Ischemic cascade

The concept of neuroprotection relies on the fact that delayed neuronal injury occurs after ischemia, and each step along the ischemic cascade provides a target for therapeutic intervention. Thus, understanding the cellular and molecular mechanisms that underlie the development of neuronal and vascular injury is critical to optimize treatment. This chapter reviews experimental evidence from studies on focal cerebral ischemia and mild hypothermia, as well as the mechanisms involved in mild hypothermic neuroprotection. 

Nesto R, Kowaldruk G. The ischemic cascade temporal sequence of hemodynamic, electrocardiographic, and symptomatic expressions of ischemia. Am J Cardiol 1987 57 23C. 

Entires M, Dirnagl U, Moskowitz MA. Chapter 2 The ischemic cascade and mediators of ischemic injury. Handb Clin Neurol. 2008 92 31-41... 

Pharmacologic techniques counteract the propensity for thrombosis formation by dampening the coagulation cascade. Appropriately selected therapy can dramatically reduce the incidence of VTE after hip or knee replacement, general surgery, myocardial infarction, and ischemic stroke. 

Since Andreas Gruntzig described the first percutaneous coronary intervention (PCI) in 1978 (I), the field has progressed immeasurably in both equipment and pharmacotherapy The overall trend with regard to the latter has been for improved strategies aimed at inhibition of platelet aggregation and the clotting cascade. This has led to better outcomes by reduction of the ischemic complications associated with the procedure. 

The neuroprotective properties of mild hypothermia have been demonstrated in numerous experimental animal models. Research in this area has been conducted for many years, yet the mechanisms of cerebral protection by mild hypothermia remain unclear and continue to be the subject of intense investigation. The neuroprotective effects of mild hypothermia have been attributed to alterations in metabolic rate (24), neurotransmitter release (25-27), activity of protein kinases (28), resynthesis of cellular repair proteins (29), cerebral blood flow (30), preservation of the blood-brain barrier (BBB) (31), attenuation of inflammatory processes (32,33), and decreases in free radical production (34). Although these may all be components of a complex cascade leading to neurologic injury, it has become increasingly clear that the primary mechanism of action of hypothermia may be different at various temperatures as well as under different ischemic and traumatic conditions. 

The detailed mechanism of myocardial protection via PC is not fully understood yet. Many pathways have been proposed and include myocardial stunning, synthesis of heat-shock proteins, involvement of G-proteins, and nitric oxide production [3-5]. The generally accepted model is that the ischemic phase leads to enhanced catabolism of purine nucleotides, resulting in a high level of adenosine. These activate PKC and a cascade of signaling steps leading to activation of MAP, MAPK and MAPKK, culminating in a marked effect on ATP-dependent channels [3,4,6, ]. 

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