Treatment of ischaemic stroke with prostacyclin

Exploring Lysophosphatidylcholine as a Biomarker in Ischemic Stroke: The Plasma-Brain Disjunction

Lipids and their bioactive metabolites, notably lysophosphatidylcholine (LPC), are increasingly important in ischemic stroke research. Reduced plasma LPC levels have been linked to stroke occurrence and poor outcomes, positioning LPC as a potential prognostic or diagnostic marker. Nonetheless, the connection between plasma LPC levels and stroke severity remains unclear. This study aimed to elucidate this relationship by examining plasma LPC levels in conjunction with brain LPC levels to provide a deeper understanding of the underlying mechanisms. Adult male Sprague-Dawley rats underwent transient middle cerebral artery occlusion and were randomly assigned to different groups (sham-operated, vehicle, LPC supplementation, or LPC inhibition). We measured multiple LPC species in the plasma and brain, alongside assessing sensorimotor dysfunction, cerebral perfusion, lesion volume, and markers of BBB damage, inflammation, apoptosis, and oxidative stress. Among five LPC species, plasma LPC(16:0) and LPC(18:1) showed strong correlations with sensorimotor dysfunction, lesion severity, and mechanistic biomarkers in the rat stroke model. Despite notable discrepancies between plasma and brain LPC levels, both were strongly linked to functional outcomes and mechanistic biomarkers, suggesting that LPC's prognostic value is retained extracranially. This study advances the understanding of LPC as a blood marker in ischemic stroke and highlights directions for future research to further elucidate its association with stroke severity, particularly through investigations in more clinically representative models.

Cross-talk between bioactive lipid mediators and the unfolded protein response in ischemic stroke

Ischemic cerebral stroke is a severe medical condition that affects about 15 million people every year and is the second leading cause of death and disability globally. Ischemic stroke results in neuronal cell death and neurological impairment. Current therapies may not adequately address the deleterious metabolic changes and may increase neurological damage. Oxygen and nutrient depletion along with the tissue damage result in endoplasmic reticulum (ER) stress, including the Unfolded Protein Response (UPR), and neuroinflammation in the affected area and cause cell death in the lesion core. The spatio-temporal production of lipid mediators, either pro-inflammatory or pro-resolving, decides the course and outcome of stroke. The modulation of the UPR as well as the resolution of inflammation promotes post-stroke cellular viability and neuroprotection. However, studies about the interplay between the UPR and bioactive lipid mediators remain elusive and this review gives insights about the crosstalk between lipid mediators and the UPR in ischemic stroke. Overall, the treatment of ischemic stroke is often inadequate due to lack of effective drugs, thus, this review will provide novel therapeutical strategies that could promote the functional recovery from ischemic stroke.

International Union of Basic and Clinical Pharmacology. CIX. Differences and Similarities between Human and Rodent Prostaglandin E2 Receptors (EP1-4) and Prostacyclin Receptor (IP): Specific Roles in Pathophysiologic Conditions

Prostaglandins are derived from arachidonic acid metabolism through cyclooxygenase activities. Among prostaglandins (PGs), prostacyclin (PGI2) and PGE2 are strongly involved in the regulation of homeostasis and main physiologic functions. In addition, the synthesis of these two prostaglandins is significantly increased during inflammation. PGI2 and PGE2 exert their biologic actions by binding to their respective receptors, namely prostacyclin receptor (IP) and prostaglandin E2 receptor (EP) 1-4, which belong to the family of G-protein-coupled receptors. IP and EP1-4 receptors are widely distributed in the body and thus play various physiologic and pathophysiologic roles. In this review, we discuss the recent advances in studies using pharmacological approaches, genetically modified animals, and genome-wide association studies regarding the roles of IP and EP1-4 receptors in the immune, cardiovascular, nervous, gastrointestinal, respiratory, genitourinary, and musculoskeletal systems. In particular, we highlight similarities and differences between human and rodents in terms of the specific roles of IP and EP1-4 receptors and their downstream signaling pathways, functions, and activities for each biologic system. We also highlight the potential novel therapeutic benefit of targeting IP and EP1-4 receptors in several diseases based on the scientific advances, animal models, and human studies. SIGNIFICANCE STATEMENT: In this review, we present an update of the pathophysiologic role of the prostacyclin receptor, prostaglandin E2 receptor (EP) 1, EP2, EP3, and EP4 receptors when activated by the two main prostaglandins, namely prostacyclin and prostaglandin E2, produced during inflammatory conditions in human and rodents. In addition, this comparison of the published results in each tissue and/or pathology should facilitate the choice of the most appropriate model for the future studies.

Lipids and Lipid Mediators Associated with the Risk and Pathology of Ischemic Stroke

Stroke is a severe neurological disorder in humans that results from an interruption of the blood supply to the brain. Worldwide, stoke affects over 100 million people each year and is the second largest contributor to disability. Dyslipidemia is a modifiable risk factor for stroke that is associated with an increased risk of the disease. Traditional and non-traditional lipid measures are proposed as biomarkers for the better detection of subclinical disease. In the central nervous system, lipids and lipid mediators are essential to sustain the normal brain tissue structure and function. Pathways leading to post-stroke brain deterioration include the metabolism of polyunsaturated fatty acids. A variety of lipid mediators are generated from fatty acids and these molecules may have either neuroprotective or neurodegenerative effects on the post-stroke brain tissue; therefore, they largely contribute to the outcome and recovery from stroke. In this review, we provide an overview of serum lipids associated with the risk of ischemic stroke. We also discuss the role of lipid mediators, with particular emphasis on eicosanoids, in the pathology of ischemic stroke. Finally, we summarize the latest research on potential targets in lipid metabolic pathways for ischemic stroke treatment and on the development of new stroke risk biomarkers for use in clinical practice.

Genetic Deletion of Prostacyclin IP Receptor Exacerbates Transient Global Cerebral Ischemia in Aging Mice

Transient global cerebral ischemia causes delayed neuronal death in the hippocampal CA1 region. It also induces an up regulation of cyclooxygenase 2 (COX-2), which generates several metabolites of arachidonic acid, known as prostanoids, including Prostaglandin I2 (PGI2). The present study investigated whether the PGI2 IP receptor plays an important role in brain injury after global cerebral ischemia in aged mice. Adult young (2-3 months) and aged (12-15 months) male C57Bl/6 wild-type (WT) or IP receptor knockout (IP KO) mice underwent a 12 min bilateral common carotid artery occlusion (BCCAO) or a sham surgery. Behavior tests (neurologic deficit and T-maze) were performed 3 and 7 days after BCCAO. After seven days of reperfusion, the numbers of cells positive for markers of neurons, astrocytes, microglia, myeloperoxidase (MPO) and phosphorylated CREB (p-CREB) were evaluated immunohistochemically. Interestingly, in young and aged IP KO ischemic mice, there was a significant increase (p < 0.01) in cognitive deficit, hippocampal CA1 pyramidal neuron death, microglia and MPO activation, while p-CREB was reduced as compared to their corresponding WT controls. These data suggest that following ischemia, IP receptor deletion contributes to memory and cognitive deficits regulated by the CREB pathway and that treatment with IP receptor agonists could be a useful target to prevent harmful consequences.

Prostacyclin receptor deletion aggravates hippocampal neuronal loss after bilateral common carotid artery occlusion in mouse

Transient global cerebral ischemia causes delayed neuronal death in the hippocampal CA1 region. It also induces an increase in cyclooxygenase 2 (COX-2), which generates several metabolites of arachidonic acid, known as prostanoids, including prostacyclin (PGI(2)). To determine the role of the PGI(2) receptor (IP) in post-ischemic delayed cell death, wild-type and IP knockout (IP(-/-)) C57Bl/6 mice were subjected to 12-min bilateral common carotid artery occlusion or sham surgery, followed by 7 days of reperfusion. In the sham-operated mice, no statistical difference in CA1 hippocampal neuronal density was observed between the wild-type (2836+/-18/mm(2)) and IP(-/-) (2793+/-43/mm(2)) mice. Interestingly, in animals subjected to ischemia, surviving neuronal density in wild-type mice decreased to 50.5+/-7.9% and that of IP(-/-) mice decreased to 23.0+/-4.5% of their respective sham-operated controls (P<0.05). The results establish a role for the IP receptor in protecting pyramidal hippocampal neurons after this global ischemic model and suggest that IP receptor agonists could be developed to prevent delayed pyramidal neuronal cell death.

Prostacyclin and analogues for acute ischaemic stroke

BACKGROUND

Prostacyclin is an agent with a number of effects on platelets, blood vessels and nerve cells which might improve outcome after acute ischaemic stroke. NOTE: This review covers an area where no active research is taking place. It will be updated if relevant information becomes available, e.g. on completion of an appropriate study.

OBJECTIVES

The objective of this review was to assess the effect of prostacyclin or analogues on survival in people with acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched November 2003). For the first version, we also searched EMBASE (1980 to 1999), MEDLINE (1966 to 1999), Science Citation Index (1981 to 1999) and the Ottawa Stroke Trials Registry. We also contacted the manufacturers of prostacyclin and the principal investigators of the identified trials.

SELECTION CRITERIA

Randomised trials comparing prostacyclin or analogues with placebo or control. Trials where people were entered within one week of stroke onset were included.

DATA COLLECTION AND ANALYSIS

Information on the methods of randomisation, blinding, analysis, the number of patients randomised, dose and timing of prostacyclin or analogue, patient withdrawals, the number of deaths occurring in each trial, and trial quality, were collected and assessed.

MAIN RESULTS

Five trials involving 191 people were included. Six early deaths (within four weeks) occurred with prostacyclin, and nine with placebo (odds ratio (OR) 0.63, 95% confidence interval (CI) 0.22 to 1.85). One trial of 32 patients reported late deaths (by 10 to 18 months) in 50% of patients in each group.

REVIEWERS' CONCLUSIONS

Too few patients have been studied in randomised trials to allow conclusions to be drawn about the effect of prostacyclin treatment on survival of people with acute stroke.

Effect of TTC-909 on cerebral infarction following permanent occlusion of the middle cerebral artery in stroke prone spontaneously hypertensive rats

We investigated the effect of TTC-909, a drug preparation of the stable prostaglandin I(2) analogue clinprost (isocarbacyclin methylester; methyl 5-[(1S,5S,6R,7R)-7-hydroxy-6-[(E)-(S)-3-hydroxy-1-octenyl] bicyclo[3.3.0]oct-2-en-3-yl] pentanoate) incorporated into lipid microspheres, on cerebral infarction 7 days after permanent occlusion of the middle cerebral artery (MCA) in stroke prone spontaneously hypertensive rats (SHRSP). Under the anesthesia, the MCA was permanently occluded above the rhinal fissure. In schedule 1, vehicle or TTC-909 was injected i.v. once daily over 7 days starting immediately after MCA occlusion. In schedule 2, vehicle or TTC-909 was infused for 3 h starting immediately after MCA occlusion. In schedule 3, vehicle or TTC-909 was infused for 3 h starting immediately after MCA occlusion followed by bolus injection once daily over 6 days. Seven days later, the infarct volume was estimated following hematoxylin and eosin staining. Cerebral infarction produced by permanent occlusion of MCA was limited to the cerebral cortex. While this volume was reduced significantly in case of schedule 3, the infarct volume was not reduced significantly in schedules 1 and 2. Ozagrel, a thromboxane A(2) synthetase inhibitor, had no effect on the infarct volume in schedule 3. These results suggest that cerebral infarction can be developed progressively not only during the first few hours but also after a permanent occlusion of MCA in SHRSP. TTC-909 inhibited cerebral infarction, maybe by improving cerebral blood flow and by protecting against neuronal damage.

Effect of TTC-909 in a middle cerebral artery thrombosis model in stroke-prone spontaneously hypertensive rats

We investigated the effect of TTC-909, a preparation of the stable prostaglandin I(2) analogue clinprost (isocarbacyclin methylester; methyl 5-[(1S,5S,6R,7R)-7-hydroxy-6-[(E)-(S)-3-hydroxy-1-octenyl] bicyclo[3.3.0]oct-2-en-3-yl] pentanoate) incorporated into lipid microspheres, on infarct volume 24 h after photochemically induced thrombotic occlusion of the middle cerebral artery in stroke-prone spontaneously hypertensive rats (SHR). Under anesthesia, the photosensitizing dye rose bengal (20 mg/kg) was administered intravenously and photoirradiation with green light (wavelength 540 nm) on the middle cerebral artery above the rhinal fissure was achieved using a xenon lamp for 10 min. Infarct volume 24 h after the photochemically induced thrombotic occlusion of the middle cerebral artery was significantly larger in stroke-prone SHR than in Wistar rats. When TTC-909 in doses of 100, 300 and 900 ng/kg/h was intravenously infused for 3 h, starting immediately after the end of the 10-min photoirradiation, the infarct volume was dose-dependently reduced and was statistically significant at a dose of 900 ng/kg/h (p < 0.05). Ozagrel, a thromboxane A(2) synthetase inhibitor, significantly reduced the infarct volume. The model of photochemically induced thrombotic occlusion of the middle cerebral artery in stroke-prone SHR is very useful, because the cerebral infarction is large enough and reproducible. TTC-909 may be effective for the treatment of acute ischemic stroke.

An outcome study of severe traumatic head injury using the "Lund therapy" with low-dose prostacyclin

BACKGROUND

There are two independent head injury outcome studies using the "Lund concept", and both showed a mortality rate of about 10%, and a favourable outcome (Glasgow outcome scale, GOS 4 and 5) of about 70%. The Lund concept aims at controlling intracranial pressure, and improving microcirculation around contusions. Intracranial pressure is controlled by maintaining a normal colloid osmotic pressure and reducing the hydrostatic capillary pressure. Microcirculation is improved by ensuring strict normovolaemia and reducing sympathetic discharge. The endogenous substance prostacyclin with its antiaggregatory/antiadhesive effects may further improve microcirculation, which finds support from a microdialysis-based clinical study and an experimental brain trauma study. The present clinical outcome study aims at evaluating whether the previously obtained good outcome with the Lund therapy can be reproduced, and whether the addition of prostacyclin has any adverse side-effects.

METHODS

All 31 consecutive patients with severe head injury, Glasgow coma scale (GCS) < or = 8, admitted to the University Hospital of Umeå during 1998 were included. The Lund therapy including prostacyclin infusion for the first three days at a dose of 0.5 ng kg(-1) min(-1). Outcome was evaluated according to the GOS >10 months after the injury.

RESULTS

One patient died, another suffered vegetative state and 7 severe disability. Of the 22 patients with favourable outcome, 19 showed good recovery and 3 moderate disability. No adverse side-effects of prostacyclin were observed.

CONCLUSION

The outcome results from previous studies using the Lund therapy were reproduced, and no adverse side-effects of low-dose prostacyclin were observed.

Low-dose prostacyclin in treatment of severe brain trauma evaluated with microdialysis and jugular bulb oxygen measurements

BACKGROUND

The endogenous substance prostacyclin is a substance with the potential to improve microcirculation and oxygenation around contusions in the brain following a head trauma by its vasodilatory, antiaggregatory and antiadhesive effects. Microdialysis measurements of local concentrations of selected interstitial substances in the brain, and measurements of venous jugular bulb oxygenation reflecting overall brain oxygenation, might be useful to evaluate possible therapeutic effects of a specific therapy, such as treatment with prostacyclin.

METHODS

This case report study on six patients, of whom five were given prostacyclin, includes cerebral microdialysis measurements of interstitial lactate (n=5), pyruvate (n=3), glycerol (n=5) and glucose (n=4), and is combined with measurements of venous jugular bulb oxygenation in three of the patients. One microdialysis catheter was placed adjacent to a contusion, and in four of the patients another catheter was also placed in the contralateral less injured side for comparison. Low-dose prostacyclin infusion (0.5-1.0 ng kg(-1) min(-1)) was started when lactate concentrations in the more injured side was raised at a constant level for more than 10 h. The study also includes one patient used as control to whom no prostacyclin was given.

RESULTS

Lactate was markedly lower in the less injured than in the more injured area of the brain. During the prostacyclin infusion elevated lactate and lactate/pyruvate ratio were reduced. Elevated glycerol decreased, a low glucose increased and jugular bulb blood oxygenation increased following start of prostacyclin. The control patient showed an increase in lactate and lactate/pyruvate ratio.

CONCLUSION

The microdialysis data combined with the jugular bulb oxygenation data indicated that low-dose prostacyclin exerts effects compatible with improved oxygenation and reduced cell damage in the severely traumatised brain.

Prostacyclin and analogues for acute ischaemic stroke

BACKGROUND

Prostacyclin is an agent with a number of effects on platelets, blood vessels and nerve cells which might improve outcome after acute ischaemic stroke.

OBJECTIVES

The objective of this review was to assess the effect of prostacyclin or analogues on survival in people with acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (last searched: March 1999), Medline (from 1965), Embase (from 1980) and ISI (from 1981). We contacted drug companies.

SELECTION CRITERIA

Randomised trials comparing prostacyclin or analogues with placebo or control. Trials where people were entered within one week of stroke onset were included.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed.

MAIN RESULTS

Five trials involving 191 people were included. Six early deaths (within four weeks) occurred with prostacyclin and nine with placebo (odds ratio of 0.63, 95% confidence interval 0.22 to 1.85). One trial of 32 patients reported late deaths (by 10 to 18 months) in 50% of patients in each group.

REVIEWER'S CONCLUSIONS

Too few patients have been studied in randomised trials to allow conclusions to be drawn about the effect of prostacyclin treatment on survival of people with acute stroke.

Protective effect of prostaglandin I(2) analogs on ischemic delayed neuronal damage in gerbils

We found a novel subtype of prostaglandin (PG) I(2) receptor (IP(2)) expressed in the central nervous system. Recently we have demonstrated that (15R)-16-m-tolyl-17,18,19, 20-tetranorisocarbacyclin (15R-TIC) and 15-deoxy-16-m-tolyl-17,18,19, 20-tetranorisocarbacyclin (15-deoxy-TIC), IP(2)-specific ligands, significantly prevented high (50%) oxygen-induced apoptotic neuronal death in cultured hippocampal neurons. We report here a potent neuroprotective effect of such analogs on delayed neuronal death of hippocampal CA1 neurons following transient ischemia for 3 min in gerbils. (15S)-16-m-tolyl-17,18,19,20-tetranorisocarbacyclin (15S-TIC), which nonselectively acts both on the PGI(2) receptor expressed in the peripheral tissue (IP(1)) and on IP(2), also showed a neuroprotective effect on such an ischemic model at higher doses than those for 15R-TIC and 15-deoxy-TIC. These PGI(2) analogs did not affect brain temperature, indicating that the agents showed the neuroprotective effect not by a hypothermic effect, but rather by the direct action on neurons.

Reduced microvascular thrombosis and improved outcome in acute murine stroke by inhibiting GP IIb/IIIa receptor-mediated platelet aggregation

Treatment options in acute stroke are limited by a dearth of safe and effective regimens for recanalization of an occluded cerebrovascular tributary, as well as by the fact that patients present only after the occlusive event is established. We hypothesized that even if the site of major arterial occlusion is recanalized after stroke, microvascular thrombosis continues to occur at distal sites, reducing postischemic flow and contributing to ongoing neuronal death. To test this hypothesis, and to show that microvascular thrombosis occurs as an ongoing, dynamic process after the onset of stroke, we tested the effects of a potent antiplatelet agent given both before and after the onset of middle cerebral arterial (MCA) occlusion in a murine model of stroke. After 45 min of MCA occlusion and 23 h of reperfusion, fibrin accumulates in the ipsilateral cerebral hemisphere, based upon immunoblotting, and localizes to microvascular lumena, based upon immunostaining. In concordance with these data, there is a nearly threefold increase in the ipsilateral accumulation of 111In-labeled platelets in mice subjected to stroke compared with mice not subjected to stroke. When a novel inhibitor of the glycoprotein IIb/IIIa receptor (SDZ GPI 562) was administered immediately before MCA occlusion, platelet accumulation was reduced 48%, and fibrin accumulation was reduced by 47% by immunoblot densitometry. GPI 562 exhibited a dose-dependent reduction of cerebral infarct volumes measured by triphenyltetrazolium chloride staining, as well as improvement in postischemic cerebral blood flow, measured by laser doppler. GPI 562 caused a dose-dependent increase in tail vein bleeding time, but intracerebral hemorrhage (ICH) was not significantly increased at therapeutic doses; however, there was an increase in ICH at the highest doses tested. When given immediately after withdrawal of the MCA occluding suture, GPI 562 was shown to reduce cerebral infarct volumes by 70%. These data support the hypothesis that in ischemic regions of brain, microvascular thrombi continue to accumulate even after recanalization of the MCA, contributing to postischemic hypoperfusion and ongoing neuronal damage.

Protective effect of a prostaglandin I2 analog, TEI-7165, on ischemic neuronal damage in gerbils

TTC-909 (Clinprost), a chemically stable PGI2 analog, isocarbacyclin methyl ester (TEI-9090 or Clinprost) incorporated in lipid microspheres, when administered intravenously after brain ischemia, prevents ischemic neuronal damage possibly by modulating cerebral blood flow and platelet aggregation. However, the possibility exists that TEI-7165, which is the free acid form and a central metabolite of TEI-9090, has direct neurotrophic action in vivo, since TEI-7165 has been shown to block neuronal voltage-dependent Ca2+ channels in vitro, and a novel prostacyclin receptor showing high affinity with TEI-7165 has been detected in a variety of brain regions including the hippocampus. In the present study, we infused TEI-7165 for 7 days into the lateral ventricle of gerbils starting 2 h before or just after 3-min forebrain ischemia. TEI-7165 infusion prevented significantly the ischemia-induced shortening of response latency time as revealed by a step-down passive avoidance task. Subsequent light and electron microscopic examinations showed that pyramidal neurons in the hippocampal CA1 region, as well as synapses within the strata moleculare, radiatum and oriens of the region, were significantly more numerous in gerbils infused with TEI-7165 than in those receiving vehicle infusion. TEI-7165 infusion did not affect hippocampal blood flow or temperature. These findings, together with the previously depicted accumulation of centrally administered [3H]TEI-7165 around hippocampal neurons, suggest that TEI-7165 has a direct neuroprotective action in brain ischemia.

Beneficial action of beraprost sodium, a prostacyclin analog, in stroke-prone rats

Beraprost sodium is a stable analog of the vasodilator, platelet antiaggregatory eicosanoid, prostacyclin. Experiments were performed to determine whether long-term therapy with beraprost produces vascular protective effects in saline-drinking stroke-prone spontaneously hypertensive rats (SHRSPs). Oral beraprost at 30, 100, or 300 micrograms/kg/day starting at 8.4 weeks of age did not affect the progressive increase of systolic blood pressure (measured by tail-cuff plethysmography) in these rats. Additional experiments in SHRSPs, prepared for continuous monitoring of blood pressure by radiotelemetry, revealed that oral beraprost administration reduced mean arterial pressure but that these hypotensive responses were not sustained (< 4 h). In all SHRSPs receiving oral beraprost, proteinuria and cerebrovascular lesions developed. In contrast, continuous subcutaneous infusion of beraprost at 2.8 mg/kg/day from age 8.3-12.3 weeks reduced systolic blood pressure and markedly diminished the development of renal lesions and the occurrence of stroke in saline-drinking SHRSPs. Beraprost at 0.9 mg/kg/day reduced blood pressure less than did 2.8 mg/kg/day and provided partial protection against cerebral and renal lesions after a 4-week infusion period. These results indicate that long-term subcutaneous infusion of beraprost can protect saline-drinking SHRSPs against stroke and renal damage. This effect is not readily dissociated from the ability of beraprost to reduce blood pressure in SHRSPs.

Radiologic intervention in the acute stroke patient

Overall, stroke is a common disease that can have devastating results. Treatment of stoke has been, for the most part, supportive in nature. Recently, more aggressive intervention has been used, particularly thrombolysis. Although such intervention can have devastating consequences, it has shown some promise, particularly in the arena of intraarterial administration. Although much work is needed to find the ideal agents and methods of administration, screening of patients may hold the key to success and the limitations of complications. Determination of exactly which patients will benefit and which will not and which will have complications and which will not, remains for the most part an enigma. Only through further investigation in a controlled, collaborative manner can such information be obtained.

Effect of ifetroban, a thromboxane A2 receptor antagonist, in stroke-prone spontaneously hypertensive rats

Experiments were performed to determine the effect of chronic therapy with the potent and long-acting thromboxane (TX) A2/prostaglandin endoperoxide (TP) receptor antagonist, ifetroban, on hypertension development and the incidence of stroke in stroke-prone spontaneously hypertensive rats (SHRSP). SHRSP instrumented with radiotelemetry probes, for continuous monitoring of arterial blood pressure, were given 1% NaCl to drink and Stroke-Prone Rodent Diet and were chronically treated with ifetroban (20 mg/kg/day, n = 10) or vehicle (n = 12) starting at 16.5 weeks of age. Ifetroban did not affect blood pressure or the development of proteinuria and cerebrovascular lesions. Chronic administration of a higher dose ifetroban (40 mg/kg/day) starting at 7 weeks of age was also without effect on blood pressure and stroke in noninstrumented saline-drinking SHRSP. These results do not support a major role for TXA2 and its endoperoxide precursors in the elevation of blood pressure and the development of cerebrovascular lesions in saline-drinking SHRSP.

Stable prostacyclin improves postischaemic microcirculatory changes in hypertensive rats

The prostacyclin analogue TTC-909 is incorporated in lipid microspheres and is chemically very stable. We examined the efficacy of TTC-909 on cerebral microcirculation following focal cerebral ischaemia. Focal cerebral ischaemia was produced by the occlusion of the distal middle cerebral artery in stroke-prone spontaneously hypertensive rats. Intravenous administration of TTC-909 (100 ng/kg/day) or vehicle was started 30 minutes after the occlusion and repeated for 7 days. On day 7, cerebral blood flow and blood-brain barrier permeability were measured autoradiographically. Brain oedema was estimated by the gravimetric method. The size of the infarction was calculated from area measurements on serial histologic sections. Treatment with TTC-909 resulted in significant improvement in regional blood flow in the ischaemic rim (p < 0.01) and the surrounding area (p < 0.05). With TTC-909 treatment, the increased permeability was significantly reduced in the ischaemic centre (p < 0.01) and rim (p < 0.05). A decrease in specific gravity in the ischaemic region and the remote non-ischaemic regions was prevented by the treatment (p < 0.01). We assumed that the efficacy of TTC-909 maintains the blood supply in the ischaemic area, improves disruption of the blood-brain barrier and prevents development of ischaemic oedema.

Why do all drugs work in animals but none in stroke patients? 1. Drugs promoting cerebral blood flow

Medical treatments which presumably alter cerebral blood flow (CBF) have been quite unimpressive in their effect on stroke outcome. In considering experimental and clinical data from the use of haemodilution and of the antiplatelet agent prostacyclin in focal cerebral ischaemia, and the current work with fibrinolytic agents in acute stroke, several lessons are apparent. Often agents hypothesized to affect CBF receive an underserved reputation based on sparse experimental evidence. Significant even unsuspected differences between species limit application to the clinical setting. Limitations of CBF measurements in experimental models and in humans raise questions about apparent responses to those agents. The failure to confirm a relationship between CBF enhancement and reduction in infarct development experimentally has plagued these approaches. The need for early application of agents which may modulate CBF during cerebral ischaemia is critical. Attention to these general issues and careful application of appropriate models are necessary so that a potentially useful therapeutic intervention is not overlooked.

The effects of beraprost Na, a stable prostacyclin analog, on animal models of stroke

We evaluated the effects of beraprost Na (Sodium (+-)-(1R*,2R*, 3aS*,8bS*)-2,3,3a,8b-tetrahydro-2-hydroxy-1-[(E)-(3S*)-3- hyd roxy-4-methyl-1- octen-6-ynyl]-1H-cyclopenta[b]benzofuran-5-butylate, beraprost), a stable and orally active prostacyclin (PGI2) analog with potent antiplatelet and vasodilating properties, on two stroke models, namely sudden death induced by arachidonate (AA) in rabbits and spontaneous stroke in stroke-prone spontaneously hypertensive rats (SHRSP). In the AA-induced sudden death model, 30 min after beraprost administration (1 or 3 mg/kg, po), AA was injected into the rabbit internal carotid artery, and incidence of convulsion and sudden death were assessed. Beraprost decreased both incidence of convulsion and mortality of rabbits. In SHRSP, orally administered beraprost (100 micrograms/kg, twice a day from 56-385 d of age) improved survival rate and decreased incidence of stroke. Preventive effects of beraprost on the two stroke models may have been caused mainly by the improvement of cerebral circulation. These results indicate that beraprost may have potential in the treatment and/or prevention of the cerebral circulatory disorders.

The efficacy and safety of tissue plasminogen activator in acute ischemic strokes

Over the past decade there has been an increasing use of thrombolytic agents in the treatment of coronary artery disease, pulmonary embolism, and thromboembolic strokes. The use of thrombolytic agents has been most successful in treating acute myocardial infarction. When treatment with intravenous streptokinase or tissue plasminogen activator (tPA) is initiated within the first 3 to 4 hours from the onset of symptoms, the rate of reperfusion ranges from 60% to 90%, as compared to a rate of 13% to 21% for placebo control. Both streptokinase and tPA have been extensively studied as therapies for acute myocardial infarction, and in general, a higher initial rate of reperfusion is achieved in tPA-treated patients than in streptokinase-treated patients, although the final arterial patency rate may not be different in the two groups due to a higher rate of reocclusion in the tPA-treated population. Furthermore, time dependency for efficacy from the onset of symptoms to the initiation of treatment is less for tPA than for streptokinase. However, the role of thrombolytic agents in the treatment of thromboembolic strokes is more experimental than clinical at the present time. Of all agents, tPA is the most promising and the most extensively studied. This paper will review the experimental data on the use of tPA in acute thromboembolic strokes as well as the existing clinical data on stroke reperfusion.

Prostacyclin attenuates in the rabbit hippocampus early consequences of transient complete cerebral ischemia

The effects of prostacyclin (PGI2) on ischemic changes of extracellular calcium concentration (CaE+2) and the blood-brain barrier (BBB) permeability were studied by microdialysis of the rabbit hippocampus. This was combined with morphological and neurophysiological observations. Complete cerebral ischemia lasting 15 min was produced by ligation of the brachiocephalic trunk, the left subclavian and both internal thoracic arteries. PGI2 was infused continuously i.v. in the last 3 min of ischemia and for 40 min after it, at a rate of 2 micrograms/kg/min. Control rabbits were submitted to untreated 15-min complete cerebral ischemia. The animals treated with PGI2 were found to have recovered bioelectric activity of the cortex and hippocampus in half the time that it took the untreated group. Application of PGI2 reduced by 60% the depth of ischemia-evoked drop of CaE+2 without acceleration of recovery during recirculation. The postischemic increase of BBB permeability to fluorescein was diminished. The number of morphologically changed neurons in the hippocampus of PGI2-treated animals was significantly lower than in the untreated group.

A preliminary double-blind cross-over trial of lipo-PGI2, a prostacyclin derivative incorporated in lipid microspheres, in cerebral infarction

Lipo-PGI2 is a drug preparation of a PGI2 analogue (isocarbacyclin methylester) which is incorporated into lipid microspheres with a diameter of 0.2 mu. Lipo-PGI2 has been shown to accumulate at the vascular wall, particularly those of arteriosclerotic lesions, and it has a much stronger inhibitory activity on platelet aggregation than free isocarbacyclin. In this study, a preliminary double-blind cross over trial of lipo-PGI2 in cerebral infarction was carried out. Seventeen patients with chronic cerebral infarction received 2 micrograms of lipo-PGI2 and placebo daily for one week each in a cross-over double blind test. A significant improvement was noted for lipo-PGI2 compared with placebo in the overall improvement in neurological and mental symptoms (p less than 0.01). The patient's preference also indicated the effectiveness of lipo-PGI2 (p less than 0.05). Adverse reactions were noted in 3 patients receiving placebo, but not in any receiving lipo-PGI2. These results show that lipo-PGI2 at a very low dose would be beneficial as a treatment for relieving the clinical symptoms of chronic cerebral infarction and that lipid microspheres are a useful drug carrier for PGI2 analogue therapy.

Time course of release in vivo of PGE2, PGF2 alpha, 6-keto-PGF1 alpha, and TxB2 into the brain extracellular space after 15 min of complete global ischemia in the presence and absence of cyclooxygenase inhibition

The time-dependent release of prostaglandin E2 (PGE2), prostaglandin F2 alpha (PGF2 alpha), thromboxane (Tx) B2, and 6-keto-PGF1 alpha (6-keto) from brain was measured before, during, and after a 15-min interval of total ischemia (four-vessel occlusion) in halothane-anesthetized cats using the technique of cerebroventricular perfusion. Resting levels of PGE2, PGF2 alpha, 6-keto, and Tx were: 253 +/- 75, 953 +/- 300, 650 +/- 200, and 550 +/- 170 pg/ml, respectively. During the 15-min ischemia, all prostanoids rose significantly, yet the highest levels were not observed until the first 15-60 min of the reflow at which time levels of PGE2, PGF2 alpha, 6-keto, and Tx, as compared with the preischemic baseline, rose approximately 8, 3.4, 3, and 55-fold, respectively. Significantly, although all prostanoids showed increases relative to baseline, the ratios of PGF2 alpha/6-keto and PGE2/6-keto remained stable throughout the experiment in both groups of animals. In contrast, the Tx/6-keto ratio rose from approximately 1 to approximately 30 during the 60 min after reflow in untreated cats. Treatment with zomepirac sodium (5 mg/kg, i.v.), a cyclooxygenase inhibitor, resulted in highly significant reductions in the levels of all prostanoids during the preischemic period. In zomepirac sodium-treated animals, there were also highly significant reductions in the prostanoid response to ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of a prostacyclin analog OP-2507 on acute ischemic cerebral edema in cats

We evaluated the inhibitory activity of a novel prostacyclin analog, OP-2507 (15-cis-(4-n-propylcyclohexyl)-16,17,18,19,20-pentanor-9-deo xy-6,9 alpha- nitriloprostaglandin F1 methyl ester) on the brain edema induced by occlusion of the middle cerebral artery in cats. Middle cerebral artery occlusion for 4h caused a decrease of regional cerebral blood flow. The specific gravity of the cerebral cortex measured 4h after the middle cerebral artery occlusion as an index of cerebral edema showed a significant reduction. Intravenous infusion of OP-2507 at infusion rates of 10 and 50 ng/kg per min was started 30 min before the middle cerebral artery occlusion and was continued for 4.5 h. While OP-2507 did not affect the blood pressure, heart rate and regional cerebral blood flow before and after the middle cerebral artery occlusion, the reduction of the specific gravity of cerebral cortex was significantly prevented by OP-2507 treatment at both doses. Prostacyclin prevented the reduction of the specific gravity only at the higher dose of 50 ng/kg per min. The present results indicate the potential usefulness of OP-2507 in acute ischemic cerebral disorders.

The effects of prostacyclin on early ultrastructural changes in the neuron nuclei of the motor cortex in rabbits after complete 20-min cerebral ischemia

Twelve rabbits underwent 20-min of complete cerebral ischemia. They were given PGI2 for 3 min before and during ischemia and for 15 min after ischemia. Control animals with complete cerebral ischemia over the same period of time were not given PGI2 medication. The animals treated with PGI2 were found to have recovered bioelectric activity of the cerebral cortex in half the time that it took the control group. A positive effect of PGI2 on some parameters of the peripheral blood system after ischemia was observed. Under the conditions of this experiment PGI2 did not effect the ultrastructural changes in motor cortex neuron nuclei. The changes were manifested in numerous vesicular structures and nuclear inclusions. The inclusions took the forms of clusters, rodlets, and lattices constructed of filaments and/or tubules. The number of vesicular structures and inclusions grew with the lapse in time after ischemia.

Brain protection against oxygen deficiency by nizofenone

The cerebral protective effect of nizofenone against tissue oxygen deficiency was investigated in mice. Treating mice with nizofenone resulted in a dose-dependent decrease in the rate of KCN-induced mortality and significant protection was observed at a dose as low as 0.3 mg/kg (i.p.). The cerebroprotective action of nizofenone was also demonstrated biochemically: Nizofenone (10 mg/kg i.p.) ameliorated KCN-induced anoxic disorder of cerebral energy metabolism, characterized by irreversible depletions of cerebral high energy phosphate stores and glucose concentrations and a marked accumulation of lactate, while keeping the cerebral energy charge potential (ECP) close to its normal value. Nizofenone showed similar effects in another experiment in which cerebral metabolic disorder was induced by complete ischemia following decapitation. These findings suggest that nizofenone has a considerable cerebroprotective action against oxygen deficiency.

Failure of prostacyclin effect on the reversal of early ultrastructural changes in cell nuclei of adrenal cortex after complete 15-min cerebral ischemia in rabbit

The experiment was carried out on 18 rabbits in two experimental groups. Group I: animals with complete 15-min cerebral ischemia infused with PGI2 for 3 min before, during and for 15-min after ischemia. Group II = control: animals with complete 15 min cerebral ischemia. In both groups, cell nuclei of the adrenal cortex were examined. In the 3rd and 6th h after ischemia numerous vesicular structures, intranuclear filaments and granulofibrillar bodies were found in the nuclei. The vesicular structures were enclosed in a single smooth membrane, some combined with the nuclear envelope, others remained independent. Amassing in karyoplasm of vesicular structures, intranuclear filaments and granulofibrillar bodies probably leads to death of the adrenal cortex cell after complete cerebral ischemia. It is suggested that vesicular structures may form as the result of disturbances in the water-electrolyte exchange between cytoplasm and karyoplasm of adrenal cells. In the experimental conditions, PGI2 did not affect the development of irreversible ultrastructural changes in adrenal cortex cell nuclei after complete prolonged cerebral ischemia.

Focal cerebral ischemia: pathophysiologic mechanisms and rationale for future avenues of treatment

Although approximately 500,000 patients suffer from a stroke each year in the United States, treatment of these patients to date has consisted primarily of prevention, supportive measures, and rehabilitation. The modification of experimental cerebral infarction by new pharmacologic agents, along with encouraging results from the restoration of blood flow to areas of focal ischemia in both laboratory and clinical trials, suggests that a more aggressive approach might be considered in selected patients with acute stroke.

Therapeutic progress--review XXIII. Are we making progress in the treatment of acute stroke?

The principal purpose of the treatment of acute stroke is to ensure that the quality of life of those affected is returned to as near normal as possible. Early nursing and physiotherapy are important components of effective management of acute stroke. It is not the intention of this review to examine these aspects which are so well described elsewhere (1). Instead, the theoretical and clinical bases for the various specific treatments advocated in recent years to reduce brain damage after ischaemic insult will be considered to serve as a guide for clinicians. Areas in this field where further research may prove rewarding are highlighted.

Effect of preischemia cyclooxygenase inhibition by zomepirac sodium on reflow, cerebral autoregulation, and EEG recovery in the cat after global ischemia

Zomepirac sodium (ZS) (5 mg/kg i.v.) was used to evaluate the effects of preischemia cyclooxygenase inhibition on CBF (as assessed by 133Xe clearance), CBF-PaCO2 responsiveness, and electrophysiologic (EEG) parameters before and after a 15-min period of complete global ischemia produced by four-vessel occlusion and mild hypotension. During the 15-min period of ischemia, CBF was essentially zero. Following reflow all groups displayed an initial hyperemia as compared with control (92 +/- 11 vs. 141-146 ml/100 g/min). Saline-treated animals during reflow displayed a delayed hypoperfusion (26 +/- 3 ml/100 g/min), which showed no improvement during the 2-h reflow period prior to death. In contrast, ZS-treated animals during reflow displayed significantly higher flows during the hypoperfusion phase (72 +/- 9 ml/100 g/min). The CBF-PaCO2 response displayed an approximately sevenfold reduction in slope at 2 h after reflow in saline-treated animals. This decrease in PaCO2 reactivity was not observed in the ZS-pretreated animals. With regard to EEG, all animals showed a total flattening during the 15 min of ischemia. In saline-treated animals only one of seven showed any sign of even marginal recovery. In ZS-treated animals EEG activity showed prominent recovery in seven of seven. Brainstem auditory evoked potentials were monitored and showed prominent recovery of amplitude and latency in ZS but not saline-treated animals during reflow.

Cerebral protection

Cerebral protection from an ischemic/hypoxic insult implies that tissue injury can be controlled or even prevented by certain therapeutic maneuvers. For example, physiological thresholds may be altered so that tissue vulnerability to the insult is reduced, or the intensity of an insult may be blunted by enhancing brain homeostasis. Such a therapeutic maneuver is carotid endarterectomy to improve blood flow in the disordered hemisphere. Alternatively, drugs with protective properties can be used before or even after the insult to "stabilize" injured tissue and prevent the harmful secondary effects that often follow. Various past and present approaches to cerebral protection employing physiological, pharmacological, and surgical intervention are reviewed. The mechanisms by which each allegedly protects the brain from ischemia and hypoxia are discussed briefly. Promising, but not always successful, approaches used in the past have pointed the way for new and more rational therapies. Truly effective protection of the brain from ischemia and hypoxia depends directly upon our capability to explore basic mechanisms of injury and our willingness to measure accurately and objectively the outcome of newly developed protective measures.

Ginger: inhibition of thromboxane synthetase and stimulation of prostacyclin: relevance for medicine and psychiatry

Ginger, the common spice, has recently been found to act as a potent inhibitor of thromboxane synthetase, raising levels of prostacyclin, without a concomitant rise in PGE2 or PGF2 alpha. Indications for use of ginger to replace either thromboxane inhibitors having serious side effects or prostacyclin are given.

Attenuation by prostacyclin of adrenaline-stimulated lipid peroxidation in the myocardium

The study aimed to investigate the effect of adrenaline upon lipid peroxidation processes in the myocardium and to evaluate the effect of prostacyclin upon the content of lipid peroxidation products in adrenaline-treated hearts. Anaesthetized rabbits were infused for 2 hours with adrenaline /1 microgram/kg/min/, adrenaline and prostacyclin /2 ng/kg/min/ and prostacyclin alone; controls received saline. After termination of infusion lipid peroxidation products /conjugated double bonds CDB, malondialdehyde MDA, lipid-soluble fluorescent material, FM/ and SH groups were measured in the myocardial tissue. Adrenaline significantly increased the content of all three indices of lipid peroxidation and decreased the concentration of soluble SH groups. PGI2 infused simultaneously significantly decreased the concentration of final metabolites of peroxidation /MDA, FM/ and prevented decrease of SH groups. The content of intermediate products of peroxidation, CDB was elevated. In conclusion, enhanced free radical activity, resulting in increased peroxidation of myocardial lipids may contribute to known injurious effect of adrenaline upon myocardium. The finding that PGI2 prevents increased formation of final peroxidation products gives support for the hypothesis that anti-free radical activity may be a component of cytoprotective action of prostacyclin.

The effect of prostacyclin on the morphological and enzymatic properties of CNS cultures exposed to anoxia

Organotypic cultures of rat cerebella were exposed to anoxia for 30 min. Prostacyclin (0.5 micrograms/ml medium) or 0.05 M Tris buffer pH 7.5 were added to the cultures immediately before exposure to anoxia. Cultures for histological, histoenzymatic and electron microscopic examination were taken immediately, 30 min and one, three, 24 and 72 h following anoxia. Cultures pretreated with prostacyclin showed a marked decrease in lactate dehydrogenase activity. Electron microscopic examination revealed that severe swelling and degenerative changes of neurons and glia induced by anoxia were much less pronounced in cultures treated with PGI2. Prostacyclin pretreatment also resulted in the appearance of morphological features of activation in glial cells. The results indicate that prostacyclin exerts a cytoprotective effect on the nerve tissue in vitro, predominantly reducing cell swelling and acidosis. This direct protection, besides vascular action of prostacyclin, may provide a basis for its beneficial clinical effect in ischemic stroke.

The influence of prostacyclin on the recovery of bioelectric cerebral activity after complete ischemia

Complete cerebral ischemia (CCI) was evoked by closing the brachiocephalic trunk, the left subclavicular artery and both internal thoracic arteries with simultaneous depression of systemic arterial pressure (SAP) to 70-50 mm Hg. The experiments were performed with three groups of rabbits. The first group consisted of animals with 15 and 20 min CCI, not receiving PGI2. In the second group PGI2 was given for 15 min before and during 15 min CCI. The third group with 15 and 20 min CCI received PGI2 3 min before, during and for 15 min after ischemia. The recovery of ECoG and the activities of the respiratory and vasomotor centres were evaluated as were reflex reactions. In 38 percent of the second group of rabbits improvement of the neurological condition after CCI was noted, as compared with animals of the control groups and a faster recovery of the ECoG. In the third group the neurological state improved in 100 percent of cases with simultaneous significantly quicker recovery of the first symptoms of brain cortex bioelectric activity and continuous activity in ECoG records. Between groups 1 and 2, and group 3 there were differences concerning the time of recovery of ECoG, and the intensity of reflexes. The influence of PGI2 on the brain bioelectric activity of the animals after CCI was found to be favourable.