White matter injury mechanisms

White matter of the brain and spinal cord is susceptible to anoxia, ischemia, trauma and autoimmune attack. Irreversible injury to this tissue can have serious consequences for the overall function of the CNS through disruption of signal transmission. Like neurons, central myelinated axons are critically dependent on a continuous supply of oxygen and glucose. Injury causes failure of the Na-K-ATPase and accumulation of axoplasmic Na through non-inactivating Na channels, which, together with membrane depolarization, promotes reverse Na-Ca exchange and axonal Ca overload. An equally important source of deleterious Ca originates from intracellular stores, released in part by a mechanism similar to "excitation-contraction coupling" in muscle, involving activation of ryanodine receptors by L-type Ca channels. Excitotoxic mechanisms also play an important role: glutamate released by reversal of Na-dependent glutamate transporters activates AMPA/kainate receptors to cause injury to glia and myelin. Excessive accumulation of cytosolic Ca in turn activates various Ca-dependent enzymes such as calpains, phospholipases and others resulting in irreversible injury. Reoxygenation paradoxically accelerates injury in many axons, and promotes cytoskeletal degradation. Blockers of voltage-gated Na channels represent an attractive therapeutic target because of their ability to simultaneously interfere indirectly with several Ca sourcing pathways. Alternatively, or additionally, AMPA/kainate receptor inhibition has also been shown to be neuroprotective in several white matter injury paradigms. In the clinical setting, optimal protection of the CNS as a whole in common disorders such as stroke, traumatic brain and spinal cord injury, will likely require combination therapy aimed at unique steps in gray and white matter regions, or intervention at common points in the injury cascades.