1. Nervous Tissue Metabolism, Neurotransmitters & Related Diseases

2. Energy source of the brain The mass of the brain is only 2% of the total body mass, yet its energy requirement is more than seven times than that of the other organs glucose oxygen Thus for brain metabolism, there is a high requirement for glucose and oxygen at steady rate. aerobic metabolism The main source of energy is the generation of ATP by the aerobic metabolism Introduction Metabolism & CNS functions

3. Neurotransmitters Neurotransmitters : are chemicals released at synapses for transmission of nerve impulses are chemicals released at synapses for transmission of nerve impulses can be divided structurally into two categories can be divided structurally into two categories: - small nitrogen-containing neurotransmitters - neuropeptides.

4. A large number of cofactors are required for the synthesis of neurotransmitters, and deficiencies of pyridoxal phosphate, thiamine pyrophosphate, and vitamin B12 result in a variety of neurologic dysfunctions A large number of cofactors are required for the synthesis of neurotransmitters, and deficiencies of pyridoxal phosphate, thiamine pyrophosphate, and vitamin B12 result in a variety of neurologic dysfunctions

5. Glucose metabolism & neurotramsmitters (in CNS) There is a relationship between the oxidation of glucose in glycolysis and the supply of precursors for the synthesis of neurotransmitters in neurons within CNS. Accordingly, deficiencies of either glucose or oxygen (hypoglycemia or hypoxia) affect brain function because they influence: 1- ATP production for CNS neurons 2- Supply of precursors for neurotransmitter synthesis. Introduction Metabolism & CNS functions Glucose Metabolism & Neurotransmitter Synthesis

6. Clinical manifestations of hypoglycemia: Early sweatingpalpitationsanxietyhunger Early clinical signs in hypoglycemia initiated by hypothalamic sensory nuclei as sweating, palpitations, anxiety and hunger. late CNS disorders confusionlethargyseizurescoma In late stages, these symptoms give way to serious manifestations of CNS disorders as confusion, lethargy, seizures & coma Clinical manifestation & Biochemistry of Hypoglycemic Encephalopathy

7. As blood glucose falls below 45 mg/dL As blood glucose falls below 45 mg/dL the brain attempts to use internal substrates such as glutamate and TCA cycle intermediates as fuels for ATP production. quickly depleted Because the pool size of these substrates is quite small, they are quickly depleted. As the blood glucose drops from 45 to 36 mg/dL As the blood glucose drops from 45 to 36 mg/dL NO NO EEG changes are observed decreased synthesis of neurotransmitters Symptoms appear to arise from decreased synthesis of neurotransmitters in particular regions of the brain (hippocampal and cortical structures) If blood glucose levels continue to fall below 18 mg/dL If blood glucose levels continue to fall below 18 mg/dL isoelectric EEG becomes isoelectric Neuronal cell death glutamate excitotoxicity Neuronal cell death ensues that may be caused by glutamate excitotoxicity ?? (as result of ATP depletion) SO, GLUTAMATE METABOLIDSM HAS TO BE UNDERSTOOD Clinical manifestation & Biochemistry of Hypoglycemic Encephalopathy

8. Glutamate as a neurotransmitter excitatory neurotransmitter Within the CNS, glutamate is the main excitatory neurotransmitter. glutaminergic neurons Neurons that respond to glutamate are referred to as glutaminergic neurons Sources of glutamate in nerve terminals: 1- Synthesized from glucose through glucose metabolism in neurones (main source) 2- From blood (few as no cross BBB) Mechanism of action of glutamate as a neurotransmitter: 1- Synthesis from glucose metabolism & concentration in vesicles (in presynapses) 2- Release by exocytosis to synaptic cleft 3- Uptake by postsynaptic 4- Binding to glutaminergic receptors in postsynapses 5- Functional effect

10. Role of glutamate as a transmitter in CNS: glutaminergic neurons Within the CNS, glutaminergic neurons are responsible for the mediation of many vital processes such as the encoding of information, the formation and retrieval of memories, spatial recognition and the maintenance of consciousness. Postsynaptic glutaminergic neurons perform their roles through: Ionotropic receptors 1- Ionotropic receptors that bind glutamate released from presynaptic neurons kainate referred to as kainate, 2-amino-3-hydroxy-5-methyl-4-isoxalone propionic AMPANMDA acid (AMPA) and N-methyl-D-aspartate (NMDA) receptors. Metabotropic glutamate receptors 2- Metabotropic glutamate receptors that are members of the G-protein coupled receptor (GPCR) family. Glutamate as a neurotransmitter

11. Ionotropic Glutamate Receptors Non- NMDA AMPA KAINATE NMDA AMPA and Kainate receptors generally allow the passage of Na + and K + NMDA receptors allows the passage of both Na + and Ca ++ ions. (More permeable to Ca ++ )

12. Role of astrocytes in glutamate metabolism in CNS: taken up astrocytes Glutamate released during neurotransmission is taken up primarily by neighboring astrocytes. A fraction of astrocyte glutamate is converted to glutamine by glutamine synthetase, which is abundant in astrocytes and absent from neurons. Glutamine is released from astrocytes & is taken up by neurons. In neurones, glutamine is deaminated to glutamate by glutaminase in neurons. ` Glutamate as a neurotransmitter

14. Glutamate metabolism in hyperammonemia: During hyperammonemia, ammonia can diffuse into the brain from the blood. inhibit the neural glutaminase The ammonia is able to inhibit the neural glutaminase, thereby decreasing formation of glutamate in presynaptic neurones. hyperammonemia This effect of ammonia might contribute to the lethargy associated with the hyperammonemia found in patients with hepatic disease. (hepatic encephalopathy) Glutamate as a neurotransmitter

15. Glutamate Excitotoxicity Exciotoxicity is the pathological process by which nerve cells are damaged and killed by glutamate (and similar substances). over activated (overstimulated). This occurs when receptors for glutamate such as the NMDA & AMPA receptor are over activated (overstimulated). Excessive excitation of glutamate receptors has been associated with hypoglycemia & stroke (cases in which there is lack of glucose or oxygen ending in lack of energy production in CNS)

16. Glutamate excitotoxicity cellular energy reserves are depleted occurs when the cellular energy reserves are depleted (as in hypoglycemia or stroke, etc ) Failure of the energy-dependent reuptake pumps of glutamate Accumulation of glutamate in the synaptic cleft Overstimulation of the postsynaptic glutamate receptors influx of lethal amounts of Ca2 ions Prolonged glutamate receptor activation leads to prolonged opening of the receptor ion channel and the influx of lethal amounts of Ca2 ions, which can activate cytotoxic intracellular pathways in the postsynaptic neurons Glutamate Excitotoxicity

17. Cerebral Ischemia Cerebral ischemia It is the potentially reversible altered state of brain physiology and biochemistry that occurs when substrate delivery is cut off or substantially reduced by vascular stenosis or occlusionStroke is defined as “an acute neurologic dysfunction of vascular origin with sudden (within seconds) or at least rapid (within hours) occurence of symptoms and signs corresponding to the involvement of focal areas in the brain” (Goldstein et al, 1989)

18. Pathophysiology of Cerebral Ischemia ATP ↓↓ ATP Induction Amplification Expression

19. Induction Phase Phase Lack of oxygen supply to ischemic neurones lactic acid The cell switches to anaerobic metabolism, producing lactic acid. ATP depletion malfunctioning of membrane ion system Depolarisation of neurones Influx of calcium glutamate Release of neurotransmitters as glutamate ( glutamate excitotoxicity) (causing glutamate excitotoxicity) Accumulation of more intracellular levels of Ca2+ which causes additional release of glutamate (viscious cycle) AmplificationPhase

20. Expression Phase 1-overexcites cells and causes the generation of harmful chemicals like free radicals ( causing oxidative stress) free radicals ( causing oxidative stress) 2- Activation of calcium-dependent enzymes such as: calpain ( causing apoptosis) phospholipases (causing membrane breakdown) phospholipases (causing membrane breakdown) glutamate excitotoxicity 3- Calcium can also cause the release of more glutamate (glutamate excitotoxicity) phospholipases The cell's membrane is broken down by phospholipases Cell membrane becomes more permeable, and more ions and harmful chemicals flow into the cell. + apoptotic Mitochondria membrane break down, releasing toxins and apoptotic factors into the cell Ca 2+

21. lactic acid is produced in excess in ischemia In cerebral ischemia, lack of oxygen switches metabolism of glucose to the anaerobic pathway & lactic acid production Lactic acid contribute to the pathophysiology of ischemia as Lactic acid contribute to the pathophysiology of ischemia as: It decreases pH that may injure and inactivate mitochondria 1- It decreases pH that may injure and inactivate mitochondria. Lactic acid degradation of NADH 2- Lactic acid degradation of NADH (which is needed for ATP synthesis) may also interfere with adequate post-ischemic recovery of ATP levels. Lactic acid increase the amount of free-radical mediated injury 3- Lactic acid increase the amount of free-radical mediated injury.  Lactic acid in neurons  acidosis  promotes the pro-oxidant effect  ↑ the rate of conversion of O 2 - to H 2 O 2 or to hydroxyperoxyl radical

22. What is meant by ROS? Reactive oxygen species (ROS) are formed from partial reduction of molecular O 2 i.e. adding electrons to oxygen leading to the formation of superoxide, hydrogen peroxide & hydroxyl radical. ROS cause damage to DNA, protein and unsaturated lipids of the cells Generally, ROS cause damage to DNA, protein and unsaturated lipids of the cells. What is meant by oxidative stress ROS antioxidants A condition in which cells are subjected to excessive levels of ROS (free radicals) & they are unable to counterbalance their deleterious effects with antioxidants Oxidative stress is caused by ischemia

23. Oxidative Stress Why the Brain is vulnerable to Oxidative Stress High metabolic requirement for oxygen; Prevalent concentration of oxidizable polyunsaturated fatty acids (PUFAs) in membranes; Enrichment in redox active metals, most notably iron The presence of potentially phagocytic microglia which can be a major source of ROS and free radicals when activated by injury. Low levels of protective antioxidants Cerebral Vascular Effects of Oxygen Radicals Vasodilation Alteration in reactivity to CO2 and endothelium-dependent vasodilators Increased endothelial permeability Focal destructive lesions of endothelial cell membranes

24. Oxidative stress Cellular Effects of Reactive Oxygen Species in CNS Nitric oxide is over produced and turns to be a neurotoxic mediator as it reacts with superoxide anions to generate toxic peroxynitrite which leads to production of more potent neurotoxin such as hydroxyl radicals Nitric oxide is over produced and turns to be a neurotoxic mediator as it reacts with superoxide anions to generate toxic peroxynitrite which leads to production of more potent neurotoxin such as hydroxyl radicals Lipid peroxidation Lipid peroxidation Inactivation of enzymes Inactivation of enzymes Nucleic acid (DNA & RNA) damage Nucleic acid (DNA & RNA) damage Release of calcium ions from intracellular stores with more damage to neurones Release of calcium ions from intracellular stores with more damage to neurones Damage to cytoskeleton Damage to cytoskeleton

25. Apoptosis & necrosis are caused by ischemia Necrosis Necrosis: is commonly observed early after severe ischemic insults Apoptosis Apoptosis: occurs with more mild insults and with longer survival periods calpain- mediated proteolysis The mechanism of cell death involves calcium-induced calpain- mediated proteolysis of brain tissue Substrates for calpain include: – Cytoskeletal proteins – Membrane proteins – Regulatory and signaling proteins

26. Apoptosis Broughton et al., 2009; Stroke Mitochondria break down, releasing toxins and apoptotic factors into the cell. The caspase-dependent apoptosis cascade is initiated, causing cells to "commit suicide."

27. Broughton et al., 2009; Stroke Caplains are cytosolic proteinases Whose irreversible proteolytic activity is against cytoskeleton and regulatory proteins

28. Broughton et al., 2009; Stroke