Traumatic brain injury (TBI) is becoming a national epidemic, as it accounts for 1.5 million cases each year. This disorder affects primarily the young population and elderly. Currently, there is no treatment for TBI, which means that ~2% of the U.S. population is currently living with prolonged neurological damage and dysfunction. Recently, there have been many studies showing that TBI negatively impacts mitochondrial function. It has been proposed that in order to save the cell from destruction mitochondrial function must be preserved. The ketogenic diet, originally designed to mimic fasting physiology, is effective in treating epilepsy. Therefore, we have used fasting as a post injury treatment and attempted to elucidate its underlying mechanism. 24 hours of fasting after a moderate TBI increased tissue sparing, cognitive recovery, improved mitochondrial function, and decreased mitochondrial biomarkers of injury. Fasting results in hypoglycemia, the production of ketones, and the upregulation of free fatty acids (FFA). As such, we investigated the neuroprotective effect of hypoglycemia in the absence of fasting through insulin administration. Insulin administration was not neuroprotective and increased mortality in some treatment groups. However, ketone administration resulted in increased tissue sparing. Also, reduced reactive oxygen species (ROS) production, increased the efficiency of NADH utilization, and increased respiratory function. FFAs and uncoupling proteins (UCP) have been implicated in an endogenously regulated anti-ROS mechanism. FFAs of various chain lengths and saturation were screened for their ability to activate UCP mediated mitochondrial respiration and attenuate ROS production. We also measured FFA levels in serum, brain, and CSF after a 24 hour fast. We also used UCP2 transgenic overexpressing and knockout mice in our CCI injury model, which showed UCP2 overexpression increased tissue sparing, however UCP2 deficient mice did not show a decrease in tissue sparing, compared with their wild type littermates. Together our results indicate that post injury initiated fasting is neuroprotective and that this treatment is able to preserve mitochondrial function. Our work also indicates ketones and UCPs may be working together to preserve mitochondrial and cellular function in a concerted mechanism, and that this cooperative system is the underlying mechanism of fasting induced neuroprotection.

In the hours and days following acute CNS injury, a secondary wave of events is initiated that exacerbate spinal tissue damage and neuronal cell death. A potential mechanism driving these secondary events is opening of the mitochondrial permeability transition pore (mPTP) and subsequent release of several cell death proteins. Previous studies have shown that inhibition of cyclophilin D(CypD), the key regulating component in mPTP opening, was protective against insults that induce necrotic cell death. We therefore hypothesized that CypD-null mice would show improved functional and pathological outcomes following spinal cord injury (SCI) and traumatic brain injury (TBI). Moderate and severe spinal contusion was produced in wild-type (WT) and CypD-null mice at the T-10 level using the Infinite Horizon impactor. Changes in locomotor function were evaluated using the Basso Mouse Scale (BMS) at 3 days post-injury followed by weekly testing for 4 weeks. Histological assessment of tissue sparing and lesion volume was performed 4 weeks post SCI. Calpain activity, measured by calpain-mediated spectrin degradation, was assessed in moderate injury only by western blot 24 hours post SCI. Results showed that following moderate SCI, CypD-null mice had no significant improvement in locomotor recovery or tissue sparing compared to wild-type mice. Following severe SCI, CypD-null mice showed significantly lower locomotor recovery and decreased tissue sparing compared to WT mice. Calpain-mediated spectrin degradation was not significantly reduced in CypD-null mice compared to WT mice 24h post moderate SCI. The lack of protective effects in CypD-null mice suggests that more dominant mechanisms are involved in the pathology of SCI. In addition, CypD may have a pro survival role that is dependent on the severity of the spinal cord injury.

Traumatic brain injury (TBI) is a leading cause of death and long-term disability worldwide, and survivors are often left with cognitive deficits and significant problems with day to day tasks. To date, therapeutic pharmacological treatments of TBI remain elusive despite numerous clinical trials. An improved understanding of the molecular and cellular response to injury may help guide future treatment strategies. One promising marker for brain injury is the translocator protein (TSPO), which is normally expressed at a low level, but is highly expressed following brain damage and is associated with neuroinflammation. The isoquinoline carboxamide PK11195 binds selectively to the TSPO in many species, and has therefore become the most-studied TSPO ligand. To characterize the time-course of TSPO expression in the controlled cortical injury (CCI) model of TBI we subjected Sprague-Dawley rats to CCI and euthanatized them after 30 minutes, 12 hours, 1, 2, 4, or 6 days. Autoradiography with radiolabelled PK11195 was used to assess the time-course of TSPO binding following CCI. Autoradiographs were compared to adjacent tissue slices stained with the microglia/macrophage marker ED-1, with which a moderate positive correlation was discovered. PK11195 autoradiography was used as a tool with which to assess neuroinflammation following CCI and the administration of an α7 nAChR antagonist, methyllycaconitine (MLA). We hypothesized that blocking the calcium permeable α7 nAChR after brain injury would have a neuroprotective effect by attenuating excitotoxicity in the shortterm. Our study revealed clear dose-dependent tissue sparing in rats administered MLA after trauma and a modest improvement in functional outcome. The relatively modest recovery of function with MLA, which could be due to prolonged α7 nAChR blockade or downregulation lead us to explore the potential of α7 nAChR partial agonists in treating TBI. The α7 nAChR partial agonists tropisetron, ondansetron, and DMXB-A produced a moderate attenuation of cognitive deficits, but did not have a neuroprotective effect on tissue sparing. These studies show that following TBI, α7 nAChR modulation can have neuroprotective effects and attenuate cognitive deficits. Whether this modulation is best achieved through partial agonist treatment alone or a combination antagonist/agonist treatment remains to be determined.

Older individuals sustaining traumatic brain injury (TBI) experience a much higher incidence of morbidity and mortality. This age-related exacerbated response to neurological insult has been demonstrated experimentally in aged animals, which can serve as a model to combat this devastating clinical problem. The reasons for this worse initial response are unknown but may be related to age-related changes in mitochondrial respiration. Evidence is shown that mitochondrial dysfunction occurs early following traumatic brain injury (TBI), persists long after the initial insult, and is severitydependent. Synaptic and extrasynaptic mitochondrial fractions display distinct respiration capacities, stressing the importance to analyze these fractions separately. Sprague- Dawley and Fischer 344 rats, two commonly used strains used in TBI and aging research, were found to show very similar respiration profiles, indicating respiration data are not strain dependent. Neither synaptic nor extrasynaptic mitochondrial respiration significantly declined with age in naïve animals. Only the synaptic fraction displayed significant age-related increases in oxidative damage, measured by 3-nitrotyrosine (3- NT), 4-hydroxynonenal (4-HNE), and protein carbonyls (PC). Alterations in respiration with age appear to be more subtle than previously thought. Subtle declines in respiration and elevated levels of oxidative damage may not to be sufficient to produce detectable deficits until the system is challenged. Following TBI, synaptic mitochondria exhibit dysfunction that increased significantly with age at injury, evident in lower respiratory control ratio (RCR) values and declines in ATP production rates. Furthermore, synaptic mitochondria displayed increased levels of oxidative damage with age and injury, while extrasynaptic mitochondria only displayed significant elevations following the insult. Age-related synaptic mitochondrial dysfunction following TBI may contribute to an exacerbated response in the elderly population.

Traumatic brain injury (TBI) is a prevalent CNS neurodegenerative condition that results in lasting neurological dysfunction, including potentially debilitating cognitive impairments. Despite the advancements in understanding the complex damage that can culminate in cellular dysfunction and loss, no therapeutic treatment has been effective in clinical trials, highlighting that new approaches are desperately needed. A therapy that limits cell death while simultaneously promoting reparative mechanisms, including post-traumatic neurogenesis, in the injured brain may have maximum effectiveness in improving recovery of function after TBI. Insulin-like growth factor-1 (IGF-1) is a potent growth factor that has previously been shown to promote recovery of function after TBI, but no studies have evaluated the efficacy of IGF-1 to promote cell survival and modulate neurogenesis following brain injury. Systemic infusion of IGF-1 resulted in undetectable levels of IGF-1 in the brain, but did promote increased cortical activation of Akt, a pro-survival downstream mediator of IGF-1 signaling, in mice subjected to controlled cortical impact (CCI), a well-established model of contusion TBI. However, systemic infusion of IGF-1 did not promote recovery of motor function in mice after CCI. A one week central infusion of IGF-1 elevated brain levels of IGF-1, increased Akt activation and improved motor and cognitive function after CCI. Central infusion of IGF-1 also significantly increased immature neuron density at 7 d post-injury for a range of doses and when administered with a clinically relevant delayed onset of 6 hr post-injury. To mitigate potential side effects of central infusion, an alternative conditional astrocyte-specific IGF-1 overexpressing mouse model was utilized to evaluate the efficacy of IGF-1 to promote post-traumatic neurogenesis. Overexpression of IGF-1 did not protect against acute immature neuron loss, but did increase immature neuron density above uninjured levels at 10 d post-injury. The increase in immature neuron density appeared to be driven by enhanced neuronal differentiation. In wildtype mice, immature neurons exhibited injury-induced reductions in dendritic arbor complexity following severe CCI, a previously unknown pathological phenomenon. Overexpression of IGF-1 in brain-injured mice promoted the restoration of dendritic arbor complexity to the dendritic morphology observed in uninjured mice. Together, these findings provide strong evidence that treatment with IGF-1 promotes the recovery of neurobehavioral function and enhances post-traumatic neurogenesis in a mouse model of contusion TBI.

Brain trauma occurs frequently in children and its consequences cause significant health and financial burden to the patients, their carers and society. This thesis assessed the modulating effects of physiological, genetic, and biochemical factors on the sequelae of childhood brain trauma. Primary brain injury from the mechanical forces of trauma and secondary brain insults consequent on the primary injury are determinants of brain trauma outcome. The most important secondary insults recognised are reduced cerebral perfusion pressure (CPP) and raised intracranial pressure (ICP). CPP is governed by the mean arterial blood pressure and the ICP. During childhood these physiological measures change with age. With continuous physiological recordings, ‘critical’ age-related minimum CPP thresholds for children aged 2-6, 7-10 and 11-15 years were defined as 48, 54 and 58mmHg respectively. Utilising these thresholds and a novel cumulative pressure-time index (PTIc), we have demonstrated that CPP insult still remains a feature in 80% of the severe brain trauma patients and significantly relates to global outcome. Brain trauma and cerebral ischaemia are stimuli to the inflammatory cascade leading to further brain damage. Serum adhesion molecule levels after brain trauma indicate injury severity and predict outcome better than brain specific proteins. Predictability is improved using more than one serum biomarker level. Neuro-inflammatory pathways involving adhesion molecules may have a strong modulating effect on brain trauma outcome but warrants further investigations in relation to CPP insult. Genetic factors such as Apolipoprotein E (APO E) genetic polymorphisms may additionally influence outcome, but it was not known whether genetic factors lessen the quantity of CPP insult or the cellular response to it. We demonstrated that the e4 carriers who had unfavourable outcome had 22 times less CPP insult than the non-e4 carriers, while the e3 homozygous who had good recovery had 26 times more CPP insult than the non-e3 homozygous. This suggests that APO E polymorphisms may affect the patient’s cerebral ischaemic tolerance differently, indicating especially the need to prevent CPP insult among e4 carriers. Cerebral ischaemia may, therefore, be a common pathway through which physiological and genetic factors modulate outcome after brain trauma.

The aims of the thesis were to examine i) whether the endogenous opioid system (EOS) is lateralized in human brain areas involved in processing of emotions and pain; ii) whether EOS responses to unilateral brain injury depend on side of lesion, and iii) whether in human alcoholics, this system is involved in molecular adaptations in brain areas relevant for cognitive control of addictive behavior and habit formation. The main findings were that (1) opioid peptides but not opioid receptors and classic neurotransmitters are markedly lateralized in the anterior cingulate cortex involved in processing of  positive and negative emotions and affective component of pain. The region-specific lateralization of neuronal networks expressing opioid peptides may underlie in part lateralization of higher functions in the human brain including emotions and pain. (2) Analysis of the effects of traumatic brain injury (TBI) demonstrated predominant alteration of dynorphin levels in the hippocampus ipsilateral to the injury, while injury to the right hemisphere affected dynorphin levels in the striatum and frontal cortex to a greater extent than that to the left hemisphere. Thus, trauma reveals a lateralization in the mechanisms mediating the response of dynorphin expressing neuronal networks in the brain. These networks may differentially mediate effects of left or right brain injury on lateralized brain functions. (3) In human alcoholics, the enkephalin and dynorphin systems were found to be downregulated in the caudate nucleus and / or putamen that may underlie in part changes in goal directed behavior and formation of a compulsive habit in alcoholics. In contrast to downregulation in these areas, PDYN mRNA and dynorphins in dorsolateral prefrontal cortex, k-opioid receptor mRNA in orbitofrontal cortex, and dynorphins in hippocampus were upregulated in alcoholics. Activation of the k-opioid receptor by upregulated dynorphins may underlie in part neurocognitive dysfunctions relevant for addiction and disrupted inhibitory control. We conclude that the EOS exhibits region-specific lateralization in human brain and brain-area specific lateralized response after unilateral TBI in mice; and that the EOS is involved in adaptive processes associated with specific aspects of alcohol dependence.

Intact white matter is critical for normal cognitive function. In traumatic brain injury (TBI), chronic cerebral hypoperfusion and Alzheimer’s disease (AD) damage to white matter is associated with cognitive impairment. However, these conditions are associated with grey matter damage or with other pathological states and the contribution of white matter damage in isolation to their pathogenesis is not known. Furthermore, TBI is a risk factor for AD and cerebral hypoperfusion is an early feature of AD. It is hypothesised that white matter damage following TBI or chronic cerebral hypoperfusion will be associated with cognitive deficits and that white matter changes after injury contribute to AD pathogenesis. To investigate this, this thesis examined the contribution of white matter damage to cognitive deficits after TBI and chronic cerebral hypoperfusion and furthermore, investigated the role of white matter damage in the relationship between TBI and AD. Three studies addressed these aims. In the first, mild TBI was induced in wild-type mice and the effects on axons, myelin and neuronal cell bodies examined at time points from 4 hours to 6 weeks after injury. Spatial reference learning and memory was tested at 3 and 6 weeks after injury. Injured mice showed axonal damage in the cingulum, close to the injury site in the hours after injury and at 6 weeks, damage in the thalamus and external capsule were apparent. Injured and sham animals had comparable levels of neuronal damage and no change was observed in myelin. Injured animals showed impaired spatial reference learning at 3 weeks after injury, demonstrating that selective axonal damage is sufficient to impair cognition. In the second study mild TBI was induced in a transgenic mouse model of AD and the effects on white matter pathology and AD-related proteins examined 24 hours after injury. There was a significant increase in axonal damage in the cingulum and external capsule and parallel accumulations of amyloid were observed in these regions. There were no changes in tau or in overall levels of AD-related proteins. This suggests that axonal damage may have a role in mediating the link between TBI and AD. The third study used a model of chronic cerebral hypoperfusion in wild type mice and investigated white matter changes after one and two months of hypoperfusion as well as a comprehensive assessment of learning and memory. Chronic cerebral hypoperfusion resulted in diffuse myelin damage in the absence of ischaemic neuronal damage at both 1 and 2 months after induction of hypoperfusion. Hypoperfused animals also showed minimal axonal damage and microglial activation. Cognitive testing revealed a selective impairment in spatial working memory but not spatial reference or episodic memory in hypoperfused animals, showing that modest reductions in blood flow have effects on white matter sufficient to cause cognitive impairment. These results demonstrate that selective damage to white matter components can have a long-term impact on cognitive function as well as on the development of AD. This suggests that minimisation of axonal damage after TBI is a target for reducing subsequent risk of AD and that repair or prevention of white matter damage is a promising strategy for rescuing cognitive function in individuals who have experienced mild TBI or chronic cerebral hypoperfusion.

Background and aims: The provenance of post-concussion symptoms (PCS) and post-traumatic stress (PTSD) after mild traumatic brain injury (mTBI) is controversial. This thesis investigated factors influencing these two conditions separately, as well as the interplay between PCS and PTSD, in individuals with mTBI and a control sample without mTBI (orthopaedic injuries). Method: Consecutive adult attendees of an Emergency Department with mTBI or orthopaedic injury were prospectively recruited and completed the Rivermead Post-concussion Questionnaire (RPQ) and Trauma Screening Questionnaire (TSQ) for PTSD at two weeks (T1) and three months (T2) post-injury. The sample at T1 consisted of 34 with complicated mTBI, 76 with uncomplicated mTBI and 47 with orthopaedic injury, and 18 with complicated mTBI, 43 with uncomplicated mTBI and 33 orthopaedic controls at T2. Results: Although there were no differences in overall PCS symptomology between groups, a subset of PCS symptoms (headaches, dizziness and nausea) was found to be specific to mTBI at both time points. These symptoms are proposed to have a neurological basis, as opposed to a psychological basis. PTSD interacted with PCS, particularly in mTBI, such that PTSD was associated with greater “neurogenic” and “psychogenic” symptomology in this group, but only a moderate increase in psychogenic symptoms for controls. A model of the influence of PTSD on PCS is presented. PTSD was influenced by poor memory quality for the traumatic event and attribution of blame to others, but not by mTBI. Discussion and conclusions: Though mTBI may set the scene for at least neurogenic symptoms of PCS to occur, psychological mechanisms, particularly PTSD, have a significant role in the persistence of PCS. Our findings suggest the need for a clear story and sense of meaning for a traumatic event for good recovery from PTSD. Taken together, the results suggest that psychological interventions, particularly aimed at PTSD, may be most effective after mTBI.

Bakgrund: Traumatisk hjärnskada (THS) orsakas av våld mot huvud i samband med fallolyckor eller trafikolyckor. Varje år söker 20 000 personer vård på grund av skallskador. Vården för traumatiskt hjärnskadade patienter i Sverige skiljer sig åt, mycket beroende på avstånden som finns till specialistsjukhus, tiden och rätta åtgärder är avgörande faktorer för denna patientgrupp. Syfte: Att undersöka vikten och intensivvårdssjuksköterskors behov av rutiner i samband med vård av patienter med hjärnskador på allmänintensivvårdsavdelningar och på neurointensivvårdavdelningar. Metod: Kvalitativ studie med fokusgruppsintervjuer av tio intensivvårdsjuksköterskor som arbetar på en allmänintensivvårdsavdelning (IVA) och specialistneurointensivvårdavdelningen (NIVA). Resultat: På NIVA finns väl inarbetade rutiner och tydliga riktlinjer nedskrivna. Sjuksköterskornas upplevelse var att det fanns tillräckligt med rutiner, men några rutiner kunde utvecklas. På IVA fanns det inga nedskrivna riktlinjer och inga tydliga rutiner för att vårda denna patientgrupp. Vården och kontrollerna ordinerades av läkare som är i tjänst. Slutsats: Vården kring hjärnskadade patienter är ytterst viktigt då man ständigt måste förebygga sekundära skador/insulter. Rutiner är väl inarbetade på specialistsjukhuset, men vården börjar först på hemsjukhuset på IVA där tydliga rutiner och riktlinjer saknas. / Introduction: Traumatic brain injury caused by violence against the head during a fall or traffic accident. Each year 20000 people gets medical care because of head injuries. The care for traumatic brain injured patients in Sweden differ greatly depending on the distances available to specialist hospitals, the time and the proper measures are crucial factors in this population. Aim: The study aims to examine the importance and intensive care nurses need routines in connection with care of patients with brain injuries in general intensive care units and in neurological intensive care units. The study consists of three group interviews in a general ICU unit in Falun and specialist unit (NIVA). Method: A qualitative study with focus group interviews. Results: The results showed that the level have clear procedures and written guidelines regarding the "avoidable factors" which are well established, their experience was that there were enough procedures, but that some could continue to develop. IVA there were no written guidelines and no clear procedures to care for this population without the care and controls prescribed by the doctor who is on duty. Conclusion: The conclusion is that care about the brain-damaged patients is extremely important when you constantly have to prevent secondary injury / insults and check the "avoidable factors". Routines are well established on specialist hospital care but starts first at home hospital where the importance of working towards the same goal and have clear procedures and guidelines from the start.