruction in TBI is temperature-dependent and fever provokes neurologic destruction in trauma, a process that can be controlled by mild/moderate hypothermia [66]. Because TBI varies in the type of injury, patient history, and the time after injury, the available window of opportunity for interventions such as TH vary and may affect the duration of TH required for to be effective as an intervention. For all these reasons, a better understanding of underlying mechanisms of TBI-TH may help us to better target treatments, and improve outcomes. A great deal of research on the neuroprotective effects of hypothermia has been accomplished in animals, but it would be dangerous to uniformly extrapolate these ndings to clinical TBI therapy. Animals used in TBI/TH studies, most often rodents, may benet more from the effects of TH than humans [6,26] and are highly uniform. Human backgrounds vary greatly producing different pathogenic mechanisms. Further, comparisons of animal and human models often fail to consider heating/cooling parameters which consider differences in tissue mass (and therefore tissue cooling/re-warming). TH prevents several secondary injury mechanisms in human TBI including: (1) decreased cerebral metabolism, (2) prevention of cell death [necrosis/apoptosis], (3) decreased bloodbrain barrier (BBB) breakdown and edema, (4) decreased neuroinammation,

4. Cell death programs, brain injury and TH Following ischemiareperfusion, cells may recover, become necrotic, or enter apoptosis [97,52]). The pathophysiology of brain injury is highly complex involving

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inammation, immune responses, biochemical alterations, (e.g. uid imbalance and extensive activation of cell death programs ([94,32,88]). Apoptosis begins late in trauma and usually continues for at least 48 h [48]. Apoptosis, and to some extent necrosis are mechanisms that can be prevented for some time after TBI, providing a window of opportunity for TH (Fig. 1). Cell death is broadly classied as apoptosis, necrosis and autophagy. All forms of cell death aggravate brain injury by triggering neuron-vascular cell death [43]. While apoptosis and autophagy are highly regulated programs in all the species, necrosis is considered disordered and non-programed [43]. It is important and interesting to note that the proteases which are central to highly organized process of apoptosis can also mediate necrosis [36,90]. Apoptotic cell death proceeds by 2 signaling pathways: extrinsic and intrinsic cell death [34]. Extrinsic cell death is mediated by ligation of Fas-Receptor to activate caspase-8, resulting in proteolytic activation of executioner caspases-3/7 leading to cell death while intrinsic cell death is mediated by BH3 family proteins and mitochondrial dysfunction [34,91]). In this latter process, cell injury signals promote translocation of Bax and Bid proteins from the cytosol to the mitochondrial membrane diminishing the mitochondrial membrane potential and releasing cytochrome-c and apoptosis inducing factor AIF [78,64]. Cytochrome-c plays a key role in the processing and activation of caspcase-3 which leads to cleavage of several cellular substrates to accomplish cell death [60]. Activation of caspase-3 and cleavage of its downstream substrate PARP-1 as well as DNA fragmentation are considered as classical hallmarks of apoptosis [75,15]. Several molecules like calpains, cathepsins and AIF which participate in caspase-independent forms of programmed cell death and necrosis exhibit signicant crosstalk which can result in apoptosis, necrosis or intermediate forms of cell death [89,10,14,12,13]. Several of these proteases and signaling events are modied by hypothermia and resulting in protection against brain injury and ischemia. Fas-L plays a crucial role in extrinsic apoptotic cell death [28]. Activated matrix metalloproteinases (MMPs) can also cleave Fas-L to trigger binding of Fas-L to FAS and activate the extrinsic pathway. Experimental hypothermia at 33 C has shown to decrease soluble Fas-L levels resulting in increased membrane bound Fas-L. This leads to decreased caspase-8 activation both in in vitro neuronal cultures subjected to oxygenglucose deprivation and in focal cerebral ischemia [53]. In the setting of apoptosis, the Bcl-2 protein family plays a very important role in the intrinsic apoptotic pathway. While Bcl-2 attenuates apoptosis, Bax and Bid proteins induce apoptosis suggesting that the ratio of Bcl2: Bax is a determining factor in effecting cell death via caspase activation. Hypothermia is known to limit apoptotic cell death however the underlying biochemical signaling mechanisms in this process are yet not clear. One recent report by Xiong et al. have shown that hypothermia not only decreases apoptosis via Bcl-2, but also enhances neurogenesis in the injured brain. Experimental

hypothermia induced at 3233 C not only decreased lesion size in neonatal hypoxic mice (7-day old) compared to normothermic controls but also increased the number of immature (BrdU+ /Tuj-1+ ) and mature (BrdU+/Map-2+ ) neurons at 7 days. Increased neurogenesis in injured striatum correlated with increased Bcl-2 expression, indicating that protection induced by hypothermia may reect increased neurogenesis and decreased apoptosis mediated by Bcl-2 [96]. This nding highlights the importance and potential for combining hypothermia with stem cell/growth factor therapy for stroke or TBI patients. However, Yenari et al. have indicated that anti-apoptotic effects of TH (in stroke) are mainly mediated by decreased cytochrome-c translocation rather than Bcl-2:Bax. No differences in Bcl-2, Bax or caspase activation levels were observed between mild hypothermic and normothermic animals [101]. Those results rather suggest that effects of hypothermia against injury in the neonatal/developing brain differ from adult mice brains. Furthermore, the status of Bid during hypothermia is not yet clear. Nevertheless, it is clear that hypothermia attenuates apoptocic brain destruction through either intrinsic or extrinsic pathways. Whether hypothermia can positively affect neurogenesis or mobilization of stem cells (e.g. from the sub ventricular zone) during stress in the adult brains is also worth investigating. A recent report by Li and Wang showed that mild hypothermia promoted neuronal survival (decreased neuronal apoptosis), improved neurological scoring and expression second mitochondrion-derived activator of caspases (SMAC). Hypothermia not only improved neurological scores (indicating improved brain function) but also decreased SMAC expression [49]. Both mild and moderate hypothermia [77,67] were neuroprotective, with neuroprotection paralleling the degree of TH. While cell viability in mild and moderate TH-treated groups was improved (compared to normothermics), mitochondrial function and apoptosis were better preserved in the moderate hypothermia treated group in vitro [38]. The protective nature of TH against cerebral ischemia was correlated to elevation of the RNA binding protein RBM-3 which promotes cell survival. Experimental moderate TH (at 32 C) showed a marked spatial-temporal increase in RBM-3 expression correlating with double cortin (neuron precursor cells) expression in perinatal asphyxia models. Inhibition of RBM-3 with small interfering-RNAs abolished the neuroprotective effects of TH but did not affect neuronal apoptosis. Overexpression of RBM-3 did however decrease PARP-1 cleavage and DNA fragmentation (classic markers of apoptosis) and decreased LDH release (a marker of necrosis) in neurons and brain-slice cultures even in the absence of TH [19]. This indicates that the protective effects of TH may be mediated by induction of RBM-3 following ischemia or injury. These ndings need to be investigated in adult animal models of brain injury. TH also inhibits neurotoxicity of Fe2+ and ascorbic acid, reduces oxidant stress and maintains a reduced glutathione/low redox state. Increased non-heme iron and ascorbic acid were observed in the cerebrospinal uid of infants with hypoxic

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ischemic encephalopathy. Hasegawa et al. investigated the effect of free iron and ascorbic acid on in vitro model of neuronal toxicity in neuron cultures. They observed that hypothermia at 3032 C effectively blocked the mitochondrial permeability pore transition and blocked release of both cytochrome-c and AIF, which stimulate DNA fragmentation (in caspase-independent cell death). Activation of caspase-3 was delayed by TH, effectively increasing the duration of the window of therapeutic intervention. Ohmura et al. showed that TH at 30 C (low hypothermia) protected against apoptosis by blocking cytochrome-c translocation from mitochondria to cytosol and also reduced caspase-3 and calpain activation in the cortex, hippocampus, and striatum in neonatal ischemic injury. More importantly the numbers of necrotic cells identied by conventional H&E staining were also signicantly reduced indicating that TH interferes with both apoptosis and inammation as well as necrotic cell death. Furthermore, oxidative stress and protein oxidation markers like ortho-, meta-, and di-tyrosine kinases and the lipid peroxidation marker 4-hydroxynonenal were all signicantly decreased at a 32 C temperature reduction from controls. TH also maintains the GSH/GSSG ratio which in turn prevents apoptosis [37]. These results indicate that TH prevents apoptosis by maintaining a favorable redox state in the brain environment in part through reductions in oxidant formation. Apart from inhibiting neuronal apoptosis, TH also protects the endothelium against apoptosis. Hypothermia at 33 C protected human umbilical vein endothelial cells from activation of Fas, caspase-8, Bax and increased Bcl-2 levels. Furthermore caspse-3 activation and PARP cleavage are also signicantly decreased in hypothermic umbilical vein endothelial cell cultures. Interestingly GPI-6150, a PARP inhibitor decreased hypoxic brain injury independent of hypothermia, suggesting that PARP-1 activation participates in necrosis. Accordingly PARP-1 inhibition combined with TH showed a pronounced effect in reducing injury [31]. Hypothermia also decreases JNK-1 activation via MKP-1 activation in endothelial cells [99]. Apart from preventing endothelial apoptosis, mild TH (at 33 C) also decreases endothelial inammation and immune cell inltration in stroke. Mild hypothermia in focal cerebral ischemia blocks ERK-1/2 activation and STAT-3 phosphorylation attenuating STAT-3 participation in ICAM-1 mediated adhesion [20]. This Endothelial and immune-cell inammatory programs can be attenuated by TH and may be important events in TH mediatd protection against TBI. These ndings may also be relevant in lethal hemorrhage; intense TH arrest (suspended animation) was effectively used as a novel new strategy for treating uncontrolled lethal hemorrhage. TH lowered IL-6 and increased HSP-70 (a protectant against cerebral ischemia) and increased levels of IL-10 (an anti-inammatory Th2 cytokine). The success of these results all appears to depend of the rate of cooling [17]. Modulation of apoptotic pathways can therefore play an important role in providing neuroprotection and in mitigating post-traumatic injury in human TBI. The proteases

which play central roles in tissue necrosis are calpains and cathepsins. Whether TH modulation of cathepsins and lysosomal biogenesis plays a major role in necrosis is not known, however TH is known to modulate the action of calpains in both apoptosis and necrosis. Calpains mediate both caspase-dependent, and -independent programs of cell death and also participates in oncosis and necrotic cell death [98]. Increased cellular Ca2+ levels result in the activation of - and m-calpain which have diverse roles in CNS pathologies. Activated calpains also cleave several cellular substrates including spectrin, PARP-1 and MAP2. Liebetrau et al. showed that experimental TH at 32 C decreased calpain activity and MAP-2 cleavage protecting against secondary proteolytic injury mediated by calpains [50]. Calpain inhibition has also been shown to be effective in cardiac preservation during prolonged TH [74] and may nd similar applications in TBI.

5. Bloodbrain barrier disruption, edema formation and TH Traumatic brain injury can lead to disruptions in the bloodbrain barrier (BBB), which leads to the development of brain edema. This can involve the release of high levels of excitotoxic amino acids (EAA), e.g. glutamate/aspartate from neurons into the parenchyma and CSF which provoke oxidant stress and barrier failure in the neurovasculature (neurons, endothelial cells) and neuroepithelia contributing to breakdown of the BBB [79,80,95]. Hypothermia is thought to reduce the TBI-mediated release and accumulation of glutamate in [55]. TH mediated protection from EAAs like glutamate also lowers excitotoxic signaling [61]. Breakdown of the BBB in TBI can reect matrix metalloprotease (MMP-2, MMP-9) activation [90,29] leading to degradation of occludin [1]. Mild hypothermia reduces bloodbrain barrier disruption following ischemiareperfusion [42] by decreasing MMP-9 [90]. Neuronal injury in TBI appears to be MMP-3 dependent and may involve EAA (glutamate/NMDAR) activation [29]. Bloodbrain barrier stabilization due to hypothermia also decreases the post-TBI parenchymal extravasation of hemoglobin [44] to reduce the risk of Fe2+ -Fenton chemistry derived oxidants. It is also important to note that mannitol, used in TBI and stroke, to decrease cerebral edema and lower ICP, can exacerbate BBB breakdown [18].

6. Immune responses, inammation and TH In brain injury, a signicant inammatory response begins about one hour after injury. Following TBI, proinammatory cytokines such as TNF-a, IL-1b, IL-6 and IL-18 as well as TGF-b are released by microglia, astrocytes and endothelial cells [100]. Elevated levels of cytokines and other inammatory mediators, which rapidly accumulate after TBI,

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contribute to brain injury [81], and remain elevated for several days [76]. Some cytokines clearly contribute to TBI disease activity (IL-1b), others (IL-18) may be more useful as TBI biomarkers [9]. Inammatory markers like IL-1, TNF- and importantly astrogliosis are limited by TH indicating that hypothermia is effective in attenuating brain inammation [11]. TBI triggers an accumulation of neutrophils in the injured brain, via upregulation of E-selectin [92]; while TBI-induced neutrophil accumulation was blocked by TH, it apparently does not involve a net suppression of E-selectin or ICAM1. These mediators stimulate the entrapment of activated leukocytes across the bloodbrain barrier. There is also an activation of the complement system, which begins in the very early stages after TBI and further stimulates neutrophil degranulation and oxidative burst [76]. These inammatory and immunologic responses are accompanied by superoxide production, which may intensify secondary TBI injury through a vicious cycle of [76] persistent cytokine (e.g. IL-1b) production and leukocyte inltration which increase neuronal injury. This effect is time-dependent, with the destructive aspects of inammation outweighing its potential benets [58,77]. There may be an early window for therapeutic interventions to interrupt immune-mediated secondary TBI injury before it becomes destructive.

(2) the duration of cooling: better results tend to occur with longer durations of therapy; (3) the speed of re-warming better outcomes occur when re-warming is performed slowly and (4) the prevention of side effects. Therapeutic hypothermia can be divided into three phases: (1) The initiation phase, which has a goal of achieving a temperature below 34 C as soon as possible; (2) the maintenance phase, which seeks to tightly control core temperature, with no major uctuations (maximum 0.2 C0.5 C); (3) The rewarming phase, which uses tedious warming (target 0.1 C0.2 C/h). Because TH reduces intracranial pressure (ICP) and is a major factor in TH-mediated protection in TBI, rewarming must be carefully monitored as spikes in ICP are a signicant risk during re-warming [84]. While hypothermia decreases plasma K+ [57], re-warming can elevate plasma K+ with potential effects on heart rhythm.

9. Potential complications: shivering and cutaneous vasoconstriction Hypothermia has several side-effects, which can be usually be managed in the intensive care unit (ICU). In conscious patients, shivering increases oxygen consumption and metabolic rate along and increases the work of breathing, increases heart rate and myocardial oxygen consumption [67]. In surgical patients, hypothermia has been linked to an increased risk for cardiac events, particularly in elderly patients with arrhythmias, or ischemic heart disease [33]. However, these adverse consequences are linked to the hemodynamic and respiratory responses, rather than shivering. These cardiovascular and shivering responses can usually be suppressed through administration of sedatives, anesthetics, opiates, or other drugs during hypothermia. In contrast to the tachycardia that can occur with perioperative hypothermia, bradycardia often develops during therapeutic hypothermia. However, it is important to prevent and/or treat shivering because it signicantly complicates hypothermia treatment by increasing tissue metabolism and oxygen consumption [67].

7. Excitotoxicity and mitochondrial dysfunction Hypothermia decreases harmful EAA release and activation of neurons during brain injury. Levels of metabolites such ATP and phosphocreatine decrease quickly following interruption of the brains oxygen supply [82]. The breakdown of ATP, and the transition to glycolysis lead to an increase in intracellular levels of inorganic phosphate and lactic acid. Low ATP levels decrease Na/K ATPase activity, promote K+ leakage and inux of Ca2+ [85]. Diminished ATP and acidosis also inhibits Ca2+ sequestration, further aggravating calcium overload. Excess intracellular Ca2+ in turn profoundly alters mitochondrial respiration and interferes with energy metabolism. This results in both an intra- and extracellular acidosis, inux of Ca2+ , and the release of stored synaptic neurotransmitters including EAAs. TH appears to reduce both Ca2+ and neurotransmitter release, to prevent the development of continued activation and excitotoxicity.

10. Potential complications: anticoagulant effects Mild-moderate hypothermia can also induce modest blood clotting disturbances. Temperatures below 35 C can cause platelet dysfunction and a measurable decrease in platelet count; at temperatures of 33 C, several steps in the coagulation cascade may also be affected. Because hypothermia decreases blood ow, shear rate and erythrocyte deformability, the tendency to develop blood clumping is also a signicant consideration. Still, clinical experiences suggest that the risk for severe bleeding associated with TH is still relatively small; no studies in patients with cardiac arrest, severe TBI, or stroke have so far reported signicant bleeding problems [66]. Conversely, a potential

8. Application of therapeutic hypothermia Since its initial applications, techniques for inducing and maintaining TH have been rened, and have led to a renewed interest in using TH to treat TBI in the acute setting. Areas requiring further study in the application of hypothermias protective effects include the following: (1) the speed at which hypothermia is induced shows that better outcomes are observed when cooling is initiated rapidly after injury;

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side effect of TH is the increased tendency formation of platelet activation and thrombus formation. Straub et al. have shown that clinical hypothermia (28 C/18 C) induced in mice increases expression of P-selectin (a platelet activation marker), increases plateletleukocyte aggregates and thrombocytopenia. The authors also observed that TH decreased CD39 (E-NTPDase1) activity leading to lower adenosine and increased ADP levels which would drive platelet activation. However, combining an ADP receptor antagonist (P2Y1,2) with soluble CD39 during TH attenuated thrombus formation [86]. Therefore identication of TH risk mechanisms can assist rationale therapeutic design to reduce risks associated with TH, e.g. the prevention of thrombus formation. However, these types of approaches to improve and extend TH are only in their formative stage.

13. Clinical evidence on TH in TBI More than 20 large studies have assessed clinical outcomes in TBI patients treated with hypothermia and have shown variable success rates reecting randomization, clinical protocols and end-points of clinical success. Several studies of patients with elevated intracerebrellar pressure (ICP) treated with hypothermia have shown ICP reductions, and improved outcomes [55,68,102]). However, a recent multi-center randomized controlled trial of adult patients with TBI did not show hypothermia to be effective as a primary neuroprotective strategy [39]. While a 2008 randomized controlled pediatric trial showed similar disappointing results [39], the Eurotherm3235 Trial (a 3235 C hypothermia trial) is now enrolling patients with TBI and elevated ICP of at least 20 mm Hg for more than 5 min and no improvement after rst line treatment [3]. These more narrow selection criteria may help to uncover those conditions under which TH can have the greatest benet.

11. Potential complications of sustained TH: altered drug metabolism The rates of most enzyme-dependent reactions are temperature-dependent, and the rates of many metabolic reactions are dramatically depressed by hypothermia. Consequently, one of the undesirable consequences of TH is its accompanying lower enzyme metabolism and decreased hepatic metabolism of many drugs. Hypothermia-induced reductions in drug metabolism have been demonstrated for a large number of commonly used ICU medications. Prolonged TH can lead to unpredictable plasma and tissue levels of such agents as pressors, sedatives, opiates, anesthetics, benzodiazepines, and neuromuscular blocking agents. Other drugs affected by metabolic depression include antiepileptics, nitrates, and beta-blockers [66] which could all have high impacts on TBI outcomes.

14. Conclusions Therapeutic hypothermia has many speculative and potential neuroprotective implications and applications. The therapy does lower ICP, decreases cerebral metabolism, and blocks epileptic activity in TBI, but is not without some risks. Although TH was anticipated to be widely employed prior to 2001, the failure of several phase II/III randomized controlled trials to conclusively demonstrate benets to patients has led to a more guarded application of TH. Despite the effectiveness of TH in animal models, several possible reasons exist which might explain the negative results including variations between protocols, inconsistent blood pressure management, variability in the nature of TBI and suboptimal study design. Many clinical groups are pressing for more controlled studies to allow wider application of TH in TBI therapy [73]. The Eurotherm3235 Trial will be one of the largest TBI trials and will, hopefully, settle many of the unsettled questions regarding the clinical utility of therapeutic hypothermia.

12. Potential complications: infectious complications Suppression of neuroinammation is one important mechanism through which TH may exert protective effects in TBI, therefore increased risk for infection is a potential complication of TH. Although Th1 cytokine elevation in TBI is inammatory and can contribute to tissue injury, net suppression of inammatory responses could impose a signicant risk for development of post-TBI infections. For therapeutic hypothermia the risk for infection exists, and is proportional to treatment duration. It is important to note that studies which did report increased risks of infection during therapeutic cooling found that even when infections occurred, overall outcomes were not adversely affected [66]. Hypothermia also causes a decrease in insulin secretion and, in many patients, insulin resistance. This can lead to hyperglycemia, which is linked to infections in the intensive care unit. It is therefore recommended that glucose levels are closely monitored in TBI patients who receive therapeutic hypothermia.

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