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Stuckey SM, Ong LK, Collins-Praino LE, Turner RJ. Neuroinflammation as a Key Driver of Secondary Neurodegeneration Following Stroke? Int J Mol Sci 2021; 22:ijms222313101. [PMID: 34884906 PMCID: PMC8658328 DOI: 10.3390/ijms222313101] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/25/2021] [Accepted: 12/01/2021] [Indexed: 01/13/2023] Open
Abstract
Ischaemic stroke involves the rapid onset of focal neurological dysfunction, most commonly due to an arterial blockage in a specific region of the brain. Stroke is a leading cause of death and common cause of disability, with over 17 million people worldwide suffering from a stroke each year. It is now well-documented that neuroinflammation and immune mediators play a key role in acute and long-term neuronal tissue damage and healing, not only in the infarct core but also in distal regions. Importantly, in these distal regions, termed sites of secondary neurodegeneration (SND), spikes in neuroinflammation may be seen sometime after the initial stroke onset, but prior to the presence of the neuronal tissue damage within these regions. However, it is key to acknowledge that, despite the mounting information describing neuroinflammation following ischaemic stroke, the exact mechanisms whereby inflammatory cells and their mediators drive stroke-induced neuroinflammation are still not fully understood. As a result, current anti-inflammatory treatments have failed to show efficacy in clinical trials. In this review we discuss the complexities of post-stroke neuroinflammation, specifically how it affects neuronal tissue and post-stroke outcome acutely, chronically, and in sites of SND. We then discuss current and previously assessed anti-inflammatory therapies, with a particular focus on how failed anti-inflammatories may be repurposed to target SND-associated neuroinflammation.
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Affiliation(s)
- Shannon M. Stuckey
- Discipline of Anatomy and Pathology, School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide 5005, Australia; (S.M.S.); (L.E.C.-P.)
| | - Lin Kooi Ong
- School of Pharmacy, Monash University Malaysia, Subang Jaya 47500, Malaysia;
- School of Biomedical Sciences and Pharmacy and the Priority Research Centre for Stroke and Brain Injury, The University of Newcastle, Callaghan 2308, Australia
| | - Lyndsey E. Collins-Praino
- Discipline of Anatomy and Pathology, School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide 5005, Australia; (S.M.S.); (L.E.C.-P.)
| | - Renée J. Turner
- Discipline of Anatomy and Pathology, School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide 5005, Australia; (S.M.S.); (L.E.C.-P.)
- Correspondence: ; Tel.: +61-8-8313-3114
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52
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Jafari M, Katlowitz K, De la Garza C, Sellers A, Moore S, Hall H, Desai A, Singh V, Damani R. Impact of systemic inflammatory response syndrome on acute ischemic stroke patients treated with mechanical thrombectomy. J Neurol Sci 2021; 430:119988. [PMID: 34547616 DOI: 10.1016/j.jns.2021.119988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 08/12/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
AIM Systemic inflammatory response syndrome (SIRS) has been associated with poor outcomes after acute ischemic stroke (AIS). The primary goal of this study was to determine whether SIRS status on admission correlated with functional outcomes in AIS treated with mechanical thrombectomy (MT). METHODS Consecutive patients from September 2015 to April 2019 were retrospectively reviewed for SIRS on admission. SIRS was defined as the presence of ≥2 of the following: temperature < 36 °C or > 38 °C, heart rate > 90, respiratory rate > 20, and white blood cell count <4000/mm or > 12,000 mm. RESULTS Of 202 patients, 188 met inclusion criteria. 49 patients (26%) had evidence of SIRS. Neither basic patient demographics nor standard stroke risk factors predicted the development of SIRS. However, presentation with SIRS was correlated with higher rates of death (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.2-5.5) as well as lower rates of favorable functional outcomes at discharge (OR, 0.09; 95% CI, 0.02-0.40) and 3-month follow up (OR 0.12; 95% CI 0.03-0.43). These results remained significant even after adjustment for age, sex, baseline NIHSS, recanalization status, and prior co-morbidities. CONCLUSION In our sample population, SIRS was associated with worse outcomes and higher rates of mortality in AIS patients treated with MT. Recognition of key risk factors can provide better prognostication and possible future therapeutic targets.
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Affiliation(s)
- Mostafa Jafari
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Kalman Katlowitz
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Alexander Sellers
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Shawn Moore
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Hayden Hall
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Aaron Desai
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Vikramjeet Singh
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Rahul Damani
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA.
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53
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Przykaza Ł. Understanding the Connection Between Common Stroke Comorbidities, Their Associated Inflammation, and the Course of the Cerebral Ischemia/Reperfusion Cascade. Front Immunol 2021; 12:782569. [PMID: 34868060 PMCID: PMC8634336 DOI: 10.3389/fimmu.2021.782569] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/29/2021] [Indexed: 01/13/2023] Open
Abstract
Despite the enormous progress in the understanding of the course of the ischemic stroke over the last few decades, a therapy that effectively protects neurovascular units (NVUs) and significantly improves neurological functions in stroke patients has still not been achieved. The reasons for this state are unclear, but it is obvious that the cerebral ischemia and reperfusion cascade is a highly complex phenomenon, which includes the intense neuroinflammatory processes, and comorbid stroke risk factors strongly worsen stroke outcomes and likely make a substantial contribution to the pathophysiology of the ischemia/reperfusion, enhancing difficulties in searching of successful treatment. Common concomitant stroke risk factors (arterial hypertension, diabetes mellitus and hyperlipidemia) strongly drive inflammatory processes during cerebral ischemia/reperfusion; because these factors are often present for a long time before a stroke, causing low-grade background inflammation in the brain, and already initially disrupting the proper functions of NVUs. Broad consideration of this situation in basic research may prove to be crucial for the success of future clinical trials of neuroprotection, vasculoprotection and immunomodulation in stroke. This review focuses on the mechanism by which coexisting common risk factors for stroke intertwine in cerebral ischemic/reperfusion cascade and the dysfunction and disintegration of NVUs through inflammatory processes, principally activation of pattern recognition receptors, alterations in the expression of adhesion molecules and the subsequent pathophysiological consequences.
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Affiliation(s)
- Łukasz Przykaza
- Laboratory of Experimental and Clinical Neurosurgery, Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland
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54
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Mulder IA, van Bavel ET, de Vries HE, Coutinho JM. Adjunctive cytoprotective therapies in acute ischemic stroke: a systematic review. Fluids Barriers CNS 2021; 18:46. [PMID: 34666786 PMCID: PMC8524879 DOI: 10.1186/s12987-021-00280-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/29/2021] [Indexed: 01/08/2023] Open
Abstract
With the introduction of endovascular thrombectomy (EVT), a new era for treatment of acute ischemic stroke (AIS) has arrived. However, despite the much larger recanalization rate as compared to thrombolysis alone, final outcome remains far from ideal. This raises the question if some of the previously tested neuroprotective drugs warrant re-evaluation, since these compounds were all tested in studies where large-vessel recanalization was rarely achieved in the acute phase. This review provides an overview of compounds tested in clinical AIS trials and gives insight into which of these drugs warrant a re-evaluation as an add-on therapy for AIS in the era of EVT. A literature search was performed using the search terms “ischemic stroke brain” in title/abstract, and additional filters. After exclusion of papers using pre-defined selection criteria, a total of 89 trials were eligible for review which reported on 56 unique compounds. Trial compounds were divided into 6 categories based on their perceived mode of action: systemic haemodynamics, excitotoxicity, neuro-inflammation, blood–brain barrier and vasogenic edema, oxidative and nitrosative stress, neurogenesis/-regeneration and -recovery. Main trial outcomes and safety issues are summarized and promising compounds for re-evaluation are highlighted. Looking at group effect, drugs intervening with oxidative and nitrosative stress and neurogenesis/-regeneration and -recovery appear to have a favourable safety profile and show the most promising results regarding efficacy. Finally, possible theories behind individual and group effects are discussed and recommendation for promising treatment strategies are described.
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Affiliation(s)
- I A Mulder
- Department of Biomedical Engineering and Physics, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - E T van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H E de Vries
- Department of Molecular Cell Biology and Immunology, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J M Coutinho
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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55
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Zykov MV, Barbarash OL. Inflammation and Comorbidity. Are There any Chances to Improve the Prognosis in Patients with Extremely High Cardiovascular Risk? RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-08-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The review contains actual data on possible approaches aimed at improving the prognosis in a special category of patients with extremely high cardiovascular risk, as well as in patients with recent acute coronary syndrome combined with comorbidity, including multifocal atherosclerosis. Currently, there are no class I recommendations for such patients aimed at reducing the risk of adverse cardiovascular events. It is suggested that suppression of inflammation may be a new therapeutic goal in this category of patients. Given the importance of inflammation in the development and course of atherosclerosis, in recent years there have been repeated attempts to influence the various components of the pro-inflammatory cascade involved in atherogenesis, but not all of them have been successful. Special attention is given to the anti-inflammatory effects of colchicine, a drug that can improve cardiovascular outcomes in patients with proven atherosclerosis. The review provides numerous pathogenetic and clinical evidence for the effectiveness of colchicine in patients with various manifestations of atherosclerosis. It is concluded that colchicine is the most promising anti-inflammatory drug that can improve the outcome of cardiovascular diseases. Thus, there is a need to initiate new clinical trial protocols aimed at studying the anti-inflammatory potential of this drug in patients with extreme cardiovascular risk.
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Affiliation(s)
- M. V. Zykov
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - O. L. Barbarash
- Research Institute for Complex Issues of Cardiovascular Diseases
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56
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Molecular Mechanisms of Neuroimmune Crosstalk in the Pathogenesis of Stroke. Int J Mol Sci 2021; 22:ijms22179486. [PMID: 34502395 PMCID: PMC8431165 DOI: 10.3390/ijms22179486] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/26/2021] [Accepted: 08/28/2021] [Indexed: 12/21/2022] Open
Abstract
Stroke disrupts the homeostatic balance within the brain and is associated with a significant accumulation of necrotic cellular debris, fluid, and peripheral immune cells in the central nervous system (CNS). Additionally, cells, antigens, and other factors exit the brain into the periphery via damaged blood–brain barrier cells, glymphatic transport mechanisms, and lymphatic vessels, which dramatically influence the systemic immune response and lead to complex neuroimmune communication. As a result, the immunological response after stroke is a highly dynamic event that involves communication between multiple organ systems and cell types, with significant consequences on not only the initial stroke tissue injury but long-term recovery in the CNS. In this review, we discuss the complex immunological and physiological interactions that occur after stroke with a focus on how the peripheral immune system and CNS communicate to regulate post-stroke brain homeostasis. First, we discuss the post-stroke immune cascade across different contexts as well as homeostatic regulation within the brain. Then, we focus on the lymphatic vessels surrounding the brain and their ability to coordinate both immune response and fluid homeostasis within the brain after stroke. Finally, we discuss how therapeutic manipulation of peripheral systems may provide new mechanisms to treat stroke injury.
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57
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Balasa R, Barcutean L, Mosora O, Manu D. Reviewing the Significance of Blood-Brain Barrier Disruption in Multiple Sclerosis Pathology and Treatment. Int J Mol Sci 2021; 22:ijms22168370. [PMID: 34445097 PMCID: PMC8395058 DOI: 10.3390/ijms22168370] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/19/2021] [Accepted: 07/31/2021] [Indexed: 12/27/2022] Open
Abstract
The disruption of blood–brain barrier (BBB) for multiple sclerosis (MS) pathogenesis has a double effect: early on during the onset of the immune attack and later for the CNS self-sustained ‘inside-out’ demyelination and neurodegeneration processes. This review presents the characteristics of BBB malfunction in MS but mostly highlights current developments regarding the impairment of the neurovascular unit (NVU) and the metabolic and mitochondrial dysfunctions of the BBB’s endothelial cells. The hypoxic hypothesis is largely studied and agreed upon recently in the pathologic processes in MS. Hypoxia in MS might be produced per se by the NVU malfunction or secondary to mitochondria dysfunction. We present three different but related terms that denominate the ongoing neurodegenerative process in progressive forms of MS that are indirectly related to BBB disruption: progression independent of relapses, no evidence of disease activity and smoldering demyelination or silent progression. Dimethyl fumarate (DMF), modulators of S1P receptor, cladribine and laquinimode are DMTs that are able to cross the BBB and exhibit beneficial direct effects in the CNS with very different mechanisms of action, providing hope that a combined therapy might be effective in treating MS. Detailed mechanisms of action of these DMTs are described and also illustrated in dedicated images. With increasing knowledge about the involvement of BBB in MS pathology, BBB might become a therapeutic target in MS not only to make it impenetrable against activated immune cells but also to allow molecules that have a neuroprotective effect in reaching the cell target inside the CNS.
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Affiliation(s)
- Rodica Balasa
- Department of Neurology, University of Medicine, Pharmacy, Sciences and Technology “George Emil Palade”, 540136 Targu Mures, Romania;
- Neurology 1 Clinic, Emergency Clinical County Hospital Mures, 540136 Targu Mures, Romania;
| | - Laura Barcutean
- Department of Neurology, University of Medicine, Pharmacy, Sciences and Technology “George Emil Palade”, 540136 Targu Mures, Romania;
- Neurology 1 Clinic, Emergency Clinical County Hospital Mures, 540136 Targu Mures, Romania;
- Correspondence: ; Tel.: +40-745-373947
| | - Oana Mosora
- Neurology 1 Clinic, Emergency Clinical County Hospital Mures, 540136 Targu Mures, Romania;
| | - Doina Manu
- Advanced Research Center Medical and Pharmaceutical, University of Medicine, Pharmacy, Sciences and Technology “George Emil Palade”, 540142 Targu Mures, Romania;
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58
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Heindl S, Ricci A, Carofiglio O, Zhou Q, Arzberger T, Lenart N, Franzmeier N, Hortobagyi T, Nelson PT, Stowe AM, Denes A, Edbauer D, Liesz A. Chronic T cell proliferation in brains after stroke could interfere with the efficacy of immunotherapies. J Exp Med 2021; 218:e20202411. [PMID: 34037669 PMCID: PMC8160576 DOI: 10.1084/jem.20202411] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/31/2021] [Accepted: 04/28/2021] [Indexed: 01/07/2023] Open
Abstract
Neuroinflammation is an emerging focus of translational stroke research. Preclinical studies have demonstrated a critical role for brain-invading lymphocytes in post-stroke pathophysiology. Reducing cerebral lymphocyte invasion by anti-CD49d antibodies consistently improves outcome in the acute phase after experimental stroke models. However, clinical trials testing this approach failed to show efficacy in stroke patients for the chronic outcome 3 mo after stroke. Here, we identify a potential mechanistic reason for this phenomenon by detecting chronic T cell accumulation-evading the systemic therapy-in the post-ischemic brain. We observed a persistent accumulation of T cells in mice and human autopsy samples for more than 1 mo after stroke. Cerebral T cell accumulation in the post-ischemic brain was driven by increased local T cell proliferation rather than by T cell invasion. This observation urges re-evaluation of current immunotherapeutic approaches, which target circulating lymphocytes for promoting recovery after stroke.
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Affiliation(s)
- Steffanie Heindl
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Alessio Ricci
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Olga Carofiglio
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Qihui Zhou
- German Center for Neurodegenerative Diseases, Munich, Germany
| | - Thomas Arzberger
- Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
- Center for Neuropathology and Prion Research, Ludwig Maximilians University Munich, Munich, Germany
| | - Nikolett Lenart
- Momentum Laboratory of Neuroimmunology, Institute of Experimental Medicine, Budapest, Hungary
| | - Nicolai Franzmeier
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Tibor Hortobagyi
- ELKH-DE Cerebrovascular and Neurodegenerative Research Group, Department of Neurology, University of Debrecen, Debrecen, Hungary
| | | | | | - Adam Denes
- Momentum Laboratory of Neuroimmunology, Institute of Experimental Medicine, Budapest, Hungary
| | - Dieter Edbauer
- German Center for Neurodegenerative Diseases, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Arthur Liesz
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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59
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Hermann DM, Liesz A, Dzyubenko E. Implications of immune responses for ischemic brain injury and stroke recovery. Brain Behav Immun 2021; 96:292-294. [PMID: 34023355 DOI: 10.1016/j.bbi.2021.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Dirk M Hermann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
| | - Arthur Liesz
- Institute for Stroke and Dementia Research, Ludwig Maximilians University, Munich and Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Egor Dzyubenko
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Zhang D, Ren J, Luo Y, He Q, Zhao R, Chang J, Yang Y, Guo ZN. T Cell Response in Ischemic Stroke: From Mechanisms to Translational Insights. Front Immunol 2021; 12:707972. [PMID: 34335623 PMCID: PMC8320432 DOI: 10.3389/fimmu.2021.707972] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/01/2021] [Indexed: 01/01/2023] Open
Abstract
Ischemic stroke, caused by a sudden disruption of blood flow to the brain, is a leading cause of death and exerts a heavy burden on both patients and public health systems. Currently available treatments for ischemic stroke are very limited and are not feasible in many patients due to strict time windows required for their administration. Thus, novel treatment strategies are keenly required. T cells, which are part of the adaptive immune system, have gained more attention for its effects in ischemic stroke. Both preclinical and clinical studies have revealed the conflicting roles for T cells in post-stroke inflammation and as potential therapeutic targets. This review summarizes the mediators of T cell recruitment, as well as the temporal course of its infiltration through the blood-brain-barrier, choroid plexus, and meningeal pathways. Furthermore, we describe the mechanisms behind the deleterious and beneficial effects of T cells in the brain, in both antigen-dependent and antigen-independent manners, and finally we specifically focus on clinical and preclinical studies that have investigated T cells as potential therapeutic targets for ischemic stroke.
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Affiliation(s)
- Dianhui Zhang
- Stroke Center, Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Jiaxin Ren
- Stroke Center, Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Yun Luo
- Stroke Center, Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China.,Department of Rehabilitation Medicine, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Qianyan He
- Stroke Center, Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Ruoyu Zhao
- Stroke Center, Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Junlei Chang
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Yi Yang
- Stroke Center, Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Zhen-Ni Guo
- Neuroscience Center, Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
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Qiu YM, Zhang CL, Chen AQ, Wang HL, Zhou YF, Li YN, Hu B. Immune Cells in the BBB Disruption After Acute Ischemic Stroke: Targets for Immune Therapy? Front Immunol 2021; 12:678744. [PMID: 34248961 PMCID: PMC8260997 DOI: 10.3389/fimmu.2021.678744] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/31/2021] [Indexed: 12/15/2022] Open
Abstract
Blood-Brain Barrier (BBB) disruption is an important pathophysiological process of acute ischemic stroke (AIS), resulting in devastating malignant brain edema and hemorrhagic transformation. The rapid activation of immune cells plays a critical role in BBB disruption after ischemic stroke. Infiltrating blood-borne immune cells (neutrophils, monocytes, and T lymphocytes) increase BBB permeability, as they cause microvascular disorder and secrete inflammation-associated molecules. In contrast, they promote BBB repair and angiogenesis in the latter phase of ischemic stroke. The profound immunological effects of cerebral immune cells (microglia, astrocytes, and pericytes) on BBB disruption have been underestimated in ischemic stroke. Post-stroke microglia and astrocytes can adopt both an M1/A1 or M2/A2 phenotype, which influence BBB integrity differently. However, whether pericytes acquire microglia phenotype and exert immunological effects on the BBB remains controversial. Thus, better understanding the inflammatory mechanism underlying BBB disruption can lead to the identification of more promising biological targets to develop treatments that minimize the onset of life-threatening complications and to improve existing treatments in patients. However, early attempts to inhibit the infiltration of circulating immune cells into the brain by blocking adhesion molecules, that were successful in experimental stroke failed in clinical trials. Therefore, new immunoregulatory therapeutic strategies for acute ischemic stroke are desperately warranted. Herein, we highlight the role of circulating and cerebral immune cells in BBB disruption and the crosstalk between them following acute ischemic stroke. Using a robust theoretical background, we discuss potential and effective immunotherapeutic targets to regulate BBB permeability after acute ischemic stroke.
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Affiliation(s)
| | | | | | | | | | - Ya-nan Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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62
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Strong B, Pudar J, Thrift AG, Howard VJ, Hussain M, Carcel C, de Los Campos G, Reeves MJ. Sex Disparities in Enrollment in Recent Randomized Clinical Trials of Acute Stroke: A Meta-analysis. JAMA Neurol 2021; 78:666-677. [PMID: 33900363 DOI: 10.1001/jamaneurol.2021.0873] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance The underenrollment of women in randomized clinical trials represents a threat to the validity of the evidence supporting clinical guidelines and potential disparities in access to novel treatments. Objective To determine whether women were underenrolled in contemporary randomized clinical trials of acute stroke therapies published in 9 major journals after accounting for their representation in underlying stroke populations. Data Sources MEDLINE was searched for acute stroke therapeutic trials published between January 1, 2010, and June 11, 2020. Study Selection Eligible articles reported the results of a phase 2 or 3 randomized clinical trial that enrolled patients with stroke and/or transient ischemic attack and examined a therapeutic intervention initiated within 1 month of onset. Data Extraction Data extraction was performed by 2 independent authors in duplicate. Individual trials were matched to estimates of the proportion of women in underlying stroke populations using the Global Burden of Disease database. Main Outcomes and Measures The primary outcome was the enrollment disparity difference (EDD), the absolute difference between the proportion of trial participants who were women and the proportion of strokes in the underlying disease populations that occurred in women. Random-effects meta-analyses of the EDD were performed, and multivariable metaregression was used to explore the associations of trial eligibility criteria with disparity estimates. Results The search returned 1529 results, and 115 trials (7.5%) met inclusion criteria. Of 121 105 randomized patients for whom sex was reported, 52 522 (43.4%) were women. The random-effects summary EDD was -0.053 (95% CI, -0.065 to -0.040), indicating that women were underenrolled by 5.3 percentage points. This disparity persisted across virtually all geographic regions, intervention types, and stroke types, apart from subarachnoid hemorrhage (0.117 [95% CI, 0.084 to 0.150]). When subarachnoid hemorrhage trials were excluded, the summary EDD was -0.067 (95% CI, -0.078 to -0.057). In the multivariable metaregression analysis, an upper age limit of 80 years as an eligibility criterion was associated with a 6-percentage point decrease in the enrollment of women. Conclusions and Relevance Further research is needed to understand the causes of the underenrollment of women in acute stroke trials. However, to maximize representation, investigators should avoid imposing age limits on enrollment.
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Affiliation(s)
- Brent Strong
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Julia Pudar
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Murtaza Hussain
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Cheryl Carcel
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Gustavo de Los Campos
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
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63
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Lourbopoulos A, Mourouzis I, Xinaris C, Zerva N, Filippakis K, Pavlopoulos A, Pantos C. Translational Block in Stroke: A Constructive and "Out-of-the-Box" Reappraisal. Front Neurosci 2021; 15:652403. [PMID: 34054413 PMCID: PMC8160233 DOI: 10.3389/fnins.2021.652403] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/06/2021] [Indexed: 12/13/2022] Open
Abstract
Why can we still not translate preclinical research to clinical treatments for acute strokes? Despite > 1000 successful preclinical studies, drugs, and concepts for acute stroke, only two have reached clinical translation. This is the translational block. Yet, we continue to routinely model strokes using almost the same concepts we have used for over 30 years. Methodological improvements and criteria from the last decade have shed some light but have not solved the problem. In this conceptual analysis, we review the current status and reappraise it by thinking "out-of-the-box" and over the edges. As such, we query why other scientific fields have also faced the same translational failures, to find common denominators. In parallel, we query how migraine, multiple sclerosis, and hypothermia in hypoxic encephalopathy have achieved significant translation successes. Should we view ischemic stroke as a "chronic, relapsing, vascular" disease, then secondary prevention strategies are also a successful translation. Finally, based on the lessons learned, we propose how stroke should be modeled, and how preclinical and clinical scientists, editors, grant reviewers, and industry should reconsider their routine way of conducting research. Translational success for stroke treatments may eventually require a bold change with solutions that are outside of the box.
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Affiliation(s)
- Athanasios Lourbopoulos
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurointensive Care Unit, Schoen Klinik Bad Aibling, Bad Aibling, Germany
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig Maximilian University, Munich, Germany
| | - Iordanis Mourouzis
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Christodoulos Xinaris
- IRCCS – Istituto di Ricerche Farmacologiche ‘Mario Negri’, Centro Anna Maria Astori, Bergamo, Italy
- University of Nicosia Medical School, Nicosia, Cyprus
| | - Nefeli Zerva
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Filippakis
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Angelos Pavlopoulos
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Pantos
- Department of Pharmacology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Leigh R, Hitomi E, Hutchison RM, Elkins J. Post-stroke blood-brain barrier disruption predicts poor outcome in patients enrolled in the ACTION study. J Neuroimaging 2021; 31:751-757. [PMID: 33886128 DOI: 10.1111/jon.12862] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE A prior study found a link between post-stroke blood-brain barrier disruption and functional outcomes. The current study aimed to replicate this finding in a cohort of patients recruited in the context of a randomized clinical trial. METHODS The ACTION trial was a study of natalizumab in acute stroke patients. Patients with MRI-perfusion weighted imaging (PWI) were included in this post-hoc analysis. Blood-brain permeability images (BBPI) were calculated from the PWI source images. Mean BBPI values from the 24 h time point were compared with modified Rankin scores (mRS) at 5, 30, and 90-day assessments using linear regression. Good functional outcome (mRS< = 1) was compared with mean BBPI using logistic regression. RESULTS One hundred and nineteen patients were included in the analysis (median age = 74, 43% female). Higher mean BBPI was associated with worse mRS at 5 days (p = 0.002; r2 = 0.078) and 30 days (p = 0.036; r2 = 0.039) but did not reach statistical significance at 90 days (p = 0.30; r2 = 0.010). When removing high-value outliers, all outcome measures showed a stronger relationship with mean BBPI. Logistic regression found that with every 1% increase in mean BBPI measured 24 h after the stroke, the likelihood of achieving a good functional outcome at 90 days is decreased by half (OR = 0.53; CI = 0.30:0.95; p = 0.032). CONCLUSIONS With sufficient image quality, elevated BBPI measured in the days after an ischemic event is predictive of worse functional outcome and may serve as a biomarker for post-stroke inflammation.
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Affiliation(s)
- Richard Leigh
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emi Hitomi
- College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio, USA
| | | | - Jacob Elkins
- Sarepta Therapeutics, Cambridge, Massachusetts, USA
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Chavda V, Madhwani K, Chaurasia B. Stroke and immunotherapy: Potential mechanisms and its implications as immune-therapeutics. Eur J Neurosci 2021; 54:4338-4357. [PMID: 33829590 DOI: 10.1111/ejn.15224] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 12/19/2022]
Abstract
Ischemia or brain injuries are mostly associated with emergency admissions and huge mortality rates. Stroke is a fatal cerebrovascular malady and second top root of disability and death in both developing and developed countries with a projected rise of 24.9% (from 2010) by 2030. It's the most frequent cause of morbidities and systemic permanent morbidities due to its multi-organ systemic pathology. Brain edema or active immune response cause disturbed or abnormal systemic affects causing inflammatory damage leading to secondary infection and secondary immune response which leads to activation like pneumonia or urine tract infections. There are a variety of post stroke treatments available which claims their usefulness in reducing or inhibiting post stroke and recurrent stroke damage followed by heavy inflammatory actions. Stroke does change the quality of life and also ensures daily chronic rapid neurodegeneration and cognitive decline. The only approved therapies for stroke are alteplase and thrombectomy which is associated with adverse outcomes and are not a total cure for ischemic stroke. Stroke and immune response are reciprocal to the pathology and time of event and it progresses till untreated. The immune reaction during ischemia opens new doors for advanced targeted therapeutics. Nowadays stem cell therapy has shown better results in stroke-prone individuals. Few monoclonal antibodies like natalizumab have shown great impact on pre-clinical and clinical stroke trial studies. In this current review, we have explored an immunology of stroke, current therapeutic scenario and future potential targets as immunotherapeutic agents in stroke therapeutics.
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Affiliation(s)
- Vishal Chavda
- Division of Anesthesia, Sardar Women's Hospital, Ahmadabad, Gujarat, India
| | - Kajal Madhwani
- Department of Microbiology, Nirma University, Ahmadabad, Gujarat, India
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Singh D, Wasan H, Reeta KH. Preclinical Stroke Research and Translational Failure: A Bird's Eye View on Preventable Variables. Cell Mol Neurobiol 2021; 42:2003-2017. [PMID: 33786698 DOI: 10.1007/s10571-021-01083-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/18/2021] [Indexed: 02/08/2023]
Abstract
Despite achieving remarkable success in understanding the cellular, molecular and pathophysiological aspects of stroke, translation from preclinical research has always remained an area of debate. Although thousands of experimental compounds have been reported to be neuro-protective, their failures in clinical setting have left the researchers and stakeholders in doldrums. Though the failures described have been excruciating, they also give us a chance to refocus on the shortcomings. For better translational value, evidences from preclinical studies should be robust and reliable. Preclinical study design has a plethora of variables affecting the study outcome. Hence, this review focusses on the factors to be considered for a well-planned preclinical study while adhering to guidelines with emphasis on the study design, commonly used animal models, their limitations with special attention on various preventable attritions including comorbidities, aged animals, time of dosing, outcome measures and physiological variables along with the concept of multicentric preclinical randomized controlled trials. Here, we provide an overview of a panorama of practical aspects, which could be implemented, so that a well-defined preclinical study would result in a neuro-protectant with better translational value.
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Affiliation(s)
- Devendra Singh
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Himika Wasan
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - K H Reeta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Rolfes L, Riek-Burchardt M, Pawlitzki M, Minnerup J, Bock S, Schmidt M, Meuth SG, Gunzer M, Neumann J. Neutrophil granulocytes promote flow stagnation due to dynamic capillary stalls following experimental stroke. Brain Behav Immun 2021; 93:322-330. [PMID: 33486002 DOI: 10.1016/j.bbi.2021.01.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 12/01/2022] Open
Abstract
Flow stagnation of peri-ischemic capillaries due to dynamic leukocyte stalls has been described to be a contributor to ongoing penumbral injury in transient brain ischemia, but has not been investigated in permanent experimental stroke so far. Moreover, it is discussed that obstructing neutrophils are involved in this process; however, their contribution has not yet been proven. Here, we characterize the dynamics of neutrophil granulocytes in two models of permanent stroke (photothrombosis and permanent middle cerebral artery occlusion) using intravital two-photon fluorescence microscopy. Different to previous studies on LysM-eGFP+ cells we additionally apply a transgenic mouse model with tdTomato-expressing neutrophils to avoid interference from additional immune cell subsets. We identify repetitively occurring capillary stalls of varying duration promoted by neutrophils in both models of permanent cerebral ischemia, validating the suitability of our new transgenic mouse model in determining neutrophil occlusion formation in vivo. Flow cytometric analysis of peripheral blood (PB) and brain tissue from mice subjected to photothrombosis reveal an increase in the total proportion of neutrophils, with selective upregulation of endothelial adherence markers in the PB. In conclusion, the dynamic microcirculatory stall phenomenon that is described after transient ischemia followed by reperfusion also occurs after permanent small- or large-vessel stroke and is clearly attributable to neutrophils.
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Affiliation(s)
- Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Germany.
| | | | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Germany; Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany.
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Germany.
| | - Stefanie Bock
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Germany.
| | - Mariella Schmidt
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Germany.
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Germany; Department of Neurology, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany.
| | - Matthias Gunzer
- Institute for Experimental Immunology and Imaging, University Hospital Essen, Germany.
| | - Jens Neumann
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany.
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Xu J, Wang A, Meng X, Yalkun G, Xu A, Gao Z, Chen H, Ji Y, Xu J, Geng D, Zhu R, Liu B, Dong A, Mu H, Lu Z, Li S, Zheng H, Chen X, Wang Y, Zhao X, Wang Y. Edaravone Dexborneol Versus Edaravone Alone for the Treatment of Acute Ischemic Stroke: A Phase III, Randomized, Double-Blind, Comparative Trial. Stroke 2021; 52:772-780. [PMID: 33588596 DOI: 10.1161/strokeaha.120.031197] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND PURPOSE Edaravone dexborneol, comprised of 2 active ingredients, edaravone and (+)-borneol, has been developed as a novel neuroprotective agent with synergistic effects of antioxidant and anti-inflammatory in animal models. The present clinical trial aimed at testing the effects of edaravone dexborneol versus edaravone on 90-day functional outcome in patients with acute ischemic stroke (AIS). METHODS A multicenter, randomized, double-blind, comparative, phase III clinical trial was conducted at 48 hospitals in China between May 2015 and December 2016. Inclusion criteria included patients diagnosed as AIS, 35 to 80 years of age, National Institutes of Health Stroke Scale Score between 4 and 24, and within 48 hours of AIS onset. AIS patients were randomized in 1:1 ratio into 2 treatment arms: 14-day infusion of edaravone dexborneol or edaravone injection. The primary end point was the proportion of patients with modified Rankin Scale score ≤1 on day 90 after randomization. RESULTS One thousand one hundred sixty-five AIS patients were randomly allocated to the edaravone dexborneol group (n=585) or the edaravone group (n=580). The edaravone dexborneol group showed significantly higher proportion of patients experiencing good functional outcomes on day 90 after randomization, compared with the edaravone group (modified Rankin Scale score ≤1, 67.18% versus 58.97%; odds ratio, 1.42 [95% CI, 1.12-1.81]; P=0.004). The prespecified subgroup analyses indicated that a greater benefit was observed in female patients than their male counterparts (2.26, 1.49-3.43 versus 1.14, 0.85-1.52). CONCLUSIONS When edaravone dexborneol versus edaravone was administered within 48 hours after AIS, 90-day good functional outcomes favored the edaravone dexborneol group, especially in female patients. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02430350.
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Affiliation(s)
- Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
| | - Gulbahram Yalkun
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
| | - Anding Xu
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Jinan University, Guangzhou, China (A.X.)
| | - Zhiqiang Gao
- Department of Neurology, The Second Affiliated Hospital of Nanjing Medical University, China (Z.G.)
| | - Huisheng Chen
- Department of Neurology, The General Hospital of Shenyang Military, China (H.C.)
| | - Yong Ji
- Department of Neurology, Tianjin Huanhu Hospital, China (Y.J.)
| | - Jun Xu
- Department of Neurology, Subei People's Hospital of Jiangsu Province, Yangzhou, China (Jun Xu)
| | - Deqin Geng
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, China (D.G.)
| | - Runxiu Zhu
- Department of Neurology, Inner Mongolia Autonomous Region People's Hospital, Hohhot, China (R.Z.)
| | - Bo Liu
- Department of Neurology, The First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, China (B.L.)
| | - Aiqin Dong
- Department of Neurology, Cangzhou Central Hospital, China (A.D.)
| | - Hua Mu
- State Key Laboratory of Translational Medicine and Innovative Drug Development, Nanjing, China (H.M., Z.L.)
| | - Zhihong Lu
- State Key Laboratory of Translational Medicine and Innovative Drug Development, Nanjing, China (H.M., Z.L.)
| | - Shuya Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
| | - Huaguang Zheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
| | - Xia Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
- China National Clinical Research Center for Neurological Diseases, Beijing (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Jie Xu, A.W., X.M., G.Y., S.L., H.Z., X.C., Yilong Wang, X.Z., Yongjun Wang)
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Thinking outside the Ischemia Box: Advancements in the Use of Multiple Sclerosis Drugs in Ischemic Stroke. J Clin Med 2021; 10:jcm10040630. [PMID: 33562264 PMCID: PMC7914575 DOI: 10.3390/jcm10040630] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/26/2021] [Accepted: 02/03/2021] [Indexed: 12/16/2022] Open
Abstract
Ischemic stroke (IS) is a major cause of death and disability, despite early intervention. Thrombo-inflammation, the inflammatory process triggered by ischemia, is a concept that ties IS with multiple sclerosis (MS), under the wider ‘umbrella’ of neuroinflammation, i.e., the inflammation of the nervous tissue. Drawing from this, numerous studies have explored the potential of MS disease-modifying drugs in the setting of IS. In this review, we present the available studies and discuss their potential in ameliorating IS outcomes. Based on our search, the vast majority of the studies have been conducted on animals, yielding mostly positive results. Two clinical trials involving natalizumab showed that it does not confer any benefits, but four human studies regarding fingolimod have showcased its potential in improving recovery prospects. However, concerns on safety and other issues are raised, and basic questions still need to be answered.
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Mastorakos P, Mihelson N, Luby M, Burks SR, Johnson K, Hsia AW, Witko J, Frank JA, Latour L, McGavern DB. Temporally distinct myeloid cell responses mediate damage and repair after cerebrovascular injury. Nat Neurosci 2021; 24:245-258. [PMID: 33462481 PMCID: PMC7854523 DOI: 10.1038/s41593-020-00773-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 12/08/2020] [Indexed: 01/29/2023]
Abstract
Cerebrovascular injuries can cause severe edema and inflammation that adversely affect human health. Here, we observed that recanalization after successful endovascular thrombectomy for acute large vessel occlusion was associated with cerebral edema and poor clinical outcomes in patients who experienced hemorrhagic transformation. To understand this process, we developed a cerebrovascular injury model using transcranial ultrasound that enabled spatiotemporal evaluation of resident and peripheral myeloid cells. We discovered that injurious and reparative responses diverged based on time and cellular origin. Resident microglia initially stabilized damaged vessels in a purinergic receptor-dependent manner, which was followed by an influx of myelomonocytic cells that caused severe edema. Prolonged blockade of myeloid cell recruitment with anti-adhesion molecule therapy prevented severe edema but also promoted neuronal destruction and fibrosis by interfering with vascular repair subsequently orchestrated by proinflammatory monocytes and proangiogenic repair-associated microglia (RAM). These data demonstrate how temporally distinct myeloid cell responses can contain, exacerbate and ultimately repair a cerebrovascular injury.
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Affiliation(s)
- Panagiotis Mastorakos
- Viral Immunology & Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
- Department of Surgical Neurology, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Nicole Mihelson
- Viral Immunology & Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Marie Luby
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Scott R Burks
- Frank Laboratory, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Kory Johnson
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Amie W Hsia
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
- MedStar Washington Hospital Center Comprehensive Stroke Center, Washington, DC, USA
| | - Jaclyn Witko
- Frank Laboratory, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Joseph A Frank
- Frank Laboratory, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health, Bethesda, MD, USA
| | - Lawrence Latour
- Acute Cerebrovascular Diagnostics Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Dorian B McGavern
- Viral Immunology & Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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Ferro D, Matias M, Neto J, Dias R, Moreira G, Petersen N, Azevedo E, Castro P. Neutrophil-to-Lymphocyte Ratio Predicts Cerebral Edema and Clinical Worsening Early After Reperfusion Therapy in Stroke. Stroke 2021; 52:859-867. [PMID: 33517702 DOI: 10.1161/strokeaha.120.032130] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE The mechanisms linking systemic inflammation to poor outcome in ischemic stroke are not fully understood. The authors investigated if peripheral inflammation following reperfusion therapy leads to an increase in cerebral edema (CED), thus hindering the clinical recovery. METHODS We designed a single-center study conducted at Centro Hospitalar Universitário São João between 2017 and 2019. Inclusion criteria were being adult, having an anterior circulation acute ischemic stroke, and receiving reperfusion therapy. Neutrophil-to-lymphocyte, platelet-to-lymphocyte ratios, and the systemic inflammatory response syndrome criteria were determined. The presence and grade of CED were evaluated on the computed tomography performed 24 hours following event. The clinical outcomes included early neurological deterioration and functional dependence at 90 days. Adjusted odds ratio and 95% CI were obtained by ordinal and logistic regression models. Optimal cutoff values were defined using receiver operating characteristic analysis in the training cohort and validated in an independent data set. RESULTS Five hundred fifty-three patients were included. Neutrophil-to-lymphocyte increased with higher degrees of CED at 24 hours (adjusted odds ratio, 1.34 [1.09-1.68], P<0.01) and was associated with early neurological deterioration (adjusted odds ratio, 1.30 [1.04-1.63], P<0.05) and poor functional status at 90 days (adjusted odds ratio, 1.79 [1.28-2.48], P<0.01). Platelet-to-lymphocyte was not associated with the outcomes. Systemic inflammatory response syndrome was related to CED due to altered white blood cell counts. Neutrophil-to-lymphocyte was the best predictor with an area under the curve around 0.7. Neutrophil-to-lymphocyte ≥7 had and accuracy, sensitivity, and specificity around 60%. CONCLUSIONS Increased systemic inflammation is linked to the severity of CED early after reperfusion therapy in stroke. Easily obtained inflammatory markers convey early warning alerts for patients at risk of severe neurological complications with an impact on long-term functional outcome. CED quantification should be included as an end point in proof-of-concept trials in immunomodulation in stroke.
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Affiliation(s)
- Daniela Ferro
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Portugal (D.F., J.N., R.D.)
- Department of Neurology (D.F., M.M., R.D., E.A., P.C.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Margarida Matias
- Department of Neurology (D.F., M.M., R.D., E.A., P.C.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Joana Neto
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Portugal (D.F., J.N., R.D.)
| | - Rafael Dias
- Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Portugal (D.F., J.N., R.D.)
- Department of Neurology (D.F., M.M., R.D., E.A., P.C.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Goreti Moreira
- Department of Internal Medicine (G.M.), Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Nils Petersen
- Neurocritical Care and Emergency Neurology, Yale School of Medicine, Yale-New Haven Hospital, CT (N.P.)
| | - Elsa Azevedo
- Department of Neurology (D.F., M.M., R.D., E.A., P.C.), Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Portugal (E.A., P.C.)
| | - Pedro Castro
- Department of Neurology (D.F., M.M., R.D., E.A., P.C.), Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Clinical Neurosciences and Mental Health, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Portugal (E.A., P.C.)
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Beuker C, Strecker JK, Rawal R, Schmidt-Pogoda A, Ruck T, Wiendl H, Klotz L, Schäbitz WR, Sommer CJ, Minnerup H, Meuth SG, Minnerup J. Immune Cell Infiltration into the Brain After Ischemic Stroke in Humans Compared to Mice and Rats: a Systematic Review and Meta-Analysis. Transl Stroke Res 2021; 12:976-990. [PMID: 33496918 PMCID: PMC8557159 DOI: 10.1007/s12975-021-00887-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/14/2022]
Abstract
Although several studies have suggested that anti-inflammatory strategies reduce secondary infarct growth in animal stroke models, clinical studies have not yet demonstrated a clear benefit of immune modulation in patients. Potential reasons include systematic differences of post-ischemic neuroinflammation between humans and rodents. We here performed a systematic review and meta-analysis to summarize and compare the spatial and temporal distribution of immune cell infiltration in human and rodent stroke. Data on spatiotemporal distribution of immune cells (T cells, macrophages, and neutrophils) and infarct volume were extracted. Data from all rodent studies were pooled by means of a random-effect meta-analysis. Overall, 20 human and 188 rodent stroke studies were included in our analyses. In both patients and rodents, the infiltration of macrophages and neutrophils preceded the lymphocytic influx. Macrophages and neutrophils were the predominant immune cells within 72 h after infarction. Although highly heterogeneously across studies, the temporal profile of the poststroke immune response was comparable between patients and rodents. In rodent stroke, the extent of the immune cell infiltration depended on the duration and location of vessel occlusion and on the species. The density of infiltrating immune cells correlated with the infarct volume. In summary, we provide the first systematic analysis and comparison of human and rodent post-ischemic neuroinflammation. Our data suggest that the inflammatory response in rodent stroke models is comparable to that in patients with stroke. However, the overall heterogeneity of the post-ischemic immune response might contribute to the translational failure in stroke research.
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Affiliation(s)
- Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Jan-Kolja Strecker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Rajesh Rawal
- Institute of Epidemiology and Social Medicine, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Antje Schmidt-Pogoda
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Luisa Klotz
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | | | - Clemens J Sommer
- Institute of Neuropathology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Heike Minnerup
- Institute of Epidemiology and Social Medicine, University of Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.
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Lei TY, Ye YZ, Zhu XQ, Smerin D, Gu LJ, Xiong XX, Zhang HF, Jian ZH. The immune response of T cells and therapeutic targets related to regulating the levels of T helper cells after ischaemic stroke. J Neuroinflammation 2021; 18:25. [PMID: 33461586 PMCID: PMC7814595 DOI: 10.1186/s12974-020-02057-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/09/2020] [Indexed: 12/21/2022] Open
Abstract
Through considerable effort in research and clinical studies, the immune system has been identified as a participant in the onset and progression of brain injury after ischaemic stroke. Due to the involvement of all types of immune cells, the roles of the immune system in stroke pathology and associated effects are complicated. Past research concentrated on the functions of monocytes and neutrophils in the pathogenesis of ischaemic stroke and tried to demonstrate the mechanisms of tissue injury and protection involving these immune cells. Within the past several years, an increasing number of studies have elucidated the vital functions of T cells in the innate and adaptive immune responses in both the acute and chronic phases of ischaemic stroke. Recently, the phenotypes of T cells with proinflammatory or anti-inflammatory function have been demonstrated in detail. T cells with distinctive phenotypes can also influence cerebral inflammation through various pathways, such as regulating the immune response, interacting with brain-resident immune cells and modulating neurogenesis and angiogenesis during different phases following stroke. In view of the limited treatment options available following stroke other than tissue plasminogen activator therapy, understanding the function of immune responses, especially T cell responses, in the post-stroke recovery period can provide a new therapeutic direction. Here, we discuss the different functions and temporal evolution of T cells with different phenotypes during the acute and chronic phases of ischaemic stroke. We suggest that modulating the balance between the proinflammatory and anti-inflammatory functions of T cells with distinct phenotypes may become a potential therapeutic approach that reduces the mortality and improves the functional outcomes and prognosis of patients suffering from ischaemic stroke.
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Affiliation(s)
- Tian-Yu Lei
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei Province, People's Republic of China
| | - Ying-Ze Ye
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei Province, People's Republic of China
| | - Xi-Qun Zhu
- Department of Head and Neck and Neurosurgery, Hubei Cancer Hospital, Wuhan, 430079, Hubei Province, People's Republic of China
| | - Daniel Smerin
- University of Central Florida College of Medicine, Orlando, FL, 32827, USA
| | - Li-Juan Gu
- Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei Province, People's Republic of China
| | - Xiao-Xing Xiong
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei Province, People's Republic of China.,Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei Province, People's Republic of China
| | - Hong-Fei Zhang
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, People's Republic of China.
| | - Zhi-Hong Jian
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei Province, People's Republic of China.
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74
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Weitbrecht L, Berchtold D, Zhang T, Jagdmann S, Dames C, Winek K, Meisel C, Meisel A. CD4 + T cells promote delayed B cell responses in the ischemic brain after experimental stroke. Brain Behav Immun 2021; 91:601-614. [PMID: 33002634 DOI: 10.1016/j.bbi.2020.09.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 08/13/2020] [Accepted: 09/24/2020] [Indexed: 01/20/2023] Open
Abstract
CD4+ T lymphocytes are key mediators of tissue damage after ischemic stroke. However, their infiltration kinetics and interactions with other immune cells in the delayed phase of ischemia remain elusive. We hypothesized that CD4+ T cells facilitate delayed autoreactive B cell responses in the brain, which have been previously linked to post-stroke cognitive impairment (PSCI). Therefore, we treated myelin oligodendrocyte glycoprotein T cell receptor transgenic 2D2 mice of both sexes with anti-CD4 antibody following 60-minute middle cerebral artery occlusion and assessed lymphocyte infiltration for up to 72 days. Anti-CD4-treatment eliminated CD4+ T cells from the circulation and ischemic brain for 28 days and inhibited B cell infiltration into the brain, particularly in animals with large infarcts. Absence of CD4+ T cells did not influence infarct maturation or survival. Once the CD4+ population recovered in the periphery, both CD4+ T and B lymphocytes entered the infarct site forming follicle-like structures. Additionally, we provide further evidence for PSCI that could be attenuated by CD4 depletion. Our findings demonstrate that CD4+ T cells are essential in delayed B cell infiltration into the ischemic brain after stroke. Importantly, lymphocyte infiltration after stroke is a long-lasting process. As CD4 depletion improved cognitive functions in an experimental set-up, these findings set the stage to elaborate more specific immune modulating therapies in treating PSCI.
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Affiliation(s)
- Luis Weitbrecht
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Experimental Neurology, Germany
| | - Daniel Berchtold
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Experimental Neurology, Germany
| | - Tian Zhang
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Experimental Neurology, Germany
| | - Sandra Jagdmann
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Medical Immunology, Germany
| | - Claudia Dames
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Medical Immunology, Germany
| | - Katarzyna Winek
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Experimental Neurology, Germany
| | - Christian Meisel
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Medical Immunology, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Experimental Neurology, Germany; Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Stroke Research Berlin, Germany; Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Neurocure Cluster of Excellence, Germany; Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurology, Germany.
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75
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Filling the gaps on stroke research: Focus on inflammation and immunity. Brain Behav Immun 2021; 91:649-667. [PMID: 33017613 PMCID: PMC7531595 DOI: 10.1016/j.bbi.2020.09.025] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/10/2020] [Accepted: 09/23/2020] [Indexed: 02/08/2023] Open
Abstract
For the last two decades, researchers have placed hopes in a new era in which a combination of reperfusion and neuroprotection would revolutionize the treatment of stroke. Nevertheless, despite the thousands of papers available in the literature showing positive results in preclinical stroke models, randomized clinical trials have failed to show efficacy. It seems clear now that the existing data obtained in preclinical research have depicted an incomplete picture of stroke pathophysiology. In order to ameliorate bench-to-bed translation, in this review we first describe the main actors on stroke inflammatory and immune responses based on the available preclinical data, highlighting the fact that the link between leukocyte infiltration, lesion volume and neurological outcome remains unclear. We then describe what is known on neuroinflammation and immune responses in stroke patients, and summarize the results of the clinical trials on immunomodulatory drugs. In order to understand the gap between clinical trials and preclinical results on stroke, we discuss in detail the experimental results that served as the basis for the summarized clinical trials on immunomodulatory drugs, focusing on (i) experimental stroke models, (ii) the timing and selection of outcome measuring, (iii) alternative entry routes for leukocytes into the ischemic region, and (iv) factors affecting stroke outcome such as gender differences, ageing, comorbidities like hypertension and diabetes, obesity, tobacco, alcohol consumption and previous infections like Covid-19. We can do better for stroke treatment, especially when targeting inflammation following stroke. We need to re-think the design of stroke experimental setups, notably by (i) using clinically relevant models of stroke, (ii) including both radiological and neurological outcomes, (iii) performing long-term follow-up studies, (iv) conducting large-scale preclinical stroke trials, and (v) including stroke comorbidities in preclinical research.
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76
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Kannan A, Delgardo M, Pennington-FitzGerald W, Jiang EX, Christophe BR, Connolly ES. Pharmacological management of cerebral ischemia in the elderly. Expert Opin Pharmacother 2020; 22:897-906. [PMID: 33382005 DOI: 10.1080/14656566.2020.1856815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: For elderly adults in the United States, stroke is the fifth leading cause of death of which ischemic strokes comprise a vast majority. Optimal pharmacological management of elderly ischemic stroke patients involves both reperfusion and supportive care. Recent research into pharmacological management has focused on vascular, immunomodulatory, cytoprotective, and alternative agents, some of which have shown limited success in clinical trials. However, no treatments have been established as a reliable mode for management of cerebral ischemia for elderly adults beyond acute thrombolysis.Areas covered: The authors conducted a literature search for ischemic stroke management in the elderly and a search for human drug studies for managing ischemic stroke on clinicaltrials.gov. Here, they describe recent progress in the pharmacological management of cerebral ischemia in the elderly.Expert opinion: Many drug classes (antihypertensive, cytoprotective and immunomodulatory, and alternative agents) have been explored with limited success in managing ischemic stroke, though some have shown preventative benefits. We generally observed a broad gap in evidence on elderly patients from studies across all drug classes, necessitating further studies to gain an understanding of effective management of ischemic stroke in this large demographic of patients.
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Affiliation(s)
- Adithya Kannan
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Mychael Delgardo
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Enoch X Jiang
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Brandon R Christophe
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
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77
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Zhang Y, Wang Z, Peng J, Gerner ST, Yin S, Jiang Y. Gut microbiota-brain interaction: An emerging immunotherapy for traumatic brain injury. Exp Neurol 2020; 337:113585. [PMID: 33370556 DOI: 10.1016/j.expneurol.2020.113585] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/14/2020] [Accepted: 12/20/2020] [Indexed: 02/06/2023]
Abstract
Individuals suffering from traumatic brain injury (TBI) often experience the activation of the immune system, resulting in declines in cognitive and neurological function after brain injury. Despite decades of efforts, approaches for clinically effective treatment are sparse. Evidence on the association between current therapeutic strategies and clinical outcomes after TBI is limited to poorly understood mechanisms. For decades, an increasing number of studies suggest that the gut-brain axis (GBA), a bidirectional communication system between the central nervous system (CNS) and the gastrointestinal tract, plays a critical role in systemic immune response following neurological diseases. In this review, we detail current knowledge of the immune pathologies of GBA after TBI. These processes may provide a new therapeutic target and rehabilitation strategy developed and used in clinical treatment of TBI patients.
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Affiliation(s)
- Yuxuan Zhang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Zhaoyang Wang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Jianhua Peng
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; Laboratory of Neurological Diseases and Brain Function, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; Sichuan Clinical Research Center for Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen-Nuremberg, Erlangen 91054, Germany
| | - Shigang Yin
- Laboratory of Neurological Diseases and Brain Function, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China.
| | - Yong Jiang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; Laboratory of Neurological Diseases and Brain Function, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; Sichuan Clinical Research Center for Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; Academician (Expert) Workstation of Sichuan Province, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China.
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78
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Otsu Y, Namekawa M, Toriyabe M, Ninomiya I, Hatakeyama M, Uemura M, Onodera O, Shimohata T, Kanazawa M. Strategies to prevent hemorrhagic transformation after reperfusion therapies for acute ischemic stroke: A literature review. J Neurol Sci 2020; 419:117217. [PMID: 33161301 DOI: 10.1016/j.jns.2020.117217] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/09/2020] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Reperfusion therapies by tissue plasminogen activator (tPA) and mechanical thrombectomy (MT) have ushered in a new era in the treatment of acute ischemic stroke (AIS). However, reperfusion therapy-related HT remains an enigma. AIM To provide a comprehensive review focused on emerging concepts of stroke and therapeutic strategies, including the use of protective agents to prevent HT after reperfusion therapies for AIS. METHODS A literature review was performed using PubMed and the ClinicalTrials.gov database. RESULTS Risk of HT increases with delayed initiation of tPA treatment, higher baseline glucose level, age, stroke severity, episode of transient ischemic attack within 7 days of stroke onset, and hypertension. At a molecular level, HT that develops after thrombolysis is thought to be caused by reactive oxygen species, inflammation, remodeling factor-mediated effects, and tPA toxicity. Modulation of these pathophysiological mechanisms could be a therapeutic strategy to prevent HT after tPA treatment. Clinical mechanisms underlying HT after MT are thought to involve smoking, a low Alberta Stroke Program Early CT Score, use of general anesthesia, unfavorable collaterals, and thromboembolic migration. However, the molecular mechanisms are yet to be fully investigated. Clinical trials with MT and protective agents have also been planned and good outcomes are expected. CONCLUSION To fully utilize the easily accessible drug-tPA-and the high recanalization rate of MT, it is important to reduce bleeding complications after recanalization. A future study direction could be to investigate the recovery of neurological function by combining reperfusion therapies with cell therapies and/or use of pleiotropic protective agents.
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Affiliation(s)
- Yutaka Otsu
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masaki Namekawa
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masafumi Toriyabe
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan; Department of Medical Technology, Graduate School of Health Sciences, Niigata University, Niigata, Japan
| | - Itaru Ninomiya
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masahiro Hatakeyama
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masahiro Uemura
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masato Kanazawa
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan.
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Xu X, Yuan L, Wang W, Xu J, Yang Q, Zhu Y, Xu Y, Yang K, Ge L, Huang X, Zhou Z. Systemic Inflammatory Response Syndrome and Outcomes in Ischemic Patients Treated with Endovascular Treatment. Clin Interv Aging 2020; 15:2331-2340. [PMID: 33324045 PMCID: PMC7733387 DOI: 10.2147/cia.s281865] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 11/20/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose Knowledge regarding the systemic inflammatory response syndrome (SIRS) associated with emergent large vessel occlusion (ELVO) is still insufficient. We aimed to investigate the occurrence rate, predictors, and clinical outcomes of SIRS in patients with ELVO after endovascular treatment (EVT). Patients and Methods We retrospectively collected EVT data of patients with ELVO from July 2015 to August 2019 in our center. SIRS in the absence of infection was recorded in detail. A favorable outcome was defined as obtaining a 90-day modified Rankin Scale (mRS) score ≤2. Results Among the 256 patients who received EVT, 91 (35.5%) developed SIRS. The patients who developed SIRS had a reduced favorable outcome (OR 4.112 [95% CI 1.705 to 9.920]; p=0.002) and higher mortality (OR 25.336 [95% CI 8.578 to 74.835]; p<0.001) at 90 days. A greater SIRS burden was positively correlated with the NIHSS scores at discharge and mRS scores at 90 days (r=0.265, p=0.011; r=0.245, p=0.019). The development of SIRS was associated with neutrophilic leukocytosis, hyperglycemia, higher NIHSS scores at admission, and worse collateral circulation. Conclusion The patients with SIRS had higher odds of poor functional outcomes and higher mortality at 90 days in the EVT-treatment setting. The severity of the inflammatory response was positively correlated with the clinical outcomes of the patients. Clinically, SIRS was associated with neutrophilic leukocytosis, hyperglycemia, baseline stroke severity, and worse collateral circulation.
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Affiliation(s)
- Xiangjun Xu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Lili Yuan
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Wenbing Wang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Junfeng Xu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Qian Yang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Yujuan Zhu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Youqing Xu
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Ke Yang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Liang Ge
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Xianjun Huang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
| | - Zhiming Zhou
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui Province, People's Republic of China
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80
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Neuroinflammation in intracerebral haemorrhage: immunotherapies with potential for translation. Lancet Neurol 2020; 19:1023-1032. [DOI: 10.1016/s1474-4422(20)30364-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 09/12/2020] [Accepted: 09/24/2020] [Indexed: 12/22/2022]
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81
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Tettamanti M, Beretta S, Pignataro G, Fumagalli S, Perego C, Sironi L, Pedata F, Amantea D, Bacigaluppi M, Vinciguerra A, Valente A, Diamanti S, Mariani J, Viganò M, Santangelo F, Zoia CP, Rogriguez-Menendez V, Castiglioni L, Rzemieniec J, Dettori I, Bulli I, Coppi E, Gullotta GS, Bagetta G, Martino G, Ferrarese C, De Simoni MG. Multicentre translational Trial of Remote Ischaemic Conditioning in Acute Ischaemic Stroke (TRICS): protocol of multicentre, parallel group, randomised, preclinical trial in female and male rat and mouse from the Italian Stroke Organization (ISO) Basic Science network. BMJ OPEN SCIENCE 2020; 4:e100063. [PMID: 35047692 PMCID: PMC8647600 DOI: 10.1136/bmjos-2020-100063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 09/15/2020] [Accepted: 10/06/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Multicentre preclinical randomised controlled trials (pRCT) are emerging as a necessary step to confirm efficacy and improve translation into the clinic. The aim of this project is to perform two multicentre pRCTs (one in rats and one in mice) to investigate the efficacy of remote ischaemic conditioning (RIC) in an experimental model of severe ischaemic stroke. Methods and analysis Seven research laboratories within the Italian Stroke Organization (ISO) Basic Science network will participate in the study. Transient endovascular occlusion of the proximal right middle cerebral artery will be performed in two species (rats and mice) and in both sexes. Animals will be randomised to receive RIC by transient surgical occlusion of the right femoral artery, or sham surgery, after reperfusion. Blinded outcome assessment will be performed for dichotomised functional neuroscore (primary endpoint) and infarct volume (secondary endpoint) at 48 hours. A sample size of 80 animals per species will yield 82% power to detect a significant difference of 30% in the primary outcome in both pRCTs. Analyses will be performed in a blind status and according to an intention-to-treat paradigm. The results of this study will provide robust, translationally oriented, high-quality evidence on the efficacy of RIC in multiple species of rodents with large ischaemic stroke. Ethics and dissemination This is approved by the Animal Welfare Regulatory Body of the University of Milano Bicocca, under project license from the Italian Ministry of Health. Trial results will be subject to publication according to the definition of the outcome presented in this protocol. Trial registration number PCTE0000177.
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Affiliation(s)
- Mauro Tettamanti
- Department of Neuroscience Research, Istituto di Ricerche Farmacologiche Mario Negri Sede di Milano, Milano, Lombardia, Italy
| | - Simone Beretta
- Department of Medicine and Surgery, University of Milan-Bicocca, Milano, Italy
| | - Giuseppe Pignataro
- Department of Pharmacology, University of Naples Federico II, Napoli, Campania, Italy
| | - Stefano Fumagalli
- Department of Neuroscience Research, Istituto di Ricerche Farmacologiche Mario Negri Sede di Milano, Milano, Lombardia, Italy
| | - Carlo Perego
- Department of Neuroscience Research, Istituto di Ricerche Farmacologiche Mario Negri Sede di Milano, Milano, Lombardia, Italy
| | - Luigi Sironi
- Department of Pharmacology, University of Milan, Milano, Lombardia, Italy
| | - Felicita Pedata
- Department of Pharmacology, University of Florence, Firenze, Toscana, Italy
| | - Diana Amantea
- Department of Pharmacology, Università della Calabria, Arcavacata di Rende, Calabria, Italy
| | - Marco Bacigaluppi
- Department of Neurology, San Raffaele Hospital, Milano, Lombardia, Italy
| | - Antonio Vinciguerra
- Department of Pharmacology, University of Naples Federico II, Napoli, Campania, Italy
| | - Alessia Valente
- Department of Neuroscience Research, Istituto di Ricerche Farmacologiche Mario Negri Sede di Milano, Milano, Lombardia, Italy
| | - Susanna Diamanti
- Department of Medicine and Surgery, University of Milan-Bicocca, Milano, Italy
| | - Jacopo Mariani
- Department of Medicine and Surgery, University of Milan-Bicocca, Milano, Italy
| | - Martina Viganò
- Department of Medicine and Surgery, University of Milan-Bicocca, Milano, Italy
| | | | - Chiara Paola Zoia
- Department of Medicine and Surgery, University of Milan-Bicocca, Milano, Italy
| | | | - Laura Castiglioni
- Department of Pharmacology, University of Milan, Milano, Lombardia, Italy
| | - Joanna Rzemieniec
- Department of Pharmacology, University of Milan, Milano, Lombardia, Italy
| | - Ilaria Dettori
- Department of Pharmacology, University of Florence, Firenze, Toscana, Italy
| | - Irene Bulli
- Department of Pharmacology, University of Florence, Firenze, Toscana, Italy
| | - Elisabetta Coppi
- Department of Pharmacology, University of Florence, Firenze, Toscana, Italy
| | | | - Giacinto Bagetta
- Department of Pharmacology, Università della Calabria, Arcavacata di Rende, Calabria, Italy
| | - Gianvito Martino
- Department of Neurology, San Raffaele Hospital, Milano, Lombardia, Italy
| | - Carlo Ferrarese
- Department of Medicine and Surgery, University of Milan-Bicocca, Milano, Italy
| | - Maria Grazia De Simoni
- Department of Neuroscience Research, Istituto di Ricerche Farmacologiche Mario Negri Sede di Milano, Milano, Lombardia, Italy
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Paul S, Candelario-Jalil E. Emerging neuroprotective strategies for the treatment of ischemic stroke: An overview of clinical and preclinical studies. Exp Neurol 2020; 335:113518. [PMID: 33144066 DOI: 10.1016/j.expneurol.2020.113518] [Citation(s) in RCA: 288] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 12/12/2022]
Abstract
Stroke is the leading cause of disability and thesecond leading cause of death worldwide. With the global population aged 65 and over growing faster than all other age groups, the incidence of stroke is also increasing. In addition, there is a shift in the overall stroke burden towards younger age groups, particularly in low and middle-income countries. Stroke in most cases is caused due to an abrupt blockage of an artery (ischemic stroke), but in some instances stroke may be caused due to bleeding into brain tissue when a blood vessel ruptures (hemorrhagic stroke). Although treatment options for stroke are still limited, with the advancement in recanalization therapy using both pharmacological and mechanical thrombolysis some progress has been made in helping patients recover from ischemic stroke. However, there is still a substantial need for the development of therapeutic agents for neuroprotection in acute ischemic stroke to protect the brain from damage prior to and during recanalization, extend the therapeutic time window for intervention and further improve functional outcome. The current review has assessed the past challenges in developing neuroprotective strategies, evaluated the recent advances in clinical trials, discussed the recent initiative by the National Institute of Neurological Disorders and Stroke in USA for the search of novel neuroprotectants (Stroke Preclinical Assessment Network, SPAN) and identified emerging neuroprotectants being currently evaluated in preclinical studies. The underlying molecular mechanism of each of the neuroprotective strategies have also been summarized, which could assist in the development of future strategies for combinational therapy in stroke treatment.
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Affiliation(s)
- Surojit Paul
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA.
| | - Eduardo Candelario-Jalil
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
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Role of DAMPs and of Leukocytes Infiltration in Ischemic Stroke: Insights from Animal Models and Translation to the Human Disease. Cell Mol Neurobiol 2020; 42:545-556. [DOI: 10.1007/s10571-020-00966-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023]
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Hussein O, Abd Elazim A, Sawalha K, Salam S, Saba K, Hamed M, Peng J, Hinduja A. Role of Non-Perfusion Factors in Mildly Symptomatic Large Vessel Occlusion Stroke. J Stroke Cerebrovasc Dis 2020; 29:105172. [PMID: 32912550 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/25/2020] [Accepted: 07/16/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Uncertainty regarding reperfusion of mildly-symptomatic (minor) large vessel occlusion (LVO)-strokes exists. Recently, benefits from reperfusion were suggested. However, there is still no strong data to support this. Furthermore, a proportion of those patients don't improve even after non-hemorrhagic reperfusion. Our study evaluated whether or not non-perfusion factors account for such persistent deconditioning. METHODS Patients with identified minor LVO-strokes (NIHSS ≤ 8) from our stroke alert registry between January-2016 and May-2018 were included. Variables/ predictors of outcome were tested using univariate/multivariate logistic and linear regression analyses. Three month-modified ranking scale (mRS) was used to differentiate between favorable (mRS = 0-2) and unfavorable outcomes (mRS = 3-6). RESULTS Eighty-one patients were included. Significant differences between the two outcome groups regarding admission-NIHSS and discharge-NIHSS existed (OR = 0.47, 0.49 / p = 0.0005, <0.0001 respectively).The two groups had matching perfusion measures. In the poor outcome group, discharge-NIHSS was unchanged from the admission-NIHSS while in the good outcome group, discharge-NIHSS significantly improved. CONCLUSION Admission and discharge NIHSS are independent predictors of outcome in patients with minor-LVO strokes. Unchanged discharge-NIHSS predicts worse outcomes while improved discharge-NIHSS predicts good outcomes. Unchanged NIHSS in the poor outcome group was independent of the perfusion parameters. In literature, complement activation and pro-inflammatory responses to ischemia might account for the progression of stroke symptoms in major-strokes. Our study concludes similar phenomena might be present in minor-strokes. Therefore, discharge-NIHSS may be useful as a clinical marker for future therapies.
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Affiliation(s)
- Omar Hussein
- University of New Mexico Health Sciences Center, Department of Neurology, Albuquerque, New Mexico, USA.
| | - Ahmed Abd Elazim
- University of New Mexico Health Sciences Center, Department of Neurology, Albuquerque, New Mexico, USA
| | - Khalid Sawalha
- University of Massachusetts-Baystate Medical Center - Department of Internal-Medicine, 3601 Main St, Springfield, MA 01107, USA
| | - Smeer Salam
- The Ohio State University Wexner Medical Center, Department of Neurology, 410 W 10th Ave, Columbus, USA
| | - Kasser Saba
- Atrium Health, Department of Neurology, Charlotte, North Carolina, USA
| | - Mohammad Hamed
- The Ohio State University Wexner Medical Center, Department of Neurology, 410 W 10th Ave, Columbus, USA
| | - Juan Peng
- The Ohio State University, Department of Biostatistics, 410 W 10th Ave, Columbus, USA
| | - Archana Hinduja
- The Ohio State University Wexner Medical Center, Department of Neurology, 410 W 10th Ave, Columbus, USA
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Atanasov P, Diamantaras A, MacPherson A, Vinarov E, Benjamin DM, Shrier I, Paul F, Dirnagl U, Kimmelman J. Wisdom of the expert crowd prediction of response for 3 neurology randomized trials. Neurology 2020; 95:e488-e498. [PMID: 32546652 DOI: 10.1212/wnl.0000000000009819] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 01/07/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore the accuracy of combined neurology expert forecasts in predicting primary endpoints for trials. METHODS We identified one major randomized trial each in stroke, multiple sclerosis (MS), and amyotrophic lateral sclerosis (ALS) that was closing within 6 months. After recruiting a sample of neurology experts for each disease, we elicited forecasts for the primary endpoint outcomes in the trial placebo and treatment arms. Our main outcome was the accuracy of averaged predictions, measured using ordered Brier scores. Scores were compared against an algorithm that offered noncommittal predictions. RESULTS Seventy-one neurology experts participated. Combined forecasts of experts were less accurate than a noncommittal prediction algorithm for the stroke trial (pooled Brier score = 0.340, 95% subjective probability interval [sPI] 0.340 to 0.340 vs 0.185 for the uninformed prediction), and approximately as accurate for the MS study (pooled Brier score = 0.107, 95% confidence interval [CI] 0.081 to 0.133 vs 0.098 for the noncommittal prediction) and the ALS study (pooled Brier score = 0.090, 95% CI 0.081 to 0.185 vs 0.090). The 95% sPIs of individual predictions contained actual trial outcomes among 44% of experts. Only 18% showed prediction skill exceeding the noncommittal prediction. Independent experts and coinvestigators achieved similar levels of accuracy. CONCLUSION In this first-of-kind exploratory study, averaged expert judgments rarely outperformed noncommittal forecasts. However, experts at least anticipated the possibility of effects observed in trials. Our findings, if replicated in different trial samples, caution against the reliance on simple approaches for combining expert opinion in making research and policy decisions.
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Affiliation(s)
- Pavel Atanasov
- From Pytho LLC (P.A.), Brooklyn, NY; Department of Neurology (A.D.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Biomedical Ethics Unit, Department of Social Studies of Medicine (A.M., E.V., D.M.B., J.K.), and Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital (I.S.), McGill University, Montreal, Canada; Max Delbrueck Center for Molecular Medicine (F.P.), Berlin; Department of Neurology (F.P.), NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin; Humboldt-Universität zu Berlin (U.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin; and Department of Experimental Neurology and Center for Stroke Research Berlin and QUEST Center for Transforming Biomedical Research (U.D.), Berlin Institute of Health, Germany
| | - Andreas Diamantaras
- From Pytho LLC (P.A.), Brooklyn, NY; Department of Neurology (A.D.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Biomedical Ethics Unit, Department of Social Studies of Medicine (A.M., E.V., D.M.B., J.K.), and Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital (I.S.), McGill University, Montreal, Canada; Max Delbrueck Center for Molecular Medicine (F.P.), Berlin; Department of Neurology (F.P.), NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin; Humboldt-Universität zu Berlin (U.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin; and Department of Experimental Neurology and Center for Stroke Research Berlin and QUEST Center for Transforming Biomedical Research (U.D.), Berlin Institute of Health, Germany
| | - Amanda MacPherson
- From Pytho LLC (P.A.), Brooklyn, NY; Department of Neurology (A.D.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Biomedical Ethics Unit, Department of Social Studies of Medicine (A.M., E.V., D.M.B., J.K.), and Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital (I.S.), McGill University, Montreal, Canada; Max Delbrueck Center for Molecular Medicine (F.P.), Berlin; Department of Neurology (F.P.), NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin; Humboldt-Universität zu Berlin (U.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin; and Department of Experimental Neurology and Center for Stroke Research Berlin and QUEST Center for Transforming Biomedical Research (U.D.), Berlin Institute of Health, Germany
| | - Esther Vinarov
- From Pytho LLC (P.A.), Brooklyn, NY; Department of Neurology (A.D.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Biomedical Ethics Unit, Department of Social Studies of Medicine (A.M., E.V., D.M.B., J.K.), and Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital (I.S.), McGill University, Montreal, Canada; Max Delbrueck Center for Molecular Medicine (F.P.), Berlin; Department of Neurology (F.P.), NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin; Humboldt-Universität zu Berlin (U.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin; and Department of Experimental Neurology and Center for Stroke Research Berlin and QUEST Center for Transforming Biomedical Research (U.D.), Berlin Institute of Health, Germany
| | - Daniel M Benjamin
- From Pytho LLC (P.A.), Brooklyn, NY; Department of Neurology (A.D.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Biomedical Ethics Unit, Department of Social Studies of Medicine (A.M., E.V., D.M.B., J.K.), and Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital (I.S.), McGill University, Montreal, Canada; Max Delbrueck Center for Molecular Medicine (F.P.), Berlin; Department of Neurology (F.P.), NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin; Humboldt-Universität zu Berlin (U.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin; and Department of Experimental Neurology and Center for Stroke Research Berlin and QUEST Center for Transforming Biomedical Research (U.D.), Berlin Institute of Health, Germany
| | - Ian Shrier
- From Pytho LLC (P.A.), Brooklyn, NY; Department of Neurology (A.D.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Biomedical Ethics Unit, Department of Social Studies of Medicine (A.M., E.V., D.M.B., J.K.), and Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital (I.S.), McGill University, Montreal, Canada; Max Delbrueck Center for Molecular Medicine (F.P.), Berlin; Department of Neurology (F.P.), NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin; Humboldt-Universität zu Berlin (U.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin; and Department of Experimental Neurology and Center for Stroke Research Berlin and QUEST Center for Transforming Biomedical Research (U.D.), Berlin Institute of Health, Germany
| | - Friedemann Paul
- From Pytho LLC (P.A.), Brooklyn, NY; Department of Neurology (A.D.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Biomedical Ethics Unit, Department of Social Studies of Medicine (A.M., E.V., D.M.B., J.K.), and Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital (I.S.), McGill University, Montreal, Canada; Max Delbrueck Center for Molecular Medicine (F.P.), Berlin; Department of Neurology (F.P.), NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin; Humboldt-Universität zu Berlin (U.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin; and Department of Experimental Neurology and Center for Stroke Research Berlin and QUEST Center for Transforming Biomedical Research (U.D.), Berlin Institute of Health, Germany
| | - Ulrich Dirnagl
- From Pytho LLC (P.A.), Brooklyn, NY; Department of Neurology (A.D.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Biomedical Ethics Unit, Department of Social Studies of Medicine (A.M., E.V., D.M.B., J.K.), and Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital (I.S.), McGill University, Montreal, Canada; Max Delbrueck Center for Molecular Medicine (F.P.), Berlin; Department of Neurology (F.P.), NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin; Humboldt-Universität zu Berlin (U.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin; and Department of Experimental Neurology and Center for Stroke Research Berlin and QUEST Center for Transforming Biomedical Research (U.D.), Berlin Institute of Health, Germany
| | - Jonathan Kimmelman
- From Pytho LLC (P.A.), Brooklyn, NY; Department of Neurology (A.D.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Biomedical Ethics Unit, Department of Social Studies of Medicine (A.M., E.V., D.M.B., J.K.), and Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital (I.S.), McGill University, Montreal, Canada; Max Delbrueck Center for Molecular Medicine (F.P.), Berlin; Department of Neurology (F.P.), NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin; Humboldt-Universität zu Berlin (U.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin; and Department of Experimental Neurology and Center for Stroke Research Berlin and QUEST Center for Transforming Biomedical Research (U.D.), Berlin Institute of Health, Germany.
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Tian Z, Song Y, Yao Y, Guo J, Gong Z, Wang Z. Genetic Etiology Shared by Multiple Sclerosis and Ischemic Stroke. Front Genet 2020; 11:646. [PMID: 32719717 PMCID: PMC7348066 DOI: 10.3389/fgene.2020.00646] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 05/27/2020] [Indexed: 12/23/2022] Open
Abstract
Although dramatic progress has been achieved in the understanding and treatment of multiple sclerosis (MS) and ischemic stroke (IS), more precise and instructive support is required for further research. Recent large-scale genome-wide association studies (GWASs) have already revealed risk variants for IS and MS, but the common genetic etiology between MS and IS remains an unresolved issue. This research was designed to overlapping genes between MS and IS and unmask their transcriptional features. We designed a three-section analysis process. Firstly, we computed gene-based analyses of MS GWAS and IS GWAS data sets by VGEAS2. Secondly, overlapping genes of significance were identified in a meta-analysis using the Fisher’s procedure. Finally, we performed gene expression analyses to confirm transcriptional changes. We identified 24 shared genes with Bonferroni correction (Pcombined < 2.31E-04), and five (FOXP1, CAMK2G, CLEC2D, LBH, and SLC2A4RG) had significant expression differences in MS and IS gene expression omnibus data sets. These meaningful shared genes between IS and MS shed light on the underlying genetic etiologies shared by the diseases. Our results provide a basis for in-depth genomic studies of associations between MS and IS.
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Affiliation(s)
- Zhu Tian
- Department of Neurology, Tianjin First Central Hospital, Tianjin, China
| | - Yang Song
- Department of Neurology, Tianjin First Central Hospital, Tianjin, China
| | - Yang Yao
- Department of Neurology, Tianjin First Central Hospital, Tianjin, China
| | - Jie Guo
- Department of Neurology, Tianjin First Central Hospital, Tianjin, China
| | - Zhongying Gong
- Department of Neurology, Tianjin First Central Hospital, Tianjin, China
| | - Zhiyun Wang
- Department of Neurology, Tianjin First Central Hospital, Tianjin, China
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Elkind MSV, Veltkamp R, Montaner J, Johnston SC, Singhal AB, Becker K, Lansberg MG, Tang W, Kasliwal R, Elkins J. Natalizumab in acute ischemic stroke (ACTION II): A randomized, placebo-controlled trial. Neurology 2020; 95:e1091-e1104. [PMID: 32591475 PMCID: PMC7668547 DOI: 10.1212/wnl.0000000000010038] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 02/14/2020] [Indexed: 12/22/2022] Open
Abstract
Objective We evaluated the effect of 2 doses of natalizumab on functional outcomes in patients with acute ischemic stroke (AIS). Methods In this double-blind phase 2b trial, patients with AIS aged 18–80 years with NIH Stroke Scale scores of 5–23 from 53 US and European sites were randomized 1:1:1 to receive a single dose of 300 or 600 mg IV natalizumab or placebo, with randomization stratified by treatment window (≤9 or >9 to ≤24 hours from patient's last known normal state). The primary endpoint was a composite measure of excellent outcome (modified Rankin Scale score ≤1 and Barthel Index score ≥95) at day 90 assessed in all patients receiving a full dose. Sample size was estimated from a Bayesian model; p values were not used for hypothesis testing. Results An excellent outcome was less likely with natalizumab than with placebo (natalizumab 300 or 600 mg odds ratio 0.60; 95% confidence interval 0.39–0.93). There was no effect modification by time to treatment or use of thrombolysis/thrombectomy. For natalizumab 300 mg, 600 mg, or placebo, there were no differences in incidence of adverse events (90.0%, 92.1%, and 92.3%, respectively), serious adverse events (25.6%, 32.6%, and 20.9%, respectively), or deaths (6.7%, 4.5%, and 5.5%, respectively). Conclusions Natalizumab administered ≤24 hours after AIS did not improve patient outcomes. ClinicalTrials.gov identifier NCT02730455 Classification of evidence This study provides Class I evidence that for patients with AIS, an excellent outcome was less likely in patients treated with natalizumab than with placebo.
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Affiliation(s)
- Mitchell S V Elkind
- From Columbia University (M.S.V.E.), New York, NY; Imperial College London (R.V.), UK; Alfried-Krupp Krankenhaus (R.V.), Essen, Germany; Vall d'Hebron Research Institute (VHIR) (J.M.), Barcelona; Institute of Biomedicine of Seville (IBiS) Stroke Programme (J.M.), Spain; University of Texas (S.C.J.), Austin; Massachusetts General Hospital (A.B.S.), Boston; University of Washington (K.B.), Seattle; Stanford University Medical Center (M.G.L.), Stanford Stroke Center, CA; and Biogen (W.T., R.K., J.E.), Cambridge, MA.
| | - Roland Veltkamp
- From Columbia University (M.S.V.E.), New York, NY; Imperial College London (R.V.), UK; Alfried-Krupp Krankenhaus (R.V.), Essen, Germany; Vall d'Hebron Research Institute (VHIR) (J.M.), Barcelona; Institute of Biomedicine of Seville (IBiS) Stroke Programme (J.M.), Spain; University of Texas (S.C.J.), Austin; Massachusetts General Hospital (A.B.S.), Boston; University of Washington (K.B.), Seattle; Stanford University Medical Center (M.G.L.), Stanford Stroke Center, CA; and Biogen (W.T., R.K., J.E.), Cambridge, MA
| | - Joan Montaner
- From Columbia University (M.S.V.E.), New York, NY; Imperial College London (R.V.), UK; Alfried-Krupp Krankenhaus (R.V.), Essen, Germany; Vall d'Hebron Research Institute (VHIR) (J.M.), Barcelona; Institute of Biomedicine of Seville (IBiS) Stroke Programme (J.M.), Spain; University of Texas (S.C.J.), Austin; Massachusetts General Hospital (A.B.S.), Boston; University of Washington (K.B.), Seattle; Stanford University Medical Center (M.G.L.), Stanford Stroke Center, CA; and Biogen (W.T., R.K., J.E.), Cambridge, MA
| | - S Claiborne Johnston
- From Columbia University (M.S.V.E.), New York, NY; Imperial College London (R.V.), UK; Alfried-Krupp Krankenhaus (R.V.), Essen, Germany; Vall d'Hebron Research Institute (VHIR) (J.M.), Barcelona; Institute of Biomedicine of Seville (IBiS) Stroke Programme (J.M.), Spain; University of Texas (S.C.J.), Austin; Massachusetts General Hospital (A.B.S.), Boston; University of Washington (K.B.), Seattle; Stanford University Medical Center (M.G.L.), Stanford Stroke Center, CA; and Biogen (W.T., R.K., J.E.), Cambridge, MA
| | - Aneesh B Singhal
- From Columbia University (M.S.V.E.), New York, NY; Imperial College London (R.V.), UK; Alfried-Krupp Krankenhaus (R.V.), Essen, Germany; Vall d'Hebron Research Institute (VHIR) (J.M.), Barcelona; Institute of Biomedicine of Seville (IBiS) Stroke Programme (J.M.), Spain; University of Texas (S.C.J.), Austin; Massachusetts General Hospital (A.B.S.), Boston; University of Washington (K.B.), Seattle; Stanford University Medical Center (M.G.L.), Stanford Stroke Center, CA; and Biogen (W.T., R.K., J.E.), Cambridge, MA
| | - Kyra Becker
- From Columbia University (M.S.V.E.), New York, NY; Imperial College London (R.V.), UK; Alfried-Krupp Krankenhaus (R.V.), Essen, Germany; Vall d'Hebron Research Institute (VHIR) (J.M.), Barcelona; Institute of Biomedicine of Seville (IBiS) Stroke Programme (J.M.), Spain; University of Texas (S.C.J.), Austin; Massachusetts General Hospital (A.B.S.), Boston; University of Washington (K.B.), Seattle; Stanford University Medical Center (M.G.L.), Stanford Stroke Center, CA; and Biogen (W.T., R.K., J.E.), Cambridge, MA
| | - Maarten G Lansberg
- From Columbia University (M.S.V.E.), New York, NY; Imperial College London (R.V.), UK; Alfried-Krupp Krankenhaus (R.V.), Essen, Germany; Vall d'Hebron Research Institute (VHIR) (J.M.), Barcelona; Institute of Biomedicine of Seville (IBiS) Stroke Programme (J.M.), Spain; University of Texas (S.C.J.), Austin; Massachusetts General Hospital (A.B.S.), Boston; University of Washington (K.B.), Seattle; Stanford University Medical Center (M.G.L.), Stanford Stroke Center, CA; and Biogen (W.T., R.K., J.E.), Cambridge, MA
| | - Weihua Tang
- From Columbia University (M.S.V.E.), New York, NY; Imperial College London (R.V.), UK; Alfried-Krupp Krankenhaus (R.V.), Essen, Germany; Vall d'Hebron Research Institute (VHIR) (J.M.), Barcelona; Institute of Biomedicine of Seville (IBiS) Stroke Programme (J.M.), Spain; University of Texas (S.C.J.), Austin; Massachusetts General Hospital (A.B.S.), Boston; University of Washington (K.B.), Seattle; Stanford University Medical Center (M.G.L.), Stanford Stroke Center, CA; and Biogen (W.T., R.K., J.E.), Cambridge, MA
| | - Rachna Kasliwal
- From Columbia University (M.S.V.E.), New York, NY; Imperial College London (R.V.), UK; Alfried-Krupp Krankenhaus (R.V.), Essen, Germany; Vall d'Hebron Research Institute (VHIR) (J.M.), Barcelona; Institute of Biomedicine of Seville (IBiS) Stroke Programme (J.M.), Spain; University of Texas (S.C.J.), Austin; Massachusetts General Hospital (A.B.S.), Boston; University of Washington (K.B.), Seattle; Stanford University Medical Center (M.G.L.), Stanford Stroke Center, CA; and Biogen (W.T., R.K., J.E.), Cambridge, MA
| | - Jacob Elkins
- From Columbia University (M.S.V.E.), New York, NY; Imperial College London (R.V.), UK; Alfried-Krupp Krankenhaus (R.V.), Essen, Germany; Vall d'Hebron Research Institute (VHIR) (J.M.), Barcelona; Institute of Biomedicine of Seville (IBiS) Stroke Programme (J.M.), Spain; University of Texas (S.C.J.), Austin; Massachusetts General Hospital (A.B.S.), Boston; University of Washington (K.B.), Seattle; Stanford University Medical Center (M.G.L.), Stanford Stroke Center, CA; and Biogen (W.T., R.K., J.E.), Cambridge, MA
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Mastorakos P, McGavern D. The anatomy and immunology of vasculature in the central nervous system. Sci Immunol 2020; 4:4/37/eaav0492. [PMID: 31300479 DOI: 10.1126/sciimmunol.aav0492] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 06/13/2019] [Indexed: 12/21/2022]
Abstract
Barriers between circulation and the central nervous system (CNS) play a key role in the development and modulation of CNS immune responses. Structural variations in the vasculature traversing different anatomical regions within the CNS strongly influence where and how CNS immune responses first develop. Here, we provide an overview of cerebrovascular anatomy, focusing on the blood-CNS interface and how anatomical variations influence steady-state immunology in the compartment. We then discuss how CNS vasculature is affected by and influences the development of different pathophysiological states, such as CNS autoimmune disease, cerebrovascular injury, cerebral ischemia, and infection.
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Affiliation(s)
- Panagiotis Mastorakos
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Dorian McGavern
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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Iadecola C, Buckwalter MS, Anrather J. Immune responses to stroke: mechanisms, modulation, and therapeutic potential. J Clin Invest 2020; 130:2777-2788. [PMID: 32391806 PMCID: PMC7260029 DOI: 10.1172/jci135530] [Citation(s) in RCA: 350] [Impact Index Per Article: 87.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Stroke is the second leading cause of death worldwide and a leading cause of disability. Most strokes are caused by occlusion of a major cerebral artery, and substantial advances have been made in elucidating how ischemia damages the brain. In particular, increasing evidence points to a double-edged role of the immune system in stroke pathophysiology. In the acute phase, innate immune cells invade brain and meninges and contribute to ischemic damage, but may also be protective. At the same time, danger signals released into the circulation by damaged brain cells lead to activation of systemic immunity, followed by profound immunodepression that promotes life-threatening infections. In the chronic phase, antigen presentation initiates an adaptive immune response targeted to the brain, which may underlie neuropsychiatric sequelae, a considerable cause of poststroke morbidity. Here, we briefly review these pathogenic processes and assess the potential therapeutic value of targeting immunity in human stroke.
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Affiliation(s)
- Costantino Iadecola
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Marion S. Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, Stanford, California, USA
| | - Josef Anrather
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
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90
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Alawieh AM, Langley EF, Feng W, Spiotta AM, Tomlinson S. Complement-Dependent Synaptic Uptake and Cognitive Decline after Stroke and Reperfusion Therapy. J Neurosci 2020; 40:4042-4058. [PMID: 32291326 PMCID: PMC7219298 DOI: 10.1523/jneurosci.2462-19.2020] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 12/13/2022] Open
Abstract
Despite the success of reperfusion therapy in significantly reducing the extent of infarct expansion after stroke, the effect of revascularization on poststroke neuroinflammation and the role of anti-inflammatory strategies in postreperfusion era are yet to be explored. Here, we investigate whether the neuroinflammatory response may still contribute to neurologic deficits after reperfused stroke by using targeted complement inhibition to suppress poststroke neuroinflammation in mice with or without concurrent reperfusion therapy. Complement inhibition was achieved using B4Crry, an injury site-targeted inhibitor of C3 activation. Following embolic stroke in male C57bl/6 mice, thrombolysis using tissue-plasminogen activator (t-PA) reduced injury and improved motor deficits, but did not improve cognitive outcomes. After both reperfused and non-reperfused stroke, complement activation and opsonization of hippocampal synapses directed ongoing microglia-dependent phagocytosis of synapses for at least 30 d after stroke, leading to a loss of synaptic density that was associated with cognitive decline. B4Crry treatment, alone or in combination with tPA, limited perilesional complement deposition, reduced microgliosis and synaptic uptake, and improved cognitive outcome without affecting regenerative responses. Furthermore, complement inhibition improved the safety, efficacy, and treatment window of reperfusion therapy with t-PA by limiting hemorrhagic transformation. This work thus demonstrates that poststroke neuroinflammation contributes to hemorrhagic transformation and progression of neurodegenerative responses in the brain even following early and successful revascularization.SIGNIFICANCE STATEMENT This study addresses two major challenges facing the treatment of stroke in the era of reperfusion therapy: hemorrhagic transformation and the disconnect between successful revascularization and functional outcomes. We studied how complement-dependent neuroinflammation drives the pathophysiology behind these challenges using a translationally relevant strategy. Complement inhibition was achieved using B4Crry, an injury site-targeted inhibitor of C3 activation. Following embolic stroke, pharmacological thrombolysis limited infarct size, but did not prevent complement activation. In reperfused and non-reperfused stroke, complement activation and opsonization of hippocampal synapses resulted in synaptic phagocytosis and subsequent cognitive decline. B4Crry treatment limited perilesional complement deposition, reduced microgliosis and synaptic uptake, and improved cognitive outcomes. Complement inhibition also improved the safety, efficacy, and treatment window of thrombolytic therapy.
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Affiliation(s)
- Ali M Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia 30322
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina 29425
| | - E Farris Langley
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina 29425
| | - Wuwei Feng
- Department of Neurology, Duke University Medical Center, Durham, NC, 27710
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina 29425
| | - Stephen Tomlinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, South Carolina 29425
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina 29401
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91
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Shimamura M, Nakagami H, Sasaki T, Morishita R, Mochizuki H. [Current status and perspectives in the development of therapeutic agents targeting post-ischemic inflammation in the acute stage of stroke]. Rinsho Shinkeigaku 2020; 60:253-259. [PMID: 32238749 DOI: 10.5692/clinicalneurol.cn-001401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We have developed a partial peptide of RANKL (receptor activator of NF-κB ligand) that suppresses TLR (toll-like receptor)-related inflammation via RANKL/RANK (receptor activator of nuclear factor-κB) signals in the acute phase of ischemic stroke. This peptide has been found to be a therapeutic agent for ischemic stroke that can be used in combination with tPA in a mouse model. Based on the findings, we are working on translational research to aim for clinical application of this peptide through collaboration with pharmacy companies. However, the problem is that the need for development of medication in the acute stage of ischemic stroke is currently low in pharmaceutical companies due to the failure of many investigational drugs in the past. To overcome the problem, we are examining the effects of this peptide in other diseases included in the company's priority areas and explaining the environmental changes in the clinical trials due to the development of endovascular treatment in the acute stage of ischemic stroke.
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Affiliation(s)
- Munehisa Shimamura
- Department of Neurology, Osaka University.,Department of Health Development and Medicine, Graduate School of Medicine, Osaka University
| | - Hironori Nakagami
- Department of Health Development and Medicine, Graduate School of Medicine, Osaka University
| | | | - Ryuichi Morishita
- Department of Clinical Gene Therapy, Graduate School of Medicine, Osaka University
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92
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Abstract
Despite thousands of neuroprotectants demonstrating promise in preclinical trials, a neuroprotective therapeutic has yet to be approved for the treatment of acute brain injuries such as stroke or traumatic brain injury. Developing a more detailed understanding of models and populations demonstrating "neurological resilience" in spite of brain injury can give us important insights into new translational therapies. Resilience is the process of active adaptation to a stressor. In the context of neuroprotection, models of preconditioning and unique animal models of extreme physiology (such as hibernating species) reliably demonstrate resilience in the laboratory setting. In the clinical setting, resilience is observed in young patients and can be found in those with specific genetic polymorphisms. These important examples of resilience can help transform and extend the current neuroprotective framework from simply countering the injurious cascade into one that anticipates, monitors, and optimizes patients' physiological responses from the time of injury throughout the process of recovery. This review summarizes the underpinnings of key adaptations common to models of resilience and how this understanding can be applied to new neuroprotective approaches.
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Affiliation(s)
- Neel S Singhal
- Department of Neurology, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA.
| | - Chung-Huan Sun
- Department of Neurology, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA
| | - Evan M Lee
- Cardiovascular Research Institute, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA
- Department of Physiology, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA
| | - Dengke K Ma
- Cardiovascular Research Institute, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA
- Department of Physiology, University of California-San Francisco, 555 South Mission Bay Blvd, San Francisco, CA, 94158, USA
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93
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Zera KA, Buckwalter MS. The Local and Peripheral Immune Responses to Stroke: Implications for Therapeutic Development. Neurotherapeutics 2020; 17:414-435. [PMID: 32193840 PMCID: PMC7283378 DOI: 10.1007/s13311-020-00844-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The immune response to stroke is an exciting target for future stroke therapies. Stroke is a leading cause of morbidity and mortality worldwide, and clot removal (mechanical or pharmacological) to achieve tissue reperfusion is the only therapy currently approved for patient use. Due to a short therapeutic window and incomplete effectiveness, however, many patients are left with infarcted tissue that stimulates inflammation. Although this is critical to promote repair, it can also damage surrounding healthy brain tissue. In addition, acute immunodepression and subsequent infections are common and are associated with worse patient outcomes. Thus, the acute immune response is a major focus of researchers attempting to identify ways to amplify its benefits and suppress its negative effects to improve short-term recovery of patients. Here we review what is known about this powerful process. This includes the role of brain resident cells such as microglia, peripherally activated cells such as macrophages and neutrophils, and activated endothelium. The role of systemic immune activation and subsequent immunodepression in the days after stroke is also discussed, as is the chronic immune responses and its effects on cognitive function. The biphasic role of inflammation, as well as complex timelines of cell production, differentiation, and trafficking, suggests that the relationship between the acute and chronic phases of stroke recovery is complex. Gaining a more complete understanding of this intricate process by which inflammation is initiated, propagated, and terminated may potentially lead to therapeutics that can treat a larger population of stroke patients than what is currently available. The immune response plays a critical role in patient recovery in both the acute and chronic phases after stroke. In patients, the immune response can be beneficial by promoting repair and recovery, and also detrimental by propagating a pro-inflammatory microenvironment. Thus, it is critical to understand the mechanisms of immune activation following stroke in order to successfully design therapeutics.
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Affiliation(s)
- Kristy A Zera
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA.
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA.
- Department of Neurosurgery, Stanford Univeristy School of Medicine, Stanford, CA, USA.
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94
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Parikh NS, Merkler AE, Iadecola C. Inflammation, Autoimmunity, Infection, and Stroke: Epidemiology and Lessons From Therapeutic Intervention. Stroke 2020; 51:711-718. [PMID: 32078460 DOI: 10.1161/strokeaha.119.024157] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Neal S Parikh
- From the Department of Neurology, Columbia University Medical College (N.S.P.), Weill Cornell Medicine, New York, NY.,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY.,Department of Neurology (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY.,Department of Neurology (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY.,Department of Neurology (N.S.P., A.E.M., C.I.), Weill Cornell Medicine, New York, NY
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95
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Giede-Jeppe A, Reichl J, Sprügel MI, Lücking H, Hoelter P, Eyüpoglu IY, Kuramatsu JB, Huttner HB, Gerner ST. Neutrophil-to-lymphocyte ratio as an independent predictor for unfavorable functional outcome in aneurysmal subarachnoid hemorrhage. J Neurosurg 2020; 132:400-407. [DOI: 10.3171/2018.9.jns181975] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEStroke-associated immunosuppression and inflammation are increasingly recognized as factors triggering infections and thus potentially influencing outcome after stroke. Several studies have demonstrated that elevated neutrophil-to-lymphocyte ratio (NLR) is a significant predictor of adverse outcomes for patients with ischemic stroke or intracerebral hemorrhage. Thus far, in patients with subarachnoid hemorrhage the association between NLR and outcome is insufficiently established. The authors sought to investigate the association between NLR on admission and functional outcome in aneurysmal subarachnoid hemorrhage (aSAH).METHODSThis observational study included all consecutive aSAH patients admitted to a German tertiary center over a 5-year period (2008–2012). Data regarding patient demographics and clinical, laboratory, and in-hospital measures, as well as neuroradiological data, were retrieved from institutional databases. Functional outcome was assessed at 3 and 12 months using the modified Rankin Scale (mRS) score and categorized into favorable (mRS score 0–2) and unfavorable (mRS score 3–6). Patients’ radiological and laboratory characteristics were compared between aSAH patients with favorable and those with unfavorable outcome at 3 months. In addition, multivariate analysis was conducted to investigate parameters independently associated with favorable outcome. Receiver operating characteristic (ROC) curve analysis was undertaken to identify the best cutoff for NLR to discriminate between favorable and unfavorable outcome in these patients. To account for imbalances in baseline characteristics, propensity score matching was carried out to assess the influence of NLR on outcome measures.RESULTSOverall, 319 patients with aSAH were included. Patients with unfavorable outcome at 3 months were older, had worse clinical status on admission (Glasgow Coma Scale score and Hunt and Hess grade), greater amount of subarachnoidal and intraventricular hemorrhage (modified Fisher Scale grade and Graeb score), and higher rates of infectious complications (pneumonia and sepsis). A significantly higher NLR on admission was observed in patients with unfavorable outcome according to mRS score (median [IQR] NLR 5.8 [3.0–10.0] for mRS score 0–2 vs NLR 8.3 [4.5–12.6] for mRS score 3–6; p < 0.001). After adjustments, NLR on admission remained a significant predictor for unfavorable outcome in SAH patients (OR [95% CI] 1.014 [1.001–1.027]; p = 0.028). In ROC analysis, an NLR of 7.05 was identified as the best cutoff value to discriminate between favorable and unfavorable outcome (area under the curve = 0.614, p < 0.001, Youden’s index = 0.211; mRS score 3–6: 94/153 [61.4%] for NLR ≥ 7.05 vs 67/166 [40.4%] for NLR < 7.05; p < 0.001). Subanalysis of patients with NLR levels ≥ 7.05 vs < 7.05, performed using 2 propensity score–matched cohorts (n = 133 patients in each group), revealed an increased proportion of patients with unfavorable functional outcome at 3 months in patients with NLR ≥ 7.05 (mRS score 3–6 at 3 months: NLR ≥ 7.05 82/133 [61.7%] vs NLR < 7.05 62/133 [46.6%]; p = 0.014), yet without differences in mortality at 3 months (NLR ≥ 7.05 37/133 [27.8%] vs NLR < 7.05 27/133 [20.3%]; p = 0.131).CONCLUSIONSAmong aSAH patients, NLR represents an independent parameter associated with unfavorable functional outcome. Whether the impact of NLR on functional outcome is related to preexisting comorbidities or represents independent causal relationships in the context of stroke-associated immunosuppression should be investigated in future studies.
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96
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Abstract
Ischemic strokes occur when a major cerebral artery or its branches are occluded, resulting in activation of inflammatory processes that cause secondary tissue injury, breakdown of the blood–brain barrier, edema or hemorrhage. Treatments that inhibit inflammatory processes may thus be highly beneficial. A key regulator of the inflammatory process is the nuclear factor kappa B (NF-κB) pathway. In its active form, NF-κB regulates expression of proinflammatory and proapoptotic genes. The molecules that interact with NF-κB, and the subunits that compose NF-κB itself, represent therapeutic targets that can be modulated to decrease inflammation. This review focuses on our current understanding of the NF-κB pathway and the potential benefits of inhibiting NF-κB in ischemia-reperfusion injury of the brain.
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97
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de Falco A, De Simone M, d'Onofrio F, Spitaleri D, de Falco FA. Treating acute ischemic stroke in a patient with multiple sclerosis: A challenging issue. Mult Scler Relat Disord 2020; 40:101962. [PMID: 32014810 DOI: 10.1016/j.msard.2020.101962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 01/15/2020] [Accepted: 01/19/2020] [Indexed: 10/25/2022]
Abstract
Multiple sclerosis (MS) is a chronic disease characterized by inflammation, demyelination and neurodegeneration in the central nervous system. Recent studies suggested that patients with MS might have a greater risk of ischaemic stroke (IS). IS treatment with intravenous alteplase (IVA) in MS has rarely been reported. This could be due to the challenging diagnosis between acute IS and MS relapse, considering that clinical and neuroradiological findings might overlap. Here we report a 47-year-old man with a 6-year history of relapsing-remitting MS who presented to the emergency room for acute left limbs weakness and hypoesthesia diagnosed as ischemic stroke after advanced MRI imaging. Patient was treated with IVA and treatment was complicated by a parenchymal hematoma (PH) despite low risks due to young age, low NIHSS score, small ischemic lesion and absence of multiple vascular risk factors. We discuss the possible relationship between MS and IS and the use of IVA in MS patients and finally we consider the possible causes of the PH including the MS disease-modifying therapies.
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Affiliation(s)
- Arturo de Falco
- Neurology and Stroke Unit, Azienda Ospedaliera San G. Moscati, Contrada Amoretta, Avellino 83100, Italy.
| | - Marta De Simone
- Neuroradiology Unit, Azienda Ospedaliera San G. Moscati, Contrada Amoretta, Avellino 83100, Italy
| | - Florindo d'Onofrio
- Neurology and Stroke Unit, Azienda Ospedaliera San G. Moscati, Contrada Amoretta, Avellino 83100, Italy
| | - Daniele Spitaleri
- Neurology and Stroke Unit, Azienda Ospedaliera San G. Moscati, Contrada Amoretta, Avellino 83100, Italy
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98
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Nozohouri S, Sifat AE, Vaidya B, Abbruscato TJ. Novel approaches for the delivery of therapeutics in ischemic stroke. Drug Discov Today 2020; 25:535-551. [PMID: 31978522 DOI: 10.1016/j.drudis.2020.01.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/20/2019] [Accepted: 01/15/2020] [Indexed: 02/06/2023]
Abstract
Here, we review novel approaches to deliver neuroprotective drugs to salvageable penumbral brain areas of stroke injury with the goals of offsetting ischemic brain injury and enhancing recovery.
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Affiliation(s)
- Saeideh Nozohouri
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Ali Ehsan Sifat
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
| | - Bhuvaneshwar Vaidya
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA.
| | - Thomas J Abbruscato
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA.
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99
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Vogelgesang A, Domanska G, Ruhnau J, Dressel A, Kirsch M, Schulze J. Siponimod (BAF312) Treatment Reduces Brain Infiltration but Not Lesion Volume in Middle-Aged Mice in Experimental Stroke. Stroke 2020; 50:1224-1231. [PMID: 31009359 DOI: 10.1161/strokeaha.118.023667] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background and Purpose- The contribution of neuroinflammation and, in particular, the infiltration of the brain by lymphocytes is increasingly recognized as a substantial pathophysiological mechanism after stroke. The interaction of lymphocytes with endothelial cells and platelets, termed thromboinflammation, fosters microvascular dysfunction and secondary infarct growth. Siponimod is an S1PR (sphingosine-1-phosphate receptor) modulator, which blocks the egress of lymphocytes from lymphoid organs and has demonstrated beneficial effects in multiple sclerosis treatment. We investigated the effect of treatment with siponimod on stroke outcome in a mouse model of cerebral ischemia. Methods- Transient middle cerebral artery occlusion was induced in middle-aged wild-type mice. Animals were either treated with siponimod (3 mg/kg; intraperitoneal) or vehicle for 6 days. Stroke outcome was assessed by magnetic resonance imaging (spleen volume: prestroke, day 3, and day 7; infarct volume: days 1, 3, and 7) and behavioral tests (prestroke, day 2, and day 6). Immune cells of the peripheral blood and brain-infiltrating cells ipsilateral and contralateral were analyzed by VETScan and by flow cytometry. Results- Siponimod significantly induced lymphopenia on day 7 after transient middle cerebral artery occlusion and reduced T-lymphocyte accumulation in the central nervous system. No effect was detected for lesion size. Conclusions- For siponimod administered at 3 mg/kg in transient middle cerebral artery occlusion mouse model, our findings do not provide preclinical evidence for the use of S1PR1/5 modulators as neuroprotectant in stroke therapy.
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Affiliation(s)
- Antje Vogelgesang
- From the Department of Neurology (A.V., J.R., A.D., J.S.), University Medicine, Greifswald, Germany
| | - Grazyna Domanska
- Department of Immunology (G.D.), University Medicine, Greifswald, Germany
| | - Johanna Ruhnau
- From the Department of Neurology (A.V., J.R., A.D., J.S.), University Medicine, Greifswald, Germany
| | - Alexander Dressel
- From the Department of Neurology (A.V., J.R., A.D., J.S.), University Medicine, Greifswald, Germany.,Department of Neurology, Carl-Thiem-Klinikum, Cottbus, Germany (A.D.)
| | - Michael Kirsch
- Department of Diagnostic Radiology and Neuroradiology (M.K.), University Medicine, Greifswald, Germany
| | - Juliane Schulze
- From the Department of Neurology (A.V., J.R., A.D., J.S.), University Medicine, Greifswald, Germany
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Dhir N, Medhi B, Prakash A, Goyal MK, Modi M, Mohindra S. Pre-clinical to Clinical Translational Failures and Current Status of Clinical Trials in Stroke Therapy: A Brief Review. Curr Neuropharmacol 2020; 18:596-612. [PMID: 31934841 PMCID: PMC7457423 DOI: 10.2174/1570159x18666200114160844] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/31/2019] [Accepted: 12/28/2019] [Indexed: 12/16/2022] Open
Abstract
In stroke (cerebral ischemia), despite continuous efforts both at the experimental and clinical level, the only approved pharmacological treatment has been restricted to tissue plasminogen activator (tPA). Stroke is the leading cause of functional disability and mortality throughout worldwide. Its pathophysiology starts with energy pump failure, followed by complex signaling cascade that ultimately ends in neuronal cell death. Ischemic cascade involves excessive glutamate release followed by raised intracellular sodium and calcium influx along with free radicals' generation, activation of inflammatory cytokines, NO synthases, lipases, endonucleases and other apoptotic pathways leading to cell edema and death. At the pre-clinical stage, several agents have been tried and proven as an effective neuroprotectant in animal models of ischemia. However, these agents failed to show convincing results in terms of efficacy and safety when the trials were conducted in humans following stroke. This article highlights the various agents which have been tried in the past but failed to translate into stroke therapy along with key points that are responsible for the lagging of experimental success to translational failure in stroke treatment.
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Affiliation(s)
| | - Bikash Medhi
- Address correspondence to this author at the Department of Pharmacology, Research Block B, 4th Floor, Room no 4043, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, 160012, India; E-mail:
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