Short-Term Acute Exercise Preconditioning Reduces Neurovascular Injury After Stroke Through Induced eNOS Activation

Physical exercise is known to reduce cardiovascular risk but its role in ischemic stroke is not clear. It was previously shown that an acute single bout of exercise reduced increased eNOS activation in the heart and reduced myocardial infarction. However, the impact of a single bout or short-term exercise on eNOS-induced neuroprotection after stroke was not previously studied. Accordingly, this study was designed to test the hypothesis that short-term acute exercise can provide "immediate neuroprotection" and improve stroke outcomes through induced eNOS activation. Male Wistar rats (300 g) were subjected to HIIT treadmill exercise for 4 days (25 min/day), break for 2 days, and then one acute bout for 30 min. Exercised animals were subjected to thromboembolic stroke 1 h, 6 h, 24 h, or 72 h after the last exercise session. At 24 h after stroke, control (sedentary) and exercised rats were tested for neurological outcomes, infarct size, and edema. The expression of active eNOS (p-S1177-eNOS) and active AMPK (p-T172-AMPK) was measured in the brain, cerebral vessels, and aorta. In an additional cohort, animals were treated with the eNOS inhibitor, L-NIO (I.P, 20 mg/kg), and stroked 1 h after exercise and compared with non-exercise animals. Acute exercise significantly reduced infarct size, edema, and improved functional outcomes, and significantly increased the expression of peNOS and pAMPK in the brain, cerebral vessels, and aorta. eNOS inhibition abolished the exercise-induced improvement in outcomes. Short-term acute preconditioning exercise reduced the neurovascular injury and improved functional outcomes after stroke through eNOS activation.

Proceedings from the Albert Charitable Trust Inaugural Workshop on white matter and cognition in aging

This third in a series of vascular cognitive impairment (VCI) workshops, supported by "The Leo and Anne Albert Charitable Trust," was held from February 8 to 12 at the Omni Resort in Carlsbad, CA. This workshop followed the information gathered from the earlier two workshops suggesting that we focus more specifically on brain white matter in age-related cognitive impairment. The Scientific Program Committee (Frank Barone, Shawn Whitehead, Eric Smith, and Rod Corriveau) assembled translational, clinical, and basic scientists with unique expertise in acute and chronic white matter injury at the intersection of cerebrovascular and neurodegenerative etiologies. As in previous Albert Trust workshops, invited participants addressed key topics related to mechanisms of white matter injury, biomarkers of white matter injury, and interventions to prevent white matter injury and age-related cognitive decline. This report provides a synopsis of the presentations and discussions by the participants, including the existing knowledge gaps and the delineation of the next steps towards advancing our understanding of white matter injury and age-related cognitive decline. Workshop discussions and consensus resulted in action by The Albert Trust to (1) increase support from biannual to annual "White Matter and Cognition" workshops; (2) provide funding for two collaborative, novel research grants annually submitted by meeting participants; and (3) coordinate the formation of the "Albert Research Institute for White Matter and Cognition." This institute will fill a gap in white matter science, providing white matter and cognition communications, including annual updates from workshops and the literature and interconnecting with other Albert Trust scientific endeavors in cognition and dementia, and providing support for newly established collaborations between seasoned investigators and to the development of talented young investigators in the VCI-dementia (VCID) and white matter cognition arena.

The Association Between Stroke Mortality and Time of Admission and Participation in a Telestroke Network

OBJECTIVES

Acute ischemic stroke is one of the leading causes of death. Patient outcomes, such as in-patient mortality, may be impacted by the time of arrival to the hospital. Telestroke networks have been found to be effective and safe at treating acute ischemic strokes. This paper investigated the association between mortality and time of arrival and hospital's participation in a telestroke network.

METHODS

Data were collected on ischemic stroke patients who arrived at 15 nonteaching hospitals in Georgia's Paul Coverdell Acute stroke registry from 2009 to 2016. After controlling for patient and hospital characteristics, multivariate logistic regression was conducted to assess whether time of arrival and telestroke participation was associated with in-hospital mortality. Subgroup analysis was conducted based on hospital bed size.

RESULTS

Overall, a total of 19,759 admissions for acute ischemic stroke were included in this analysis. The odds of dying in the hospital when arriving during the nighttime are 1.22 times the odds of dying when arriving during the day (95% CI: 1.04-1.45) and the odds of dying at a telestroke hospital are 53% lower than at a nontelestroke hospital (OR .47, 95% CI .31-.71). The associations were more prominent in large hospitals.

CONCLUSIONS

Our study found that the hour of arrival for acute ischemic stroke is linked with in-hospital mortality in large hospitals, with patients more likely to die if they arrive during the nighttime hours as compared to the daytime hours. Telestroke participation is linked with lower odds of hospital mortality in all hospitals.

A multicentre, randomised, sham-controlled trial on REmote iSchemic conditioning In patients with acute STroke (RESIST) - Rationale and study design

Rationale

Remote ischaemic conditioning, applied in the prehospital setting and continued in-hospital, may improve functional outcome in patients with acute ischaemic stroke and intracerebral haemorrhage.

Aims

To evaluate whether combined remote ischaemic per- and postconditioning can improve long-term functional outcome in acute ischaemic stroke and intracerebral haemorrhage patients.

Methods and design

Danish multicentre, prospective, randomised, patient-assessor blinded, sham-controlled study. Adult patients with a putative stroke identified prehospital with symptom duration <4 h, who are independent in daily activities will be randomised 1:1 to remote ischaemic conditioning or Sham-remote ischaemic conditioning. The treatment protocol will be five cycles, each consisting of 5 min with a blood pressure cuff inflation and 5 min with a deflated cuff placed on the upper extremity. The cuff pressure for remote ischaemic conditioning will be 200 mmHg-285 mmHg according to the individual systolic blood pressure and 20 mmHg sham-remote ischaemic conditioning during inflation. The study is approved as an acute study and consent is waived in the acute phase.Sample size estimation: For a 7% increased odds for a beneficial shift on the modified Rankin Scale at a significance level of 5% and power of 90%, 1000 patients with a target diagnosis of acute ischaemic stroke and intracerebral haemorrhage and a total of 1500 patients with a prehospital presumed stroke will be included.Study outcomes: The primary outcome will be the modified Rankin Scale score measured at three-month follow-up (analysed using ordinal logistic regression). ClinicalTrials.gov Identifier: NCT03481777.

Abstract TP320: Endothelial Nitric Oxide Synthase (eNOS) Inhibition Abolishes the Exercise-Induced Improvement in Neurovascular and Neurobehavioral Stroke Outcomes

Background: Clinically, it was shown that increased physical activity reduces the risk of stroke and severity of outcomes. However, the underlying mechanism is not clear. Endothelial nitric oxide synthase (eNOS) activation was shown to improve vascular function and reduce the risk of cardiovascular diseases. However, the role of eNOS in mediating short term exercise-induced improvement in stroke outcome was not previously studied. Accordingly, we tested the hypothesis that acute short term pre-stroke exercise improves stroke outcomes through increased eNOS activity, and that eNOS inhibition abolishes these beneficial effects.

Methods: Male Wistar rats (300 g) were subjected to high intensity interval training (HIIT) through treadmill running sessions for four days (25 minutes/day), break for 2 days and then one acute bout for 30 minutes. Exercised animals were subjected to thromboembolic stroke at 1h, 6h, 24h or 72h after the last exercise session. At 24h after stroke, sedentary and exercised rats were tested for neurological outcomes, infarct size and cerebral edema. Western Blotting was used to measure the expression of active eNOS (p-S1177-eNOS) in brain and cerebral vessels. Additional control and 1h exercise groups were treated with eNOS inhibitor (L-NIO (L-N 5 -1-Iminoethyl ornithine)) right after stroke (I.P. injection, dose: 20 mg/Kg).

Results: Acute exercise significantly reduced infarct size, edema and improved functional outcomes, and increased the expression of peNOS in the brain and cerebral vessels. eNOS inhibition significantly increased the infarct size, edema and worsened the neurobehavioral outcomes in exercised animals compared to non-treated group (table).

Conclusion: Short term acute pre-stroke exercise significantly reduced neurovascular injury and improved neurobehavioral and functional outcomes after stroke, and eNOS inhibition abolished these beneficial effects.

Stem Cell Therapy in Cerebrovascular Disease

PURPOSE OF REVIEW

The purpose of this article is to provide a review of state-of-the-art cellular therapy in cerebrovascular diseases by discussing published and ongoing clinical trials.

RECENT FINDINGS

In spite of the challenge in translating the success of cellular therapy in acute strokes from preclinical models to clinical trials, early phase clinical trial have recently shown promise in overcoming these challenges. Various stem cell types and doses are being studied, different routes of administration are under investigation, as well as defining the optimal time window to intervene. In addition, experimental methods to enhance cellular therapy, such as ischemic preconditioning, are evolving. After the failure of neuroprotectants in cerebrovascular diseases, researchers have been keen to provide a way of replacement of damaged brain tissue and to promote recovery in order to achieve better outcomes. The field has progressed from intravenous delivery in the 24- to 36-h time window to later intracerebral administration in chronic stroke in clinical trials. New optimism in acute stroke care fostered by the success of mechanical thrombectomy will hopefully extend into cell therapy to promote recovery.

Remote ischemic post-conditioning promotes hematoma resolution via AMPK-dependent immune regulation

Intracerebral hemorrhage is a devastating neurological injury that produces poor patient outcomes. In this report, Vaibhav et al. demonstrate that remote ischemic post-conditioning noninvasively accelerates hematoma resolution by enhancing AMPK-dependent alternative macrophage activation.

Spontaneous intracerebral hemorrhage (ICH) produces the highest acute mortality and worst outcomes of all stroke subtypes. Hematoma volume is an independent determinant of ICH patient outcomes, making clot resolution a primary goal of clinical management. Herein, remote-limb ischemic post-conditioning (RIC), the repetitive inflation–deflation of a blood pressure cuff on a limb, accelerated hematoma resolution and improved neurological outcomes after ICH in mice. Parabiosis studies revealed RIC accelerated clot resolution via a humoral-mediated mechanism. Whereas RIC increased anti-inflammatory macrophage activation, myeloid cell depletion eliminated the beneficial effects of RIC after ICH. Myeloid-specific inactivation of the metabolic regulator, AMPKα1, attenuated RIC-induced anti-inflammatory macrophage polarization and delayed hematoma resolution, providing a molecular link between RIC and immune activation. Finally, chimera studies implicated myeloid CD36 expression in RIC-mediated neurological recovery after ICH. Thus, RIC, a clinically well-tolerated therapy, noninvasively modulates innate immune responses to improve ICH outcomes. Moreover, immunometabolic changes may provide pharmacodynamic blood biomarkers to clinically monitor the therapeutic efficacy of RIC.

Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association

Intracranial endovascular interventions provide effective and minimally invasive treatment of a broad spectrum of diseases. This area of expertise has continued to gain both wider application and greater depth as new and better techniques are developed and as landmark clinical studies are performed to guide their use. Some of the greatest advances since the last American Heart Association scientific statement on this topic have been made in the treatment of ischemic stroke from large intracranial vessel occlusion, with more effective devices and large randomized clinical trials showing striking therapeutic benefit. The treatment of cerebral aneurysms has also seen substantial evolution, increasing the number of aneurysms that can be treated successfully with minimally invasive therapy. Endovascular therapies for such other diseases as arteriovenous malformations, dural arteriovenous fistulas, idiopathic intracranial hypertension, venous thrombosis, and neoplasms continue to improve. The purpose of the present document is to review current information on the efficacy and safety of procedures used for intracranial endovascular interventional treatment of cerebrovascular diseases and to summarize key aspects of best practice.

Human Neural Stem Cell Extracellular Vesicles Improve Recovery in a Porcine Model of Ischemic Stroke

BACKGROUND AND PURPOSE

Recent work from our group suggests that human neural stem cell-derived extracellular vesicle (NSC EV) treatment improves both tissue and sensorimotor function in a preclinical thromboembolic mouse model of stroke. In this study, NSC EVs were evaluated in a pig ischemic stroke model, where clinically relevant end points were used to assess recovery in a more translational large animal model.

METHODS

Ischemic stroke was induced by permanent middle cerebral artery occlusion (MCAO), and either NSC EV or PBS treatment was administered intravenously at 2, 14, and 24 hours post-MCAO. NSC EV effects on tissue level recovery were evaluated via magnetic resonance imaging at 1 and 84 days post-MCAO. Effects on functional recovery were also assessed through longitudinal behavior and gait analysis testing.

RESULTS

NSC EV treatment was neuroprotective and led to significant improvements at the tissue and functional levels in stroked pigs. NSC EV treatment eliminated intracranial hemorrhage in ischemic lesions in NSC EV pigs (0 of 7) versus control pigs (7 of 8). NSC EV-treated pigs exhibited a significant decrease in cerebral lesion volume and decreased brain swelling relative to control pigs 1-day post-MCAO. NSC EVs significantly reduced edema in treated pigs relative to control pigs, as assessed by improved diffusivity through apparent diffusion coefficient maps. NSC EVs preserved white matter integrity with increased corpus callosum fractional anisotropy values 84 days post-MCAO. Behavior and mobility improvements paralleled structural changes as NSC EV-treated pigs exhibited improved outcomes, including increased exploratory behavior and faster restoration of spatiotemporal gait parameters.

CONCLUSIONS

This study demonstrated for the first time that in a large animal model novel NSC EVs significantly improved neural tissue preservation and functional levels post-MCAO, suggesting NSC EVs may be a paradigm changing stroke therapeutic.

Selective activation of cannabinoid receptor-2 reduces neuroinflammation after traumatic brain injury via alternative macrophage polarization

Inflammation is an important mediator of secondary neurological injury after traumatic brain injury (TBI). Endocannabinoids, endogenously produced arachidonate based lipids, have recently emerged as powerful anti-inflammatory compounds, yet the molecular and cellular mechanisms underlying these effects are poorly defined. Endocannabinoids are physiological ligands for two known cannabinoid receptors, CB1R and CB2R. In the present study, we hypothesized that selective activation of CB2R attenuates neuroinflammation and reduces neurovascular injury after TBI. Using a murine controlled cortical impact (CCI) model of TBI, we observed a dramatic upregulation of CB2R within infiltrating myeloid cells beginning at 72 h. Administration of the selective CB2R agonist, GP1a (1-5 mg/kg), attenuated pro-inflammatory M1 macrophage polarization, increased anti-inflammatory M2 polarization, reduced edema development, enhanced cerebral blood flow, and improved neurobehavioral outcomes after TBI. In contrast, the CB2R antagonist, AM630, worsened outcomes. Taken together, our findings support the development of selective CB2R agonists as a therapeutic strategy to improve TBI outcomes while avoiding the psychoactive effects of CB1R activation.

Abstract TP428: The Beneficial Effects of Chronic Remote Ischemic Conditioning in a VCID Mouse Model are eNOS Dependent

Background and Purpose: Chronic remote ischemic conditioning (C-RIC) is effective at improving cerebral blood flow (CBF) inducing vascular remodeling, and improving cognition in a bilateral carotid artery stenosis (BCAS) mouse model, a model for Vascular Cognitive Impairment and Dementia (VCID). This improvement is associated with elevations of plasma nitrite. Our aim was to determine if the beneficial effect of C-RIC was eNOS dependent.

Methods: Microcoil (01.8 mm) induced BCAS model was used to induce chronic hypoperfusion. Adult eNOS-KO male mice (5-6 months) were randomly assigned to 2-groups (N=5): (1) BCAS and (2) BCAS+RIC. RIC was started 7d post-surgery daily for 3 weeks. Behavioral test and CBF was performed before termination. Functional outcomes were assessed using novel object recognition (NOR) test for non-spatial working memory, and hanging wire and beam walk test for motor/muscular impairment. Mice were followed for 4 weeks.

Results: C-RIC-therapy for 3 weeks did not improve CBF in the BCAS+RIC groups at either a 2 nd weeks or 4 th weeks compared to BCAS-Sham RIC groups. There was no significant change between the BCAS and BCAS+RIC groups in the discrimination index as determined by the NOR test or poor motor function as determined by hanging wire and beam walk test.

Conclusions: The beneficial effect of C-RIC in the BCAS model is abrogated in eNOS KO mice indicating that the effect of C-RIC is eNOS dependent.

Ischemic Conditioning and neonatal hypoxic ischemic encephalopathy: a literature review

Hypoxic Ischemic Encephalopathy (HIE) is the result of severe anoxic brain injury during the neonatal period and causes life-long morbidity and premature mortality. Currently, therapeutic hypothermia immediately after birth is the standard of care for clinically relevant HIE. However, therapeutic hypothermia alone does not provide complete neuroprotection and there is an urgent need for adjunctive therapies. Ischemic conditioning is an adaptive process of endogenous protection in which small doses of sub-lethal ischemia can provide a protection against a lethal ischemic event. Remote Ischemic Post-conditioning (RIPC), a form of ischemic conditioning, is highly translatable for HIE diagnosed immediately after birth as the conditioned ischemic stimulus is applied at the limb after the lethal ischemic episode. A number of studies in neonatal rats have demonstrated that RIPC is effective at reducing injury in focal cerebral ischemia models and improves neurological outcomes. In this review, we focus on the available data on HIE and its current treatment, models in HIE studies, ischemic conditioning/RIPC and its mechanism. We discuss in particular the effect of RIPC on neonatal brain with HIE. We postulate that combining RIPC with standard therapeutic hypothermia can be an attractive therapeutic approach for HIE.

Minocycline in Acute Cerebral Hemorrhage: An Early Phase Randomized Trial

BACKGROUND AND PURPOSE

Minocycline is under investigation as a neurovascular protective agent for stroke. This study evaluated the pharmacokinetic, anti-inflammatory, and safety profile of minocycline after intracerebral hemorrhage.

METHODS

This study was a single-site, randomized controlled trial of minocycline conducted from 2013 to 2016. Adults ≥18 years with primary intracerebral hemorrhage who could have study drug administered within 24 hours of onset were included. Patients received 400 mg of intravenous minocycline, followed by 400 mg minocycline oral daily for 4 days. Serum concentrations of minocycline after the last oral dose and biomarkers were sampled to determine the peak concentration, half-life, and anti-inflammatory profile.

RESULTS

A total of 16 consecutive eligible patients were enrolled, with 8 randomized to minocycline. Although the literature supports a time to peak concentration (T_max) of 1 hour for oral minocycline, the T_max was estimated to be at least 6 hours in this cohort. The elimination half-life (available on 7 patients) was 17.5 hours (SD±3.5). No differences were observed in inflammatory biomarkers, hematoma volume, or perihematomal edema. Concentrations remained at neuroprotective levels (>3 mg/L) throughout the dosing interval in 5 of 7 patients.

CONCLUSIONS

In intracerebral hemorrhage, a 400 mg dose of minocycline was safe and achieved neuroprotective serum concentrations. However, oral administration led to delayed absorption in these critically ill patients and should not be used when rapid, high concentrations are desired. Given the safety and pharmacokinetic profile of minocycline in intracerebral hemorrhage and promising data in the treatment of ischemic stroke, intravenous minocycline is an excellent candidate for a prehospital treatment trial.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01805895.

Chronic Remote Ischemic Conditioning Is Cerebroprotective and Induces Vascular Remodeling in a VCID Model

Vascular contributions to cognitive impairment and dementia (VCID) make up 50% of the cases of dementia. The purpose of this study was to determine the effect of chronic remote ischemic conditioning (C-RIC) on improving long-term (6 months) outcomes and cerebral blood flow (CBF) and collateral formation in a mouse model of VCID. Adult C57BL/6J male mice (10 weeks) were randomly assigned to four different groups: (1) sham-bilateral carotid artery stenosis (BCAS), (2) BCAS + sham RIC, (3) BCAS+C-RIC for 1 month (1MO), and (4) BCAS+C-RIC-4 months (4MO). CBF, cognitive impairment, and functional outcomes were performed up for 6 months after BCAS surgery. The expression of CD31, α-SMA, and myelin basic protein (MBP) was assessed by immunohistochemistry (IHC). Additional set of mice were randomized to sham, BCAS, and BCAS+C-RIC. The cerebrovascular angioarchitecture was studied with micro-CT. RIC therapy for either 1 or 4 months significantly improved CBF, new collateral formation, functional and cognitive outcomes, and prevented white matter damage. There was no difference between C-RIC for 1 or 4 months; IHC studies at 6 months showed an increase in brain CD31 and α-SMA expression indicating increased angiogenesis and MBP indicating preservation of white matter in animals receiving RIC. One month of daily RIC is as effective as 4 months of daily RIC in improving CBF, angiogenesis, and long-term functional outcomes (6 months) in a VCID model. This suggests that 1 month of RIC is sufficient to reduce cognitive impairment and induce beneficial cerebrovascular remodeling.

Intracerebral Xenotransplantation of GFP Mouse Bone Marrow Stromal Cells in Intact and Stroke Rat Brain: Graft Survival and Immunologic Response

The present study characterized survival and immunologic response of bone marrow stromal cells (BMSCs) following transplantation into intact and stroke brains. In the first study, intrastriatal transplantation of BMSC (60,000 in 3 μl) or vehicle was performed in normal adult Sprague-Dawley male rats that subsequently received daily cyclosporin A (CsA, 10 mg/kg, IP in 3 ml) or vehicle (olive oil, similar volume) starting on day of surgery up to 3 days posttransplantation. Animals were euthanized at 3 or 30 days posttransplantation and brains were processed either for green fluorescent protein (GFP) microscopy or flow cytometry (FACS). Both GFP epifluorescence and FACS scanning revealed GFP+ BMSCs in both groups of transplanted rats with or without CsA, although significantly increased (1.6- to 3-fold more) survival of GFP+ BMSCs was observed in the immunosuppressed animals. Further histologic examination revealed widespread dispersal of BMSCs away from the graft core accompanied by many long outgrowth processes in non-CsA-transplanted animals, whereas a very dense graft core, with cells expressing only sporadic short outgrowth processes, was observed in CsA-transplanted animals. There were no detectable GFP+ BMSCs in nontrans-planted rats that received CsA or vehicle. Immunologic response via FACS analysis revealed a decreased presence of cytotoxic cells, characterized by near complete absence of CD8+ cells, and lack of activation depicted by low CD69 expression in CsA-treated transplanted animals. In contrast, elevated levels of CD8+ cells and increased activation of CD69 expression were observed in transplanted animals that received vehicle alone. CD4+ helper cells were almost nondetectable in transplanted rats that received CsA, but also only minimally elevated in transplanted rats that received vehicle. Nontransplanted rats that received either CsA or vehicle displayed very minimal detectable levels of all three lymphocyte markers. In the second study, a new set of male Sprague-Dawley rats initially received bilateral stereotaxic intrastriatal transplantation of BMSCs and 3 days after were subjected to unilateral transient occlusion of middle cerebral artery. The animals were allowed to survive for 3 days after stroke without CsA immunosuppression. Epifluorescence microscopy revealed significantly higher (5-fold more) survival of transplanted GFP+ BMSCs in the stroke striatum compared with the intact striatum. The majority of the grafts remained within the original dorsal striatal transplant site, characterized by no obvious migration in intact striatum, but with long-distance migration along the ischemic penumbra in the stroke striatum. Moreover, FACS scanning analyses revealed low levels of immunologic response of grafted BMSCs in both stroke and intact striata. These results, taken together, suggest that xenotransplantation of mouse BMSCs into adult rats is feasible. Immunosuppression therapy can enhance xenograft survival and reduce graft-induced immunologic response; however, in the acute phase posttransplantation, BMSCs can survive in intact and stroke brain, and may even exhibit long-distance migration and increased outgrowth processes without immunosuppression.

Behavioral and Histological Characterization of Intrahippocampal Grafts of Human Bone Marrow-Derived Multipotent Progenitor Cells in Neonatal Rats with Hypoxic-Ischemic Injury

Children born with hypoxic-ischemic (HI) brain injury account for a significant number of live births wherein no clinical treatment is available. Limited clinical trials of stem cell therapy have been initiated in a number of neurological disorders, but the preclinical evidence of a cell-based therapy for neonatal HI injury remains in its infancy. One major postulated mechanism underlying therapeutic benefits of stem cell therapy involves stimulation of endogenous neurogenesis via transplantation of exogenous stem cells. To this end, transplantation has targeted neurogenic sites, such as the hippocampus, for brain protection and repair. The hippocampus has been shown to secrete growth factors, especially during the postnatal period, suggesting that this brain region presents as highly conducive microenvironment for cell survival. Based on its neurogenic and neurotrophic factor-secreting features, the hippocampus stands as an appealing target for stem cell therapy. Here, we investigated the efficacy of intrahippocampal transplantation of multipotent progenitor cells (MPCs), which are pluripotent progenitor cells with the ability to differentiate into a neuronal lineage. Seven-day-old Sprague-Dawley rats were initially subjected to unilateral HI injury, which involved permanent ligation of the right common carotid artery and subsequent exposure to hypoxic environment. At day 7 after HI injury, animals received stereotaxic hippocampal injections of vehicle or cryopreserved MPCs (thawed just prior to transplantation) derived either from Sprague-Dawley rats (syngeneic) or Fisher rats (allogeneic). All animals were treated with daily immunosuppression throughout the survival period. Behavioral tests were conducted on posttransplantation days 7 and 14 using the elevated body swing test and the rotarod to reveal general and coordinated motor functions. MPC transplanted animals exhibited reduced motor asymmetry and longer time spent on the rotarod than those that received the vehicle infusion. Both syngeneic and allogeneic MPC transplanted injured animals did not significantly differ in their behavioral improvements at both test periods. Immunohistochemical evaluations of graft survival after behavioral testing at day 14 posttransplantation revealed that syngeneic and allogeneic transplanted MPCs survived in the hippocampal region. These results demonstrate for the first time that transplantation of MPCs ameliorated motor deficits associated with HI injury. In view of comparable behavioral recovery produced by syngeneic and allogeneic MPC grafts, allogeneic transplantation poses as a feasible and efficacious cell replacement strategy with direct clinical application. An equally major finding is the observation lending support to the hippocampus as an excellent target brain region for stem cell therapy in treating HI injury.

Transplantation of Bone Marrow-Derived Stem Cells: A Promising Therapy for Stroke

Stroke remains a major cause of death in the US and around the world. Over the last decade, stem cell therapy has been introduced as an experimental treatment for stroke. Transplantation of stem cells or progenitors into the injured site to replace the nonfunctional cells, and enhancement of proliferation or differentiation of endogenous stem or progenitor cells stand as the two major cell-based strategies. Potential sources of stem/progenitor cells for stroke include fetal neural stem cells, embryonic stem cells, neuroteratocarcinoma cells, umbilical cord blood-derived nonhematopoietic stem cells, and bone marrow-derived stem cells. The goal of this article is to provide an update on the preclinical use of bone marrow-derived stem cells with major emphasis on mesenchymal stem cells (MSCs) and multipotent adult progenitor cells (MAPCs) because they are currently most widely applied in experimental stroke studies and are now being phased into early clinical trials. The phenotypic features of MSCs and MAPCs, as well as their application in stroke, are described.

Safety and efficacy of multipotent adult progenitor cells in acute ischaemic stroke (MASTERS): a randomised, double-blind, placebo-controlled, phase 2 trial

BACKGROUND

Multipotent adult progenitor cells are a bone marrow-derived, allogeneic, cell therapy product that modulates the immune system, and represents a promising therapy for acute stroke. We aimed to identify the highest, well-tolerated, and safest single dose of multipotent adult progenitor cells, and if they were efficacious as a treatment for stroke recovery.

METHODS

We did a phase 2, randomised, double-blind, placebo-controlled, dose-escalation trial of intravenous multipotent adult progenitor cells in 33 centres in the UK and the USA. We used a computer-generated randomisation sequence and interactive voice and web response system to assign patients aged 18-83 years with moderately severe acute ischaemic stroke and a National Institutes of Health Stroke Scale (NIHSS) score of 8-20 to treatment with intravenous multipotent adult progenitor cells (400 million or 1200 million cells) or placebo between 24 h and 48 h after symptom onset. Patients were ineligible if there was a change in NIHSS of four or more points during at least a 6 h period between screening and randomisation, had brainstem or lacunar infarct, a substantial comorbid disease, an inability to undergo an MRI scan, or had a history of splenectomy. In group 1, patients were enrolled and randomly assigned in a 3:1 ratio to receive 400 million cells or placebo and assessed for safety through 7 days. In group 2, patients were randomly assigned in a 3:1 ratio to receive 1200 million cells or placebo and assessed for safety through the first 7 days. In group 3, patients were enrolled, randomly assigned, and stratified by baseline NIHSS score to receive 1200 million cells or placebo in a 1:1 ratio within 24-48 h. Patients, investigators, and clinicians were masked to treatment assignment. The primary safety outcome was dose-limiting toxicity effects. The primary efficacy endpoint was global stroke recovery, which combines dichotomised results from the modified Rankin scale, change in NIHSS score from baseline, and Barthel index at day 90. Analysis was by intention to treat (ITT) including all patients in groups 2 and 3 who received the investigational agent or placebo. This study is registered with ClinicalTrials.gov, number NCT01436487.

FINDINGS

The study was done between Oct 24, 2011, and Dec 7, 2015. After safety assessments in eight patients in group 1, 129 patients were randomly assigned (67 to receive multipotent adult progenitor cells and 62 to receive placebo) in groups 2 and 3 (1200 million cells). The ITT populations consisted of 65 patients who received multipotent adult progenitor cells and 61 patients who received placebo. There were no dose-limiting toxicity events in either group. There were no infusional or allergic reactions and no difference in treatment-emergent adverse events between the groups (64 [99%] of 65 patients in the multipotent adult progenitor cell group vs 59 [97%] of 61 in the placebo group). There was no difference between the multipotent adult progenitor cell group and placebo groups in global stroke recovery at day 90 (odds ratio 1·08 [95% CI 0·55-2·09], p=0·83).

INTERPRETATION

Administration of multipotent adult progenitor cells was safe and well tolerated in patients with acute ischaemic stroke. Although no significant improvement was observed at 90 days in neurological outcomes with multipotent adult progenitor cells treatment, further clinical trials evaluating the efficacy of the intervention in an earlier time window after stroke (<36 h) are planned.

FUNDING

Athersys Inc.

Abstract WP296: Short Term Acute Preconditioning Exercise Improves Stroke Outcomes and Reduces Neurovascular Injury via Increased Endothelial Nitric Oxide Synthase Activity

Physical exercise is becoming a prominent therapeutic strategy to improve stroke outcomes. It was previously shown that long term exercise reduces infarct volume, but this was never tested in acute short term preconditioning exercise in a thromboembolic model of stroke. Exercise induced shear stress improves vascular function through increased activity of endothelial nitric oxide synthase (eNOS) and its upstream principal activator, AMP-activated protein kinase (AMPK). However, this was not previously tested in a stroke setting. Accordingly, we tested the hypothesis that acute short term preconditioning exercise improves stroke outcomes through increased AMPK and eNOS activity.

Methods: Male Wistar rats (300g) were subjected to treadmill exercise for four days (25 minutes/day), break for 2 days and then one acute bout for 30 minutes. Exercised animals were subjected to thromboembolic stroke at 1h, 6h or 24h after the last exercise session. At 24h, control (sedentary) and exercised rats were tested for neurological outcomes, infarct size and edema. Western Blotting was used to measure the expression of active eNOS (p-S1177-eNOS) and active AMPK (p-T172-AMPK).

Results: Acute exercise significantly reduced infarct size and edema and improved functional outcomes compared to control. It also significantly increased the expression of peNOS and pAMPK in the brain, cerebral vessels and aorta (Table).

Conclusion: Acute exercise preconditioning significantly reduced neurovascular injury and improved functional outcome after stroke through increased eNOS activity. Our findings are novel to point out the role of preconditioning exercise induced AMPK and eNOS activation in improving stroke outcomes.

Abstract TP435: Remote Ischemic Conditioning Augments Collateral Circulation and Angiogenesis in a Bilateral Carotid Artery Stenosis Model in Mice

Background and Purpose: The Bilateral carotid artery stenosis model in mice (BCAS) is regarded as a model for vascular cognitive impairment (VCI) and cerebral small vessel disease (SVD). We have shown that repetitive remote ischemic conditioning (RIC) increases cerebral blood flow (CBF), reduces white matter damage and improves cognition in the BCAS mouse model. The purpose of this study was to determine whether RIC increased angiogenesis and increased endothelial progenitor cells (EPC) in the blood or changed the polarization of macrophages in the blood.

Methods: Microcoil induced bilateral common carotid artery (BCAS) model was used to induce chronic hypoperfusion. Adult C57BL/6J male mice of (10-weeks) were randomized to 3-different groups (N=9), and subjected to Sham-(procedures of BCAS and RIC), BCAS+shamRIC and BCAS+RIC. RIC was started 7d post-surgery daily for 3 weeks. In all the experimental groups and after 3 weeks blood were collected through cardiac puncture and perfused with BriteVu. EPC (CD31, VEFR2, CD34) and M1/M2 macrophages were assessed through flow cytometry and angioarchitecture (vascular volume, number of vessels, linear spacing between vessels, density, average lumen thickness, and collateral circulation vessels) was performed with micro-CT scanner. All observers were blinded. Statistical significance was determined at p <0.05.

Results: RIC-therapy significantly improved CBF in the BCAS+RIC group compared to BCAS +shamRIC. EPCs were increased in the blood of the BCAS+RIC compared to BCAS+sham RIC and there was increased polarization (ratio of M2/M1) of macrophages in the blood in BCAS+RIC group compared to BCAS+shamRIC. RIC increased angiogenesis compared to sham RIC with increased vascular volume, number of vessels and decreased space between vessels.

Conclusions: Repetitive RIC increases angiogenesis and increases EPCs in the blood after BCAS. RIC also polarizes macrophages to the M2 (anti-inflammatory subset). Repetitive RIC may be an effective therapy to slow down the progression of VCI and SVD by promoting angiogenesis and vascular remodeling.

Abstract 133: Effectiveness of a Stem Cell-derived Therapeutic Factor Concentrate in a Mouse Embolic Stroke Model

Background: Early clinical trials of cell-based therapies in stroke have been very encouraging; however, technical hurdles may prevent widespread adoption. The salutary effects appear to be through release of “trophic” factors and immunomodulators which affect host repair and protection responses. We are developing a novel stroke therapy which is a clinically compliant cell-free, therapeutic factor concentrate (TFC) derived from adipose stem cell conditioned medium (ASC-CM). We will present data from a murine embolic stroke model study to determine the potential for clinical translation of TFC.

Methods: Embolic stroke was induced in C57/Bl6 male mice (16 - 18 wks old) by delivering 9 - 10 mm clot into the middle cerebral artery (MCA) territory. Mice were randomly picked up for the intravenous treatments (either vehicle or 20/50/100 uL of TFC; N= 10/group) immediately after stroke. Neurological deficits were evaluated at 48 hrs post stroke, and mice were also tested for the somatosensory functions using adhesive tape removal test (ATT) at 72 hrs before the sacrifice for TTC-stained infarct analysis. Statistical significance was determined at P < 0.05.

Results: Our data demonstrate a clear dose dependent response, with the highest dose tested (100 uL; ~4 mg total protein/kg body weight) being the most effective in the embolic stroke model. While the low-dose (20 uL; 0.8 mg/kg) did not show an effect in any outcomes measured, the middle dose (50 uL, ~2 mg/kg) was effective but less so than the highest dose (100 uL). TFC at 100 uL significantly improved neurological outcomes on Bederson scale, and also somatosensory function as determined by ATT. There was also a trend toward improved survival after stroke in 100 uL TFC treated group. Most importantly, while the 50 uL dose reduced the infarction volume by ~20%, the effect was >50% reduction with 100 uL treatment. TFC at any dose did not show any adverse effects such as the hemorrhagic transformation.

Conclusion: TFC is a potential therapy to improve post-stroke outcomes. We are repeating these studies with ovariectomized female mice and extending the studies to 1 month. Future studies with this model will test TFC (1) in combination with IV-tPA, (2) with delayed delivery (up to 24 hours post-stroke), (3) and in aged animals.

Abstract WP449: Short Term (1 month) Daily Remote Ischemic Conditioning (RIC) Induces Vascular Remodeling and Improves Long Term Outcomes (6 month) in a Mouse Model of Vascular Cognitive Impairment (VCI)

Background and Purpose: There is presently no specific therapy for the treatment of VCI. The bilateral carotid artery stenosis (BCAS) model is regarded as a valid model for VCI and vascular dementia. We reported that daily RIC is effective by improving cerebral blood flow (CBF), reducing white matter (WM) damage and improving cognition. The purpose of this study was to determine if 1MO RIC is as effective as 4MO RIC and if the treatment effects are durable out to 6MO.

Methods: Microcoil induced BCAS model was used to induce chronic hypoperfusion. Adult C57BL/6J male mice (10-weeks) were randomly assigned to 4-different groups (N=10), and subjected to Sham-BCAS, BCAS-(+sham RIC), BCAS+RIC-1MO and BCAS+RIC-4MO. RIC was started 7d post-surgery daily for 1MO or 4MOs. Behavioral test and CBF was performed at 1, 4 and 6MO after BCAS surgery. Functional outcomes were assessed using novel object recognition (NOR) test for non-spatial working memory, and hanging wire test for motor impairment. Histopathology as well as immunohistochemistry for CD31 and myelin basic protein (MBP) were also performed on the of the brain tissue collected after the neurobehavioral tests. Statistical significance was determined at p <0.05.

Results: RIC-therapy for 1MO or 4MO significantly improved CBF in the BCAS+RIC groups. The RIC-1MO treatment was effective as the RIC-4MO treatment at improving CBF at 6MO. Mice from the BCAS group showed significant loss in the discrimination index as determined by the NOR test, and poor motor function in hanging wire test. RIC-therapy in BCAS+RIC (1MO & 4MO) groups significantly improved functional outcomes as compared to the BCAS group whereas there was no difference between the RIC groups. Histopathological studies showed prevention of WM degeneration by RIC. Immunohistochemical analysis at 6 MOs showed increased CD31 staining (angiogenesis) and increased MBP staining (myelination) in the RIC groups compared to sham RIC.

Conclusions: Both 1MO and 4MO RIC-therapy improve long term CBF and angiogenesis at 6 MO and reduce WM damage and improve functional outcomes. One month of daily RIC is as effective as 4MO of daily RIC at improving CBF and long term functional outcomes (6MO) in the BCAS model. This suggests that 1MO of RIC induces durable vascular remodeling.