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Fernández-Gómez B, Marchena MA, Piñeiro D, Gómez-Martín P, Sánchez E, Laó Y, Valencia G, Nocera S, Benítez-Fernández R, Castaño-León AM, Lagares A, Hernández-Jiménez M, de Castro F. ApTOLL: A new therapeutic aptamer for cytoprotection and (re)myelination after multiple sclerosis. Br J Pharmacol 2024; 181:3263-3281. [PMID: 38742374 DOI: 10.1111/bph.16399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/17/2023] [Accepted: 12/11/2023] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND AND PURPOSE ApTOLL is an aptamer selected to antagonize toll-like receptor 4 (TLR4), a relevant actor for innate immunity involved in inflammatory responses in multiple sclerosis (MS) and other diseases. The currently available therapeutic arsenal to treat MS is composed of immunomodulators but, to date, there are no (re)myelinating drugs available in clinics. In our present study, we studied the effect of ApTOLL on different animal models of MS. EXPERIMENTAL APPROACH The experimental autoimmune encephalomyelitis (EAE) model was used to evaluate the effect of ApTOLL on reducing the inflammatory component. A more direct effect on oligodendroglia was studied with the cuprizone model and purified primary cultures of murine and human oligodendrocyte precursor cells (OPCs) isolated through magnetic-activated cell sorting (MACS) from samples of brain cortex. Also, we tested these effects in an ex vivo model of organotypic cultures demyelinated with lysolecithin (LPC). KEY RESULTS ApTOLL treatment positively impacted the clinical symptomatology of mice in the EAE and cuprizone models, which was associated with better preservation plus restoration of myelin and oligodendrocytes in the demyelinated lesions of animals. Restoration was corroborated on purified cultures of rodent and human OPCs. CONCLUSION AND IMPLICATIONS Our findings reveal a new therapeutic approach for the treatment of inflammatory and demyelinating diseases such as MS. The molecular nature of the aptamer exerts not only an anti-inflammatory effect but also neuroprotective and remyelinating effects. The excellent safety profile demonstrated by ApTOLL in animals and humans opens the door to future clinical trials in MS patients.
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Affiliation(s)
- Beatriz Fernández-Gómez
- Instituto Cajal-CSIC, Madrid, Spain
- AptaTargets SL, Madrid, Spain
- PhD Program in Neuroscience, Universidad Autónoma de Madrid-Cajal Institute, Madrid, Spain
| | - Miguel A Marchena
- Instituto Cajal-CSIC, Madrid, Spain
- Facultad HM de Ciencias de la Salud de la Universidad Camilo José Cela
- Instituto de Investigación Sanitaria HM Hospitales
| | | | | | | | | | | | | | | | | | - Alfonso Lagares
- Servicio de Neurocirugía, Hospital 12 de Octubre, Madrid, Spain
| | - Macarena Hernández-Jiménez
- AptaTargets SL, Madrid, Spain
- Unidad de Investigación Neurovascular, Departamento de Farmacología y Toxicología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Scheldeman L, Sinnaeve P, Albers GW, Lemmens R, Van de Werf F. Acute myocardial infarction and ischaemic stroke: differences and similarities in reperfusion therapies-a review. Eur Heart J 2024; 45:2735-2747. [PMID: 38941344 DOI: 10.1093/eurheartj/ehae371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/16/2024] [Accepted: 05/28/2024] [Indexed: 06/30/2024] Open
Abstract
Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.
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Affiliation(s)
- Lauranne Scheldeman
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology KU Leuven - University of Leuven, Leuven, Belgium
| | - Peter Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Gregory W Albers
- Department of Neurology, Stanford University Medical Center, Palo Alto, USA
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology KU Leuven - University of Leuven, Leuven, Belgium
| | - Frans Van de Werf
- Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
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3
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Zhu L, Shang J, Li Y, Zhang Z, Fu P, Zong Y, Chen S, Wang J, Zhang J, Wang J, Jiang C. Toll-Like Receptors Mediate Opposing Dendritic Cell Effects on Treg/Th17 Balance in Mice With Intracerebral Hemorrhage. Stroke 2024; 55:2126-2138. [PMID: 38920054 DOI: 10.1161/strokeaha.124.046394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/23/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Dendritic cells (DCs) regulate the immune response associated with T lymphocytes, but their role in stroke remains unclear. In this study, we investigated the causal relationship between DCs and T-cell response in intracerebral hemorrhage (ICH) by focusing on TLRs (toll-like receptors) that may modulate the function of DCs. METHODS We studied the effects of TLR4, TLR2, and TLR9 on DC-mediated T-cell response and the outcomes of ICH using male C57BL/6 and CD11c-DTx (diphtheria toxin) receptor mice. We administered specific agents intraperitoneally or orally and evaluated the results using flow cytometry, real-time polymerase chain reaction, Western blotting, immunofluorescence staining, histopathology, and behavioral tests. RESULTS TLR4 and TLR2 activation induces DC maturation and reduces the ratio of regulatory T to T-helper 17 cells in the brain and periphery after ICH. When either of these receptors is activated, it can worsen neuroinflammation and exacerbate ICH outcomes. TLR9 also promotes DC maturation, stabilizing the number of DCs, particularly conventional DCs. TLR9 has the opposite effects on regulatory T/T-helper 17 balance, neuroinflammation, and ICH outcomes compared with TLR4 and TLR2. Upon stimulation, TLR4 and TLR9 may achieve these effects through the p38-MAPK (p38-mitogen-activated protein kinase)/MyD88 (myeloid differentiation primary response gene 88) and indoleamine 2,3-dioxygenase 1 (IDO1)/GCN2 (general control nonderepressible 2) signaling pathways, respectively. DCs act as intermediaries for TLR-mediated T-cell response. CONCLUSIONS TLR-mediated opposing effects of DCs on T-cell response may provide novel strategies to treat ICH.
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Affiliation(s)
- Li Zhu
- Department of Neurology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
- The Laboratory of Cerebrovascular Diseases and Neuroimmunology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
| | - Junkui Shang
- Department of Neurology, People's Hospital of Zhengzhou University, China (J.S., J.Z., C.J.)
| | - Yinuo Li
- Department of Neurology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
- The Laboratory of Cerebrovascular Diseases and Neuroimmunology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
| | - Zhiying Zhang
- Department of Neurology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
- The Laboratory of Cerebrovascular Diseases and Neuroimmunology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
| | - Peiji Fu
- Department of Neurology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
- The Laboratory of Cerebrovascular Diseases and Neuroimmunology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
| | - Yan Zong
- Department of Neurology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
- The Laboratory of Cerebrovascular Diseases and Neuroimmunology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
| | - Shuai Chen
- Department of Neurology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
- The Laboratory of Cerebrovascular Diseases and Neuroimmunology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
| | - Junmin Wang
- Department of Anatomy, School of Basic Medical Sciences, Zhengzhou University, China (Junmin Wang, Jian Wang)
| | - Jiewen Zhang
- Department of Neurology, People's Hospital of Zhengzhou University, China (J.S., J.Z., C.J.)
| | - Jian Wang
- Department of Anatomy, School of Basic Medical Sciences, Zhengzhou University, China (Junmin Wang, Jian Wang)
| | - Chao Jiang
- Department of Neurology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
- The Laboratory of Cerebrovascular Diseases and Neuroimmunology (L.Z., Y.L., Z.Z., P.F., Y.Z., S.C., C.J.), The Fifth Affiliated Hospital of Zhengzhou University, China
- Department of Neurology, People's Hospital of Zhengzhou University, China (J.S., J.Z., C.J.)
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Pérez-Mato M, López-Arias E, Bugallo-Casal A, Correa-Paz C, Arias S, Rodríguez-Yáñez M, Santamaría-Cadavid M, Campos F. New Perspectives in Neuroprotection for Ischemic Stroke. Neuroscience 2024; 550:30-42. [PMID: 38387732 DOI: 10.1016/j.neuroscience.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 02/24/2024]
Abstract
The constant failure of new neuroprotective therapies for ischemic stroke has partially halted the search for new therapies in recent years, mainly because of the high investment risk required to develop a new treatment for a complex pathology, such as stroke, with a narrow intervention window and associated comorbidities. However, owing to recent progress in understanding the stroke pathophysiology, improvement in patient care in stroke units, development of new imaging techniques, search for new biomarkers for early diagnosis, and increasingly widespread use of mechanical recanalization therapies, new opportunities have opened for the study of neuroprotection. This review summarizes the main protective agents currently in use, some of which are already in the clinical evaluation phase. It also includes an analysis of how recanalization therapies, new imaging techniques, and biomarkers have improved their efficacy.
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Affiliation(s)
- María Pérez-Mato
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Esteban López-Arias
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Ana Bugallo-Casal
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Clara Correa-Paz
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Susana Arias
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Manuel Rodríguez-Yáñez
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - María Santamaría-Cadavid
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Francisco Campos
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain.
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5
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Santarpia G, Carnes E. Therapeutic Applications of Aptamers. Int J Mol Sci 2024; 25:6742. [PMID: 38928448 PMCID: PMC11204156 DOI: 10.3390/ijms25126742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/13/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Affinity reagents, or target-binding molecules, are quite versatile and are major workhorses in molecular biology and medicine. Antibodies are the most famous and frequently used type and they have been used for a wide range of applications, including laboratory techniques, diagnostics, and therapeutics. However, antibodies are not the only available affinity reagents and they do have significant drawbacks, including laborious and costly production. Aptamers are one potential alternative that have a variety of unique advantages. They are single stranded DNA or RNA molecules that can be selected for binding to many targets including proteins, carbohydrates, and small molecules-for which antibodies typically have low affinity. There are also a variety of cost-effective methods for producing and modifying nucleic acids in vitro without cells, whereas antibodies typically require cells or even whole animals. While there are also significant drawbacks to using aptamers in therapeutic applications, including low in vivo stability, aptamers have had success in clinical trials for treating a variety of diseases and two aptamer-based drugs have gained FDA approval. Aptamer development is still ongoing, which could lead to additional applications of aptamer therapeutics, including antitoxins, and combinatorial approaches with nanoparticles and other nucleic acid therapeutics that could improve efficacy.
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Affiliation(s)
- George Santarpia
- College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Eric Carnes
- College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA
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6
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Aliena-Valero A, Hernández-Jiménez M, López-Morales MA, Tamayo-Torres E, Castelló-Ruiz M, Piñeiro D, Ribó M, Salom JB. Cerebroprotective Effects of the TLR4-Binding DNA Aptamer ApTOLL in a Rat Model of Ischemic Stroke and Thrombectomy Recanalization. Pharmaceutics 2024; 16:741. [PMID: 38931862 PMCID: PMC11206667 DOI: 10.3390/pharmaceutics16060741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
ApTOLL, a TLR4 modulator aptamer, has demonstrated cerebroprotective effects in a permanent ischemic stroke mouse model, as well as safety and efficacy in early phase clinical trials. We carried out reverse translation research according to STAIR recommendations to further characterize the effects and mechanisms of ApTOLL after transient ischemic stroke in rats and to better inform the design of pivotal clinical trials. Adult male rats subjected to transient middle cerebral artery occlusion were treated either with ApTOLL or the vehicle intravenously at different doses and time-points. ApTOLL was compared with TAK-242 (a TLR4 inhibitor). Female rats were also studied. After neurofunctional evaluation, brains were removed for infarct/edema volume, hemorrhagic transformation, and histologic determinations. Peripheral leukocyte populations were assessed via flow cytometry. ApTOLL showed U-shaped dose-dependent cerebroprotective effects. The maximum effective dose (0.45 mg/kg) was cerebroprotective when given both before reperfusion and up to 12 h after reperfusion and reduced the hemorrhagic risk. Similar effects occurred in female rats. Both research and clinical ApTOLL batches induced slightly superior cerebroprotection when compared with TAK-242. Finally, ApTOLL modulated circulating leukocyte levels, reached the brain ischemic tissue to bind resident and infiltrated cell types, and reduced the neutrophil density. These results show the cerebroprotective effects of ApTOLL in ischemic stroke by reducing the infarct/edema volume, neurofunctional impairment, and hemorrhagic risk, as well as the peripheral and local immune response. They provide information about ApTOLL dose effects and its therapeutic time window and target population, as well as its mode of action, which should be considered in the design of pivotal clinical trials.
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Affiliation(s)
- Alicia Aliena-Valero
- Unidad Mixta de Investigación Cerebrovascular, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain; (A.A.-V.); (M.A.L.-M.); (M.C.-R.)
| | - Macarena Hernández-Jiménez
- AptaTargets S.L., 28035 Madrid, Spain; (D.P.); (M.R.)
- Departamento de Farmacología y Toxicología, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Mikahela A. López-Morales
- Unidad Mixta de Investigación Cerebrovascular, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain; (A.A.-V.); (M.A.L.-M.); (M.C.-R.)
- Departamento de Fisioterapia, Universidad de Valencia, 46010 Valencia, Spain
| | - Eva Tamayo-Torres
- Departamento de Fisiología, Universidad de Valencia, 46010 Valencia, Spain;
| | - María Castelló-Ruiz
- Unidad Mixta de Investigación Cerebrovascular, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain; (A.A.-V.); (M.A.L.-M.); (M.C.-R.)
- Departamento de Biología Celular, Biología Funcional y Antropología Física, Universidad de Valencia, 46100 Valencia, Spain
| | - David Piñeiro
- AptaTargets S.L., 28035 Madrid, Spain; (D.P.); (M.R.)
| | - Marc Ribó
- AptaTargets S.L., 28035 Madrid, Spain; (D.P.); (M.R.)
- Unidad de Ictus, Departamento de Neurología, Hospital Vall d’Hebron, 08035 Barcelona, Spain
| | - Juan B. Salom
- Unidad Mixta de Investigación Cerebrovascular, Instituto de Investigación Sanitaria La Fe, 46026 Valencia, Spain; (A.A.-V.); (M.A.L.-M.); (M.C.-R.)
- Departamento de Fisiología, Universidad de Valencia, 46010 Valencia, Spain;
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7
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Arnalich-Montiel A, Burgos-Santamaría A, Pazó-Sayós L, Quintana-Villamandos B. Comprehensive Management of Stroke: From Mechanisms to Therapeutic Approaches. Int J Mol Sci 2024; 25:5252. [PMID: 38791292 PMCID: PMC11120719 DOI: 10.3390/ijms25105252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/29/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Acute ischemic stroke (AIS) is a challenging disease, which needs urgent comprehensive management. Endovascular thrombectomy (EVT), alone or combined with iv thrombolysis, is currently the most effective therapy for patients with acute ischemic stroke (AIS). However, only a limited number of patients are eligible for this time-sensitive treatment. Even though there is still significant room for improvement in the management of this group of patients, up until now there have been no alternative therapies approved for use in clinical practice. However, there is still hope, as clinical research with novel emerging therapies is now generating promising results. These drugs happen to stop or palliate some of the underlying molecular mechanisms involved in cerebral ischemia and secondary brain damage. The aim of this review is to provide a deep understanding of these mechanisms and the pathogenesis of AIS. Later, we will discuss the potential therapies that have already demonstrated, in preclinical or clinical studies, to improve the outcomes of patients with AIS.
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Affiliation(s)
- Ana Arnalich-Montiel
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
- Department of Pharmacology, College of Medicine, Complutense University, 28040 Madrid, Spain
| | - Alba Burgos-Santamaría
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
| | - Laia Pazó-Sayós
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
| | - Begoña Quintana-Villamandos
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
- Department of Pharmacology, College of Medicine, Complutense University, 28040 Madrid, Spain
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8
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Error in Author Surname. JAMA Neurol 2024:2815573. [PMID: 38407880 PMCID: PMC10897816 DOI: 10.1001/jamaneurol.2024.0165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
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9
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Mallard C, Ferriero DM, Vexler ZS. Immune-Neurovascular Interactions in Experimental Perinatal and Childhood Arterial Ischemic Stroke. Stroke 2024; 55:506-518. [PMID: 38252757 DOI: 10.1161/strokeaha.123.043399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Emerging clinical and preclinical data have demonstrated that the pathophysiology of arterial ischemic stroke in the adult, neonates, and children share similar mechanisms that regulate brain damage but also have distinct molecular signatures and involved cellular pathways due to the maturational stage of the central nervous system and the immune system at the time of the insult. In this review, we discuss similarities and differences identified thus far in rodent models of 2 different diseases-neonatal (perinatal) and childhood arterial ischemic stroke. In particular, we review acquired knowledge of the role of resident and peripheral immune populations in modulating outcomes in models of perinatal and childhood arterial ischemic stroke and the most recent and relevant findings in relation to the immune-neurovascular crosstalk, and how the influence of inflammatory mediators is dependent on specific brain maturation stages. Finally, we discuss the current state of treatments geared toward age-appropriate therapies that signal via the immune-neurovascular interaction and consider sex differences to achieve successful translation.
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Affiliation(s)
- Carina Mallard
- Department of Physiology, Institute of Neuroscience and Physiology, University of Gothenburg, Sweden (C.M.)
| | - Donna M Ferriero
- Department of Pediatrics, UCSF, San Francisco, CA (D.M.F.)
- Department of Neurology, UCSF, Weill Institute for Neurosciences, San Francisco, CA (D.M.F., Z.S.V.)
| | - Zinaida S Vexler
- Department of Neurology, UCSF, Weill Institute for Neurosciences, San Francisco, CA (D.M.F., Z.S.V.)
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10
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Dammavalam V, Lin S, Nessa S, Daksla N, Stefanowski K, Costa A, Bergese S. Neuroprotection during Thrombectomy for Acute Ischemic Stroke: A Review of Future Therapies. Int J Mol Sci 2024; 25:891. [PMID: 38255965 PMCID: PMC10815099 DOI: 10.3390/ijms25020891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Stroke is a major cause of death and disability worldwide. Endovascular thrombectomy has been impactful in decreasing mortality. However, many clinical results continue to show suboptimal functional outcomes despite high recanalization rates. This gap in recanalization and symptomatic improvement suggests a need for adjunctive therapies in post-thrombectomy care. With greater insight into ischemia-reperfusion injury, recent preclinical testing of neuroprotective agents has shifted towards preventing oxidative stress through upregulation of antioxidants and downstream effectors, with positive results. Advances in multiple neuroprotective therapies, including uric acid, activated protein C, nerinetide, otaplimastat, imatinib, verapamil, butylphthalide, edaravone, nelonemdaz, ApTOLL, regional hypothermia, remote ischemic conditioning, normobaric oxygen, and especially nuclear factor erythroid 2-related factor 2, have promising evidence for improving stroke care. Sedation and blood pressure management in endovascular thrombectomy also play crucial roles in improved stroke outcomes. A hand-in-hand approach with both endovascular therapy and neuroprotection may be the key to targeting disability due to stroke.
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Affiliation(s)
- Vikalpa Dammavalam
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Sandra Lin
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Sayedatun Nessa
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Neil Daksla
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Kamil Stefanowski
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Ana Costa
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
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Denorme F, Ajanel A, Campbell RA. Immunothrombosis in neurovascular disease. Res Pract Thromb Haemost 2024; 8:102298. [PMID: 38292352 PMCID: PMC10825058 DOI: 10.1016/j.rpth.2023.102298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 02/01/2024] Open
Abstract
A State of the Art lecture titled "Immunothrombosis in Neurovascular Diseases" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. Despite significant clinical advancements in stroke therapy, stroke remains a prominent contributor to both mortality and disability worldwide. Brain injury resulting from an ischemic stroke is a dynamic process that unfolds over time. Initially, an infarct core forms due to the abrupt and substantial blockage of blood flow. In the subsequent hours to days, the surrounding tissue undergoes gradual deterioration, primarily driven by sustained hypoperfusion, programmed cell death, and inflammation. While anti-inflammatory strategies have proven highly effective in experimental models of stroke, their successful translation to clinical use has proven challenging. To overcome this translational hurdle, a better understanding of the distinct immune response driving ischemic stroke brain injury is needed. In this review article, we give an overview of current knowledge regarding the immune response in ischemic stroke and the contribution of immunothrombosis to this process. We discuss therapeutic approaches to overcome detrimental immunothrombosis in ischemic stroke and how these can be extrapolated to other neurovascular diseases, such as Alzheimer's disease and multiple sclerosis. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- Frederik Denorme
- University of Utah Molecular Medicine Program, Salt Lake City, Utah, USA
- Division of Vascular Neurology, Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Abigail Ajanel
- University of Utah Molecular Medicine Program, Salt Lake City, Utah, USA
- Division of Microbiology and Pathology, Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Robert A. Campbell
- University of Utah Molecular Medicine Program, Salt Lake City, Utah, USA
- Division of Microbiology and Pathology, Department of Pathology, University of Utah, Salt Lake City, Utah, USA
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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Vlegels N, Gonzalez-Ortiz F, Knuth NL, Khalifeh N, Gesierich B, Müller F, Müller P, Klein M, Dimitriadis K, Franzmeier N, Liebig T, Duering M, Reidler P, Dichgans M, Karikari TK, Blennow K, Tiedt S. Brain-derived Tau for Monitoring Brain Injury in Acute Ischemic Stroke. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.18.23298728. [PMID: 38014197 PMCID: PMC10680879 DOI: 10.1101/2023.11.18.23298728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The evolution of infarcts varies widely among patients with acute ischemic stroke (IS) and influences treatment decisions. Neuroimaging is not applicable for frequent monitoring and there is no blood-based biomarker to track ongoing brain injury in acute IS. Here, we examined the utility of plasma brain-derived tau (BD-tau) as a biomarker for brain injury in acute IS. We conducted the prospective, observational Precision Medicine in Stroke [PROMISE] study with serial blood sampling upon hospital admission and at days 2, 3, and 7 in patients with acute ischemic stroke (IS) and for comparison, in patients with stroke mimics (SM). We determined the temporal course of plasma BD-tau, its relation to infarct size and admission imaging-based metrics of brain injury, and its value to predict functional outcome. Upon admission (median time-from-onset, 4.4h), BD-tau levels in IS patients correlated with ASPECTS (ρ=-0.21, P<.0001) and were predictive of final infarct volume (ρ=0.26, P<.0001). In contrast to SM patients, BD-tau levels in IS patients increased from admission (median, 2.9 pg/ml [IQR, 1.8-4.8]) to day 2 (median time-from-onset, 22.7h; median BD-tau, 5.0 pg/ml [IQR, 2.6-10.3]; P<.0001). The rate of change of BD-tau from admission to day 2 was significantly associated with collateral supply (R2=0.10, P<.0001) and infarct progression (ρ=0.58, P<.0001). At day 2, BD-tau was predictive of final infarct volume (ρ=0.59, P<.0001) and showed superior value for predicting the 90-day mRS score compared with final infarct volume. In conclusion, in 502 patients with acute IS, plasma BD-tau was associated with imaging-based metrics of brain injury upon admission, increased within the first 24 hours in correlation with infarct progression, and at 24 hours was superior to final infarct volume in predicting 90-day functional outcome. Further research is needed to determine whether BD-tau assessments can inform decision-making in stroke care.
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Affiliation(s)
- Naomi Vlegels
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
| | - Fernando Gonzalez-Ortiz
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Nicoló Luca Knuth
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
| | - Nada Khalifeh
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
| | - Benno Gesierich
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
- Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Franziska Müller
- Department of Radiology, LMU University Hospital, LMU Munich, Germany
| | - Philipp Müller
- Department of Radiology, LMU University Hospital, LMU Munich, Germany
| | - Matthias Klein
- Department of Neurology, LMU University Hospital, LMU Munich, Germany
| | | | - Nicolai Franzmeier
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Germany
| | - Marco Duering
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
- Medical Image Analysis Center (MIAC) and Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Paul Reidler
- Department of Radiology, LMU University Hospital, LMU Munich, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE, Munich), Munich, Germany
- German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Thomas K Karikari
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Germany
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Puig N, Solé A, Aguilera-Simon A, Griñán R, Rotllan N, Camps-Renom P, Benitez S. Novel Therapeutic Approaches to Prevent Atherothrombotic Ischemic Stroke in Patients with Carotid Atherosclerosis. Int J Mol Sci 2023; 24:14325. [PMID: 37762627 PMCID: PMC10531661 DOI: 10.3390/ijms241814325] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
Atherothrombotic stroke represents approximately 20% of all ischemic strokes. It is caused by large-artery atherosclerosis, mostly in the internal carotid artery, and it is associated with a high risk of early recurrence. After an ischemic stroke, tissue plasminogen activator is used in clinical practice, although it is not possible in all patients. In severe clinical situations, such as high carotid stenosis (≥70%), revascularization by carotid endarterectomy or by stent placement is carried out to avoid recurrences. In stroke prevention, the pharmacological recommendations are based on antithrombotic, lipid-lowering, and antihypertensive therapy. Inflammation is a promising target in stroke prevention, particularly in ischemic strokes associated with atherosclerosis. However, the use of anti-inflammatory strategies has been scarcely studied. No clinical trials are clearly successful and most preclinical studies are focused on protection after a stroke. The present review describes novel therapies addressed to counteract inflammation in the prevention of the first-ever or recurrent stroke. The putative clinical use of broad-spectrum and specific anti-inflammatory drugs, such as monoclonal antibodies and microRNAs (miRNAs) as regulators of atherosclerosis, will be outlined. Further studies are necessary to ascertain which patients may benefit from anti-inflammatory agents and how.
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Affiliation(s)
- Núria Puig
- Cardiovascular Biochemistry, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain; (N.P.); (A.S.)
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, Building M, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallés, 08193 Barcelona, Spain; (A.A.-S.); (R.G.)
| | - Arnau Solé
- Cardiovascular Biochemistry, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain; (N.P.); (A.S.)
| | - Ana Aguilera-Simon
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, Building M, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallés, 08193 Barcelona, Spain; (A.A.-S.); (R.G.)
- Stroke Unit, Department of Neurology, Hospital de La Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain
| | - Raquel Griñán
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, Building M, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallés, 08193 Barcelona, Spain; (A.A.-S.); (R.G.)
- Pathofisiology of Lipid-Related Deseases, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain;
| | - Noemi Rotllan
- Pathofisiology of Lipid-Related Deseases, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain;
- CIBER of Diabetes and Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Pol Camps-Renom
- Stroke Unit, Department of Neurology, Hospital de La Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain
| | - Sonia Benitez
- Cardiovascular Biochemistry, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain; (N.P.); (A.S.)
- CIBER of Diabetes and Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, 28029 Madrid, Spain
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14
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Sahoo A, Abdalkader M, Yamagami H, Huo X, Sun D, Jia B, Weyland CS, Diana F, Kaliaev A, Klein P, Bui J, Kasab SA, de Havenon A, Zaidat OO, Zi W, Yang Q, Michel P, Siegler JE, Yaghi S, Hu W, Nguyen TN. Endovascular Therapy for Acute Stroke: New Evidence and Indications. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:232-242. [PMID: 38025253 PMCID: PMC10657733 DOI: 10.5797/jnet.ra.2023-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/25/2023] [Indexed: 12/01/2023]
Abstract
Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke. In the past few years, endovascular treatment indications have expanded to include patients being treated in the extended window, with large ischemic core infarction, basilar artery occlusion (BAO) thrombectomy, as demonstrated by several randomized clinical trials. Intravenous thrombolysis (IVT) bridging to mechanical thrombectomy has also been studied via several randomized clinical trials, with the overall results indicating that IVT should not be skipped in patients who are candidates for both IVT and EVT. Simplification of neuroimaging protocols in the extended window to permit non-contrast CT, CTA collaterals have also expanded access to mechanical thrombectomy, particularly in regions across the world where access to advanced imaging may not be available. Ongoing study of areas to develop include rescue stenting in patients with failed thrombectomy, medium vessel occlusion thrombectomy, and carotid tandem occlusions. In this narrative review, we summarize recent trials and key data in the treatment of patients with large ischemic core infarct, simplification of neuroimaging protocols for the treatment of patients presenting in the late window, bridging thrombolysis, and BAO EVT evidence. We also summarize areas of ongoing study including medium and distal vessel occlusion.
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Affiliation(s)
- Anurag Sahoo
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Mohamad Abdalkader
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Hiroshi Yamagami
- Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Xiaochuan Huo
- Cerebrovascular Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | | | - Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
- Vall d'Hebron Research Institute, Barcelona, Spain
| | - Artem Kaliaev
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Piers Klein
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Jenny Bui
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sami Al Kasab
- Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Wenjie Zi
- Neurology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Qingwu Yang
- Neurology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Patrik Michel
- Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Shadi Yaghi
- Neurology, Rhode Island Hospital, Brown University School of Medicine, Providence, RI, USA
| | - Wei Hu
- Neurology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Thanh N Nguyen
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
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