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Lee TH, Uchiyama S, Kusuma Y, Chiu HC, Navarro JC, Tan KS, Pandian J, Guo L, Wong Y, Venketasubramanian N. A systematic-search-and-review of registered pharmacological therapies investigated to improve neuro-recovery after a stroke. Front Neurol 2024; 15:1346177. [PMID: 38356890 PMCID: PMC10866005 DOI: 10.3389/fneur.2024.1346177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/08/2024] [Indexed: 02/16/2024] Open
Abstract
Background Stroke burden is largely due to long-term impairments requiring prolonged care with loss of productivity. We aimed to identify and assess studies of different registered pharmacological therapies as treatments to improve post-stroke impairments and/or disabilities. Methods We performed a systematic-search-and-review of treatments that have been investigated as recovery-enhancing or recovery-promoting therapies in adult patients with stroke. The treatment must have received registration or market authorization in any country regardless of primary indication. Outcomes included in the review were neurological impairments and functional/disability assessments. "The best available studies" based on study design, study size, and/or date of publication were selected and graded for level of evidence (LOE) by consensus. Results Our systematic search yielded 7,801 citations, and we reviewed 665 full-text papers. Fifty-eight publications were selected as "the best studies" across 25 pharmacological classes: 31 on ischemic stroke, 21 on ischemic or hemorrhagic stroke, 4 on intracerebral hemorrhage, and 2 on subarachnoid hemorrhage (SAH). Twenty-six were systematic reviews/meta-analyses, 29 were randomized clinical trials (RCTs), and three were cohort studies. Only nimodipine for SAH had LOE A of benefit (systematic review and network meta-analysis). Many studies, some of which showed treatment effects, were assessed as LOE C-LD, mainly due to small sample sizes or poor quality. Seven interventions had LOE B-R (systematic review/meta-analysis or RCT) of treatment effects. Conclusion Only one commercially available treatment has LOE A for routine use in stroke. Further studies of putative neuroprotective drugs as adjunctive treatment to revascularization procedures and more confirmatory trials on recovery-promoting therapies will enhance the certainty of their benefit. The decision on their use must be guided by the clinical profile, neurological impairments, and target outcomes based on the available evidence. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=376973, PROSPERO, CRD42022376973.
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Affiliation(s)
- Tsong-Hai Lee
- Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Medical Center, Tokyo, Japan
| | | | - Hou Chang Chiu
- Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
| | | | - Kay Sin Tan
- University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | | | - Liang Guo
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, Singapore, Singapore
| | - Yoko Wong
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, Singapore, Singapore
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Takematsu E, Massidda M, Howe G, Goldman J, Felli P, Mei L, Callahan G, Sligar AD, Smalling R, Baker AB. Transmembrane stem factor nanodiscs enhanced revascularization in a hind limb ischemia model in diabetic, hyperlipidemic rabbits. Sci Rep 2024; 14:2352. [PMID: 38287067 PMCID: PMC10825164 DOI: 10.1038/s41598-024-52888-6] [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: 05/29/2023] [Accepted: 01/24/2024] [Indexed: 01/31/2024] Open
Abstract
Therapies to revascularize ischemic tissue have long been a goal for the treatment of vascular disease and other disorders. Therapies using stem cell factor (SCF), also known as a c-Kit ligand, had great promise for treating ischemia for myocardial infarct and stroke, however clinical development for SCF was stopped due to toxic side effects including mast cell activation in patients. We recently developed a novel therapy using a transmembrane form of SCF (tmSCF) delivered in lipid nanodiscs. In previous studies, we demonstrated tmSCF nanodiscs were able to induce revascularization of ischemia limbs in mice and did not activate mast cells. To advance this therapeutic towards clinical application, we tested this therapy in an advanced model of hindlimb ischemia in rabbits with hyperlipidemia and diabetes. This model has therapeutic resistance to angiogenic therapies and maintains long term deficits in recovery from ischemic injury. We treated rabbits with local treatment with tmSCF nanodiscs or control solution delivered locally from an alginate gel delivered into the ischemic limb of the rabbits. After eight weeks, we found significantly higher vascularity in the tmSCF nanodisc-treated group in comparison to alginate treated control as quantified through angiography. Histological analysis also showed a significantly higher number of small and large blood vessels in the ischemic muscles of the tmSCF nanodisc treated group. Importantly, we did not observe inflammation or mast cell activation in the rabbits. Overall, this study supports the therapeutic potential of tmSCF nanodiscs for treating peripheral ischemia.
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Affiliation(s)
- Eri Takematsu
- Department of Biomedical Engineering, University of Texas at Austin, 1 University Station, BME 5.202D, C0800, Austin, TX, 78712, USA
- School of Medicine, Surgery, Stanford University, Stanford, CA, USA
| | - Miles Massidda
- Department of Biomedical Engineering, University of Texas at Austin, 1 University Station, BME 5.202D, C0800, Austin, TX, 78712, USA
| | - Gretchen Howe
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Texas Medical School at Houston, Houston, TX, USA
| | - Julia Goldman
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Texas Medical School at Houston, Houston, TX, USA
- Center for Laboratory Animal Medicine and Care, UT Health Science Center at Houston, Houston, TX, USA
| | - Patricia Felli
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Texas Medical School at Houston, Houston, TX, USA
- Center for Laboratory Animal Medicine and Care, UT Health Science Center at Houston, Houston, TX, USA
| | - Lei Mei
- Department of Biomedical Engineering, University of Texas at Austin, 1 University Station, BME 5.202D, C0800, Austin, TX, 78712, USA
| | - Gregory Callahan
- Department of Biomedical Engineering, University of Texas at Austin, 1 University Station, BME 5.202D, C0800, Austin, TX, 78712, USA
| | - Andrew D Sligar
- Department of Biomedical Engineering, University of Texas at Austin, 1 University Station, BME 5.202D, C0800, Austin, TX, 78712, USA
| | - Richard Smalling
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Texas Medical School at Houston, Houston, TX, USA
- Memorial Hermann Heart and Vascular Institute, Houston, TX, USA
| | - Aaron B Baker
- Department of Biomedical Engineering, University of Texas at Austin, 1 University Station, BME 5.202D, C0800, Austin, TX, 78712, USA.
- Institute for Cellular and Molecular Biology, University of Texas at Austin, Austin, TX, USA.
- The Institute for Computational Engineering and Sciences, University of Texas at Austin, Austin, TX, USA.
- Institute for Biomaterials, Drug Delivery and Regenerative Medicine, University of Texas at Austin, Austin, TX, USA.
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Abstract
BACKGROUND Cerebrolysin is a mixture of low-molecular-weight peptides and amino acids derived from porcine brain, which has potential neuroprotective properties. It is widely used in the treatment of acute ischaemic stroke in Russia, Eastern Europe, China, and other Asian and post-Soviet countries. This is an update of a review first published in 2010 and last updated in 2020. OBJECTIVES To assess the benefits and harms of Cerebrolysin or Cerebrolysin-like agents for treating acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, Web of Science Core Collection, with Science Citation Index, and LILACS in May 2022 and a number of Russian databases in June 2022. We also searched reference lists, ongoing trials registers, and conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing Cerebrolysin or Cerebrolysin-like agents started within 48 hours of stroke onset and continued for any length of time, with placebo or no treatment in people with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS Three review authors independently applied the inclusion criteria, assessed trial quality and risk of bias, extracted data, and applied GRADE criteria to the evidence. MAIN RESULTS Seven RCTs (1773 participants) met the inclusion criteria of the review. In this update we added one RCT of Cerebrolysin-like agent Cortexin, which contributed 272 participants. We used the same approach for risk of bias assessment that was re-evaluated for the previous update: we added consideration of the public availability of study protocols and reported outcomes to the selective outcome reporting judgement, through identification, examination, and evaluation of study protocols. For the Cerebrolysin studies, we judged the risk of bias for selective outcome reporting to be unclear across all studies; for blinding of participants and personnel to be low in three studies and unclear in the remaining four; and for blinding of outcome assessors to be low in three studies and unclear in four studies. We judged the risk of bias for generation of allocation sequence to be low in one study and unclear in the remaining six studies; for allocation concealment to be low in one study and unclear in six studies; and for incomplete outcome data to be low in three studies and high in the remaining four studies. The manufacturer of Cerebrolysin supported three multicentre studies, either totally, or by providing Cerebrolysin and placebo, randomisation codes, research grants, or statisticians. We judged two studies to be at high risk of other bias and the remaining five studies to be at unclear risk of other bias. We judged the study of Cortexin to be at low risk of bias for incomplete outcome data and at unclear risk of bias for all other domains. All-cause death: Cerebrolysin or Cortexin probably result in little to no difference in all-cause death (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.65 to 1.41; 6 trials, 1689 participants; moderate-certainty evidence). None of the included studies reported on poor functional outcome, defined as death or dependence at the end of the follow-up period, early death (within two weeks of stroke onset), quality of life, or time to restoration of capacity for work. Only one study clearly reported on the cause of death: cerebral infarct (four in the Cerebrolysin and two in the placebo group), heart failure (two in the Cerebrolysin and one in the placebo group), pulmonary embolism (two in the placebo group), and pneumonia (one in the placebo group). Non-death attrition (secondary outcome): Cerebrolysin or similar peptide mixtures may result in little to no difference in non-death attrition, but the evidence is very uncertain, with a considerable level of heterogeneity (RR 0.72, 95% CI 0.38 to 1.39; 6 trials, 1689 participants; very low-certainty evidence). Serious adverse events (SAEs): Cerebrolysin probably results in little to no difference in the total number of people with SAEs (RR 1.16, 95% CI 0.81 to 1.66; 3 trials, 1335 participants; moderate-certainty evidence). This comprised fatal SAEs (RR 0.90, 95% CI 0.59 to 1.38; 3 trials, 1335 participants; moderate-certainty evidence) and an increase in the total number of people with non-fatal SAEs (RR 2.39, 95% CI 1.10 to 5.23; 3 trials, 1335 participants; moderate-certainty evidence). In the subgroup of dosing schedule 30 mL for 10 days (cumulative dose 300 mL), the increase was more prominent (RR 2.87, 95% CI 1.24 to 6.69; 2 trials, 1189 participants). Total number of people with adverse events: Cerebrolysin or similar peptide mixtures may result in little to no difference in the total number of people with adverse events (RR 1.03, 95% CI 0.92 to 1.14; 4 trials, 1607 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Moderate-certainty evidence indicates that Cerebrolysin or Cerebrolysin-like peptide mixtures derived from cattle brain probably have no beneficial effect on preventing all-cause death in acute ischaemic stroke. Moderate-certainty evidence suggests that Cerebrolysin probably has no beneficial effect on the total number of people with serious adverse events. Moderate-certainty evidence also indicates a potential increase in non-fatal serious adverse events with Cerebrolysin use.
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Affiliation(s)
- Liliya Eugenevna Ziganshina
- Centre for Knowledge Translation, Federal State Budgetary Educational Institution of Continuing Professional Education "Russian Medical Academy of Continuing Professional Education", The Ministry of Health of the Russian Federation (RMANPO), Moscow, Russian Federation
- Department of Pharmacology, Kazan State Medical University (KSMU), The Ministry of Health of the Russian Federation, Kazan, Russian Federation
- Department of General and Clinical Pharmacology, RUDN University named after Patrice Lumumba, Moscow, Russian Federation
| | - Tatyana Abakumova
- Department of Biochemistry, Biotechnology and Pharmacology, Kazan (Volga region) Federal University, Kazan, Russian Federation
| | - Dilyara Nurkhametova
- Centre for Knowledge Translation, Federal State Budgetary Educational Institution of Continuing Professional Education "Russian Medical Academy of Continuing Professional Education", The Ministry of Health of the Russian Federation (RMANPO), Moscow, Russian Federation
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Takematsu E, Massidda M, Howe G, Goldman J, Felli P, Mei L, Callahan G, Sligar A, Smalling R, Baker A. Transmembrane Stem Factor Nanodiscs Enhanced Revascularization in a Hind Limb Ischemia Model in Diabetic, Hyperlipidemic Rabbits. RESEARCH SQUARE 2023:rs.3.rs-2997323. [PMID: 37398327 PMCID: PMC10312936 DOI: 10.21203/rs.3.rs-2997323/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Therapies to revascularize ischemic tissue have long been a goal for the treatment of vascular disease and other disorders. Therapies using stem cell factor (SCF), also known as a c-Kit ligand, had great promise for treating ischemia for myocardial infarct and stroke, however clinical development for SCF was stopped due to toxic side effects including mast cell activation in patients. We recently developed a novel therapy using a transmembrane form of SCF (tmSCF) delivered in lipid nanodiscs. In previous studies, we demonstrated tmSCF nanodiscs were able to induce revascularization of ischemia limbs in mice and did not activate mast cells. To advance this therapeutic towards clinical application, we tested this therapy in an advanced model of hindlimb ischemia in rabbits with hyperlipidemia and diabetes. This model has therapeutic resistance to angiogenic therapies and maintains long term deficits in recovery from ischemic injury. We treated rabbits with local treatment with tmSCF nanodiscs or control solution delivered locally from an alginate gel delivered into the ischemic limb of the rabbits. After eight weeks, we found significantly higher vascularity in the tmSCF nanodisc-treated group in comparison to alginate treated control as quantified through angiography. Histological analysis also showed a significantly higher number of small and large blood vessels in the ischemic muscles of the tmSCF nanodisc treated group. Importantly, we did not observe inflammation or mast cell activation in the rabbits. Overall, this study supports the therapeutic potential of tmSCF nanodiscs for treating peripheral ischemia.
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Affiliation(s)
| | | | - Gretchen Howe
- The University of Texas Health Science Center at Houston
| | - Julia Goldman
- The University of Texas Health Science Center at Houston
| | - Patricia Felli
- The University of Texas Health Science Center at Houston
| | - Lei Mei
- The University of Texas at Austin
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Takematsu E, Massidda M, Howe G, Goldman J, Felli P, Mei L, Callahan G, Sligar AD, Smalling R, Baker AB. Transmembrane Stem Factor Nanodiscs Enhanced Revascularization in a Hind Limb Ischemia Model in Diabetic, Hyperlipidemic Rabbits. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.03.20.533550. [PMID: 36993249 PMCID: PMC10055194 DOI: 10.1101/2023.03.20.533550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Therapies to revascularize ischemic tissue have long been a goal for the treatment of vascular disease and other disorders. Therapies using stem cell factor (SCF), also known as a c-Kit ligand, had great promise for treating ischemia for myocardial infarct and stroke, however clinical development for SCF was stopped due to toxic side effects including mast cell activation in patients. We recently developed a novel therapy using a transmembrane form of SCF (tmSCF) delivered in lipid nanodiscs. In previous studies, we demonstrated tmSCF nanodiscs were able to induce revascularization of ischemia limbs in mice and did not activate mast cells. To advance this therapeutic towards clinical application, we tested this therapy in an advanced model of hindlimb ischemia in rabbits with hyperlipidemia and diabetes. This model has therapeutic resistance to angiogenic therapies and maintains long term deficits in recovery from ischemic injury. We treated rabbits with local treatment with tmSCF nanodiscs or control solution delivered locally from an alginate gel delivered into the ischemic limb of the rabbits. After eight weeks, we found significantly higher vascularity in the tmSCF nanodisc-treated group in comparison to alginate treated control as quantified through angiography. Histological analysis also showed a significantly higher number of small and large blood vessels in the ischemic muscles of the tmSCF nanodisc treated group. Importantly, we did not observe inflammation or mast cell activation in the rabbits. Overall, this study supports the therapeutic potential of tmSCF nanodiscs for treating peripheral ischemia.
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Takematsu E, Massidda M, Auster J, Chen PC, Im B, Srinath S, Canga S, Singh A, Majid M, Sherman M, Dunn A, Graham A, Martin P, Baker AB. Transmembrane stem cell factor protein therapeutics enhance revascularization in ischemia without mast cell activation. Nat Commun 2022; 13:2497. [PMID: 35523773 PMCID: PMC9076913 DOI: 10.1038/s41467-022-30103-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/08/2022] [Indexed: 11/30/2022] Open
Abstract
Stem cell factor (SCF) is a cytokine that regulates hematopoiesis and other biological processes. While clinical treatments using SCF would be highly beneficial, these have been limited by toxicity related to mast cell activation. Transmembrane SCF (tmSCF) has differential activity from soluble SCF and has not been explored as a therapeutic agent. We created novel therapeutics using tmSCF embedded in proteoliposomes or lipid nanodiscs. Mouse models of anaphylaxis and ischemia revealed the tmSCF-based therapies did not activate mast cells and improved the revascularization in the ischemic hind limb. Proteoliposomal tmSCF preferentially acted on endothelial cells to induce angiogenesis while tmSCF nanodiscs had greater activity in inducing stem cell mobilization and recruitment to the site of injury. The type of lipid nanocarrier used altered the relative cellular uptake pathways and signaling in a cell type dependent manner. Overall, we found that tmSCF-based therapies can provide therapeutic benefits without off target effects.
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Affiliation(s)
- Eri Takematsu
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Miles Massidda
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Jeff Auster
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Po-Chih Chen
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - ByungGee Im
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Sanjana Srinath
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Sophia Canga
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Aditya Singh
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Marjan Majid
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Michael Sherman
- Department of Biochemistry & Molecular Biology, University of Texas Medical Branch, Galveston, TX, USA
| | - Andrew Dunn
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA
| | - Annette Graham
- Department of Biological and Biomedical Sciences, School of Health and Life Sciences, Glasgow Caledonian University, G4 0BA, Scotland, UK
| | - Patricia Martin
- Department of Biological and Biomedical Sciences, School of Health and Life Sciences, Glasgow Caledonian University, G4 0BA, Scotland, UK
| | - Aaron B Baker
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX, USA.
- Institute for Cellular and Molecular Biology, University of Texas at Austin, Austin, TX, USA.
- The Institute for Computational Engineering and Sciences, University of Texas at Austin, Austin, TX, USA.
- Institute for Biomaterials, Drug Delivery and Regenerative Medicine, University of Texas at Austin, Austin, TX, USA.
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Sommer CJ, Schäbitz WR. Principles and requirements for stroke recovery science. J Cereb Blood Flow Metab 2021; 41:471-485. [PMID: 33175596 PMCID: PMC7907998 DOI: 10.1177/0271678x20970048] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 12/11/2022]
Abstract
The disappointing results in bench-to-bedside translation of neuroprotective strategies caused a certain shift in stroke research towards enhancing the endogenous recovery potential of the brain. One reason for this focus on recovery is the much wider time window for therapeutic interventions which is open for at least several months. Since recently two large clinical studies using d-amphetamine or fluoxetine, respectively, to enhance post-stroke neurological outcome failed again it is a good time for a critical reflection on principles and requirements for stroke recovery science. In principal, stroke recovery science deals with all events from the molecular up to the functional and behavioral level occurring after brain ischemia eventually ending up with any measurable improvement of various clinical parameters. A detailed knowledge of the spontaneously occurring post-ischemic regeneration processes is the indispensable prerequisite for any therapeutic approaches aiming to modify these responses to enhance post-stroke recovery. This review will briefly illuminate the molecular mechanisms of post-ischemic regeneration and the principle possibilities to foster post-stroke recovery. In this context, recent translational approaches are analyzed. Finally, the principal and specific requirements and pitfalls in stroke recovery research as well as potential explanations for translational failures will be discussed.
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Affiliation(s)
- Clemens J Sommer
- Institute of Neuropathology, University Medical Center of the
Johannes Gutenberg-University Mainz, Mainz, Germany
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Patel AMR, Apaijai N, Chattipakorn N, Chattipakorn SC. The Protective and Reparative Role of Colony-Stimulating Factors in the Brain with Cerebral Ischemia/Reperfusion Injury. Neuroendocrinology 2021; 111:1029-1065. [PMID: 33075777 DOI: 10.1159/000512367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/19/2020] [Indexed: 11/19/2022]
Abstract
Stroke is a debilitating disease and has the ability to culminate in devastating clinical outcomes. Ischemic stroke followed by reperfusion entrains cerebral ischemia/reperfusion (I/R) injury, which is a complex pathological process and is associated with serious clinical manifestations. Therefore, the development of a robust and effective poststroke therapy is crucial. Granulocyte colony-stimulating factor (GCSF) and erythropoietin (EPO), originally discovered as hematopoietic growth factors, are versatile and have transcended beyond their traditional role of orchestrating the proliferation, differentiation, and survival of hematopoietic progenitors to one that fosters brain protection/neuroregeneration. The clinical indication regarding GCSF and EPO as an auspicious therapeutic strategy is conferred in a plethora of illnesses, including anemia and neutropenia. EPO and GCSF alleviate cerebral I/R injury through a multitude of mechanisms, involving antiapoptotic, anti-inflammatory, antioxidant, neurogenic, and angiogenic effects. Despite bolstering evidence from preclinical studies, the multiple brain protective modalities of GCSF and EPO failed to translate in clinical trials and thereby raises several questions. The present review comprehensively compiles and discusses key findings from in vitro, in vivo, and clinical data pertaining to the administration of EPO, GCSF, and other drugs, which alter levels of colony-stimulating factor (CSF) in the brain following cerebral I/R injury, and elaborates on the contributing factors, which led to the lost in translation of CSFs from bench to bedside. Any controversial findings are discussed to enable a clear overview of the role of EPO and GCSF as robust and effective candidates for poststroke therapy.
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Affiliation(s)
- Aysha Mohamed Rafik Patel
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
| | - Nattayaporn Apaijai
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand,
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand,
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand,
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9
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Abstract
BACKGROUND Cerebrolysin is a mixture of low-molecular-weight peptides and amino acids derived from porcine brain that has potential neuroprotective properties. It is widely used in the treatment of acute ischaemic stroke in Russia, Eastern Europe, China, and other Asian and post-Soviet countries. This is an update of a review first published in 2010 and last updated in 2017. OBJECTIVES To assess the benefits and harms of Cerebrolysin for treating acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, Web of Science Core Collection, with Science Citation Index, LILACS, OpenGrey, and a number of Russian databases in October 2019. We also searched reference lists, ongoing trials registers, and conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing Cerebrolysin, started within 48 hours of stroke onset and continued for any length of time, with placebo or no treatment in people with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria, assessed trial quality and risk of bias, extracted data, and applied GRADE criteria to the evidence. MAIN RESULTS Seven RCTs (1601 participants) met the inclusion criteria of the review. In this update we re-evaluated risk of bias through identification, examination, and evaluation of study protocols and judged it to be low, unclear, or high across studies: unclear for all domains in one study, and unclear for selective outcome reporting across all studies; low for blinding of participants and personnel in four studies and unclear in the remaining three; low for blinding of outcome assessors in three studies and unclear in four studies. We judged risk of bias to be low in two studies and unclear in the remaining five studies for generation of allocation sequence; low in one study and unclear in six studies for allocation concealment; and low in one study, unclear in one study, and high in the remaining five studies for incomplete outcome data. The manufacturer of Cerebrolysin supported four multicentre studies, either totally, or by providing Cerebrolysin and placebo, randomisation codes, research grants, or statisticians. We judged three studies to be at high risk of other bias and the remaining four studies to be at unclear risk of other bias. All-cause death: we extracted data from six trials (1517 participants). Cerebrolysin probably results in little to no difference in all-cause death: risk ratio (RR) 0.90, 95% confidence interval (CI) 0.61 to 1.32 (6 trials, 1517 participants, moderate-quality evidence). None of the included trials reported on poor functional outcome defined as death or dependence at the end of the follow-up period or early death (within two weeks of stroke onset), or time to restoration of capacity for work and quality of life. Only one trial clearly reported on the cause of death: cerebral infarct (four in the Cerebrolysin and two in the placebo group), heart failure (two in the Cerebrolysin and one in the placebo group), pulmonary embolism (two in the placebo group), and pneumonia (one in the placebo group). Serious adverse events (SAEs): Cerebrolysin probably results in little to no difference in the total number of people with SAEs (RR 1.15, 95% CI 0.81 to 1.65, 4 RCTs, 1435 participants, moderate-quality evidence). This comprised fatal SAEs (RR 0.90, 95% CI 0.59 to 1.38) and an increase in the total number of people with non-fatal SAEs (RR 2.15, 95% CI 1.01 to 4.55, P = 0.047, 4 trials, 1435 participants, moderate-quality evidence). In the subgroup of dosing schedule 30 mL for 10 days (cumulative dose 300 mL), the increase was more prominent: RR 2.86, 95% CI 1.23 to 6.66, P = 0.01 (2 trials, 1189 participants). Total number of people with adverse events: four trials reported on this outcome. Cerebrolysin may result in little to no difference in the total number of people with adverse events: RR 0.97, 95% CI 0.85 to 1.10, P = 0.90, 4 trials, 1435 participants, low-quality evidence. Non-death attrition: evidence from six trials involving 1517 participants suggests that Cerebrolysin results in little to no difference in non-death attrition, with 96 out of 764 Cerebrolysin-treated participants and 117 out of 753 placebo-treated participants being lost to follow-up for reasons other than death (very low-quality evidence). AUTHORS' CONCLUSIONS Moderate-quality evidence indicates that Cerebrolysin probably has little or no beneficial effect on preventing all-cause death in acute ischaemic stroke, or on the total number of people with serious adverse events. Moderate-quality evidence also indicates a potential increase in non-fatal serious adverse events with Cerebrolysin use.
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Affiliation(s)
- Liliya Eugenevna Ziganshina
- Cochrane Russia, Kazan, Russian Federation
- Department of Pharmacology, Kazan State Medical University, Kazan, Russian Federation
| | - Tatyana Abakumova
- Department of Biochemistry, Biotechnology and Pharmacology, Kazan (Volga region) Federal University, Kazan, Russian Federation
| | - Charles Hv Hoyle
- Cochrane Russia, Kazan, Russian Federation
- Deputy Editor-in-Chief, Kazan Medical Journal, Kazan, Russian Federation
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10
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Bonsack B, Heyck M, Kingsbury C, Cozene B, Sadanandan N, Lee JY, Borlongan CV. Fast-tracking regenerative medicine for traumatic brain injury. Neural Regen Res 2020; 15:1179-1190. [PMID: 31960797 PMCID: PMC7047809 DOI: 10.4103/1673-5374.270294] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 08/22/2019] [Accepted: 09/26/2019] [Indexed: 12/15/2022] Open
Abstract
Traumatic brain injury remains a global health crisis that spans all demographics, yet there exist limited treatment options that may effectively curtail its lingering symptoms. Traumatic brain injury pathology entails a progression from primary injury to inflammation-mediated secondary cell death. Sequestering this inflammation as a means of ameliorating the greater symptomology of traumatic brain injury has emerged as an attractive treatment prospect. In this review, we recapitulate and evaluate the important developments relating to regulating traumatic brain injury-induced neuroinflammation, edema, and blood-brain barrier disintegration through pharmacotherapy and stem cell transplants. Although these studies of stand-alone treatments have yielded some positive results, more therapeutic outcomes have been documented from the promising area of combined drug and stem cell therapy. Harnessing the facilitatory properties of certain pharmaceuticals with the anti-inflammatory and regenerative effects of stem cell transplants creates a synergistic effect greater than the sum of its parts. The burgeoning evidence in favor of combined drug and stem cell therapies warrants more elaborate preclinical studies on this topic in order to pave the way for later clinical trials.
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Affiliation(s)
- Brooke Bonsack
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Matt Heyck
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Chase Kingsbury
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Blaise Cozene
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Nadia Sadanandan
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Jea-Young Lee
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
| | - Cesar V. Borlongan
- Center of Excellence for Aging and Brain Repair, University of South Florida College of Medicine, Tampa, FL, USA
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11
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Wang K, Rong L, Wei X, Zhang Q, Xiao L. The effectiveness of various cytotherapeutic strategies for the treatment of ischemic stroke: a Bayesian network meta-analysis of randomized controlled trials. Neurol Sci 2020; 41:1705-1717. [PMID: 32130557 DOI: 10.1007/s10072-020-04312-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cytotherapy is a potential treatment for ischemic stroke (IS) patients but lacks uniform procedures. We aimed to assess the impact of the time of intervention, cell type, dose, and route of administration on the clinical effects by network meta-analysis. METHODS We searched public electronic databases through July 7, 2019. Bayesian network meta-analyses were performed to compare differences among different cytotherapeutic strategies. RESULTS Cytotherapy can significantly improve patients' activity of daily living according to the modified Rankin Scale (standard mean difference (SMD) - 0.81; 95% confidence interval (CI) - 1.58, - 0.03; p = 0.0417) and Barthel Index (SMD 0.67; 95% CI 0.05, 1.30; p = 0.036) results as well as improve neurological recovery (SMD - 0.93; 95% CI - 1.29, - 0.57; p < 0.001). Network meta-analysis showed that the intra-arterial injection of large amounts of mononuclear cells (NCs) or aldehyde dehydrogenase (ALDH)-positive cells was beneficial for improving patients' activity of daily living, while CD34+ cells through intracerebral injection had an advantage in the recovery of injured nerve function. Intravenous injection of mesenchymal stem cells (MSCs) or endothelial progenitor cells (EPCs) was beneficial in reducing mortality and serious adverse event (SAE) onset. CONCLUSIONS In the subacute stage, the intra-arterial injection of NCs or ALDH cells improves patients' activity of daily living. Additionally, CD34+ cells through intracerebral injection had an advantage in the recovery of injured nerve function even in the chronic stage. Intravenous injection of MSCs or EPCs is a safety delivery route that can reduce mortality and SAE onset. However, further clinical studies are still needed to confirm these results.
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Affiliation(s)
- Kai Wang
- Department of Neurology, Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221006, China
| | - Liangqun Rong
- Department of Neurology, Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221006, China. .,, No. 32, Meijian Road, Quanshan District, Xuzhou, Jiangsu, China.
| | - Xiue Wei
- Department of Neurology, Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221006, China
| | - Qingxiu Zhang
- Department of Neurology, Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221006, China
| | - Lijie Xiao
- Department of Neurology, Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221006, China
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12
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Le Friec A, Salabert AS, Davoust C, Demain B, Vieu C, Vaysse L, Payoux P, Loubinoux I. Enhancing Plasticity of the Central Nervous System: Drugs, Stem Cell Therapy, and Neuro-Implants. Neural Plast 2017; 2017:2545736. [PMID: 29391951 PMCID: PMC5748136 DOI: 10.1155/2017/2545736] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/19/2017] [Accepted: 10/23/2017] [Indexed: 01/01/2023] Open
Abstract
Stroke represents the first cause of adult acquired disability. Spontaneous recovery, dependent on endogenous neurogenesis, allows for limited recovery in 50% of patients who remain functionally dependent despite physiotherapy. Here, we propose a review of novel drug therapies with strong potential in the clinic. We will also discuss new avenues of stem cell therapy in patients with a cerebral lesion. A promising future for the development of efficient drugs to enhance functional recovery after stroke seems evident. These drugs will have to prove their efficacy also in severely affected patients. The efficacy of stem cell engraftment has been demonstrated but will have to prove its potential in restoring tissue function for the massive brain lesions that are most debilitating. New answers may lay in biomaterials, a steadily growing field. Biomaterials should ideally resemble lesioned brain structures in architecture and must be proven to increase functional reconnections within host tissue before clinical testing.
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Affiliation(s)
- Alice Le Friec
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Anne-Sophie Salabert
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
- Radiopharmacy Department, CHU Toulouse, Toulouse, France
| | - Carole Davoust
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Boris Demain
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Christophe Vieu
- LAAS-CNRS, Université de Toulouse, CNRS, INSA, UPS, Toulouse, France
| | - Laurence Vaysse
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Pierre Payoux
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
- Nuclear Medicine Department, CHU Toulouse, Toulouse, France
| | - Isabelle Loubinoux
- ToNIC, Toulouse NeuroImaging Center, Université de Toulouse, Inserm, UPS, Toulouse, France
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13
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Calf Spleen Extractive Injection protects mice against cyclophosphamide-induced hematopoietic injury through G-CSF-mediated JAK2/STAT3 signaling. Sci Rep 2017; 7:8402. [PMID: 28827748 PMCID: PMC5566473 DOI: 10.1038/s41598-017-08970-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/20/2017] [Indexed: 12/22/2022] Open
Abstract
Calf Spleen Extractive Injection (CSEI), extracted from the spleen of healthy cows (within 24 hours of birth), is a small-peptide-enriched extraction and often used as an ancillary agent in cancer therapy. This study evaluated the hematopoietic function of CSEI and its underlying mechanisms, principally in CHRF, K562 cells, BMNCs and a mouse model of cyclophosphamide (CTX)-induced hematopoietic suppression. CSEI promoted the proliferation and differentiation of CHRF and K562 cells, activated hematopoietic- and proliferation-related factors RSK1p90, ELK1 and c-Myc, and facilitated the expression of differentiation- and maturation-related transcription factors GATA-1, GATA-2. In the mice with hematopoietic suppression, 3 weeks of CSEI administration enhanced the bodyweights and thymus indices, suppressed the spleen indices and strongly elevated the production of HSPCs, neutrophils and B cells in bone marrow, ameliorated bone marrow cellularity, and regulated the ratio of peripheral blood cells. Proteome profiling combined with ELISA revealed that CSEI regulated the levels of cytokines, especially G-CSF and its related factors, in the spleen and plasma. Additional data revealed that CSEI promoted phosphorylation of STAT3, which was stimulated by G-CSF in both mice spleen and cultured BMNCs. Taken together, CSEI has the potential to improve hematopoietic function via the G-CSF-mediated JAK2/STAT3 signaling pathway.
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14
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Guan Z, Tao Y, Zhang X, Guo Q, Liu Y, Zhang Y, Wang Y, ji G, Wu G, Wang N, Yang H, Yu Z, Guo J, Zhou H. G-CSF and cognitive dysfunction in elderly diabetic mice with cerebral small vessel disease: Preventive intervention effects and underlying mechanisms. CNS Neurosci Ther 2017; 23:462-474. [PMID: 28374506 PMCID: PMC6492719 DOI: 10.1111/cns.12691] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/25/2017] [Accepted: 02/27/2017] [Indexed: 12/23/2022] Open
Abstract
AIMS Although cognitive dysfunction is a common neurological complication in elderly patients with diabetes, the mechanisms underlying this relationship remain unclear, and effective preventive interventions have yet to be developed. Thus, this study investigated the preventive effects and mechanisms of action associated with granulocyte colony-stimulating factor (G-CSF) on cognitive dysfunction in elderly diabetic mice with cerebral small vessel disease. METHODS This study included 40 male db/db diabetic and wild-type (WT) mice that were categorized into the following four groups at the age of 3 weeks: db/db group (DG), db/db+G-CSF group (DGG), WT group (WG), and WT+G-CSF group (WGG). The mice were fed normal diets for 4 months and then given G-CSF (75 μg/kg) via intraperitoneal injections for 1 month. At 7.5 months of age, the cognitive abilities of the mice were assessed with the Y-maze test and the Social Choice Test; body weight, blood pressure (BP), and blood glucose measurements were obtained throughout the study. Brain imaging and blood oxygen level-dependent (BOLD) contrast imaging analyses were performed with a small animal magnetic resonance imaging (MRI) system, autophagosome levels were detected with a transmission electron microscope (TEM), hippocampal neurons were assessed with hematoxylin and eosin (HE) staining, and protein expressions and distributions were evaluated using immunohistochemistry and Western blot analyses. RESULTS (i) The body weight and blood glucose levels of the DG and DGG mice were significantly higher than those of the WG and WGG mice; (ii) social choice and spatial memory capabilities were significantly reduced in DG mice but were recovered by G-CSF in DGG mice; (iii) the MRI scans revealed multiple lacunar lesions and apparent hippocampal atrophy in the brains of DG mice, but G-CSF reduced the number of lacunar lesions and ameliorated hippocampal atrophy; (iv) the MRI-BOLD scans showed a downward trend in whole-brain activity and reductions in the connectivities of the hippocampus and amygdala with subcortical structures in DG mice, but G-CSF clearly improved the altered brain activity as well as the connectivity of the hippocampus in DGG mice; (v) HE staining revealed fewer neurons in the hippocampus in DG mice; (vi) TEM analyses revealed significantly fewer autophagosomes in the hippocampi of DG mice, but G-CSF did not increase these numbers; (vii) there were significant reductions in mechanistic target of rapamycin (mTOR) and LC3-phosphatidylethanolamine conjugate (LC3)-II/I levels in the hippocampi of DG mice, whereas p62 was upregulated, and G-CSF significantly enhanced the levels of Beclin1, mTOR, and LC-II/I in DGG mice; and (viii) G-CSF significantly reversed increases in nuclear factor κB (NF-κB) protein levels in DG but not in WG mice. CONCLUSIONS In this study, aged diabetic mice were prone to cognitive dysfunction and cerebral small vessel disease. However, administration of G-CSF significantly improved cognitive function in elderly db/db diabetic mice, and this change was likely related to the regulation of autophagy and NF-κB signaling pathways.
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Affiliation(s)
- Zhu‐Fei Guan
- Department of Geriatric NeurologyHuashan HospitalFudan UniversityShanghaiChina
- State Key Laboratory of Medical NeurobiologyInstitute of Brain ScienceFudan UniversityShanghaiChina
| | - Ying‐Hong Tao
- Department of General MedicineOuyang Community Health Service CenterHongkou DistrictShanghaiChina
| | - Xiao‐Ming Zhang
- Department of Geriatric NeurologyHuashan HospitalFudan UniversityShanghaiChina
| | - Qi‐Lin Guo
- State Key Laboratory of Medical NeurobiologyInstitute of Brain ScienceFudan UniversityShanghaiChina
| | - Ying‐Chao Liu
- Department of NeurosurgeryShandong Provincial HospitalJinanChina
| | - Yu Zhang
- Department of Geriatric NeurologyHuashan HospitalFudan UniversityShanghaiChina
| | - Yan‐Mei Wang
- Department of Geriatric NeurologyHuashan HospitalFudan UniversityShanghaiChina
| | - Gang ji
- State Key Laboratory of Medical NeurobiologyInstitute of Brain ScienceFudan UniversityShanghaiChina
| | - Guo‐Feng Wu
- Department of Emergency NeurologyAffiliated HospitalGuiyang Medical UniversityGuiyangChina
| | - Na‐Na Wang
- Department of Geriatric NeurologyHuashan HospitalFudan UniversityShanghaiChina
| | - Hao Yang
- Department of Geriatric NeurologyHuashan HospitalFudan UniversityShanghaiChina
| | - Zhong‐Yu Yu
- Department of Geriatric NeurologyHuashan HospitalFudan UniversityShanghaiChina
| | - Jing‐Chun Guo
- State Key Laboratory of Medical NeurobiologyInstitute of Brain ScienceFudan UniversityShanghaiChina
| | - Hou‐Guang Zhou
- Department of Geriatric NeurologyHuashan HospitalFudan UniversityShanghaiChina
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Abstract
BACKGROUND Cerebrolysin is a mixture of low-molecular-weight peptides and amino acids derived from pigs' brain tissue, which has potential neuroprotective and neurotrophic properties. It is widely used in the treatment of acute ischaemic stroke in Russia, Eastern Europe, China, and other Asian and post-Soviet countries. OBJECTIVES To assess the benefits and risks of cerebrolysin for treating acute ischaemic stroke. SEARCH METHODS In May 2016 we searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, Web of Science Core Collection, with Science Citation Index, LILACS, OpenGrey, and a number of Russian Databases. We also searched reference lists, ongoing trials registers and conference proceedings, and contacted the manufacturer of cerebrolysin, EVER Neuro Pharma GmbH (formerly Ebewe Pharma). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing cerebrolysin, started within 48 hours of stroke onset and continued for any time, with placebo or no treatment in people with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently applied inclusion criteria, assessed trial quality and risk of bias, and extracted data. MAIN RESULTS We identified six RCTs (1501 participants) that met the inclusion criteria.We evaluated risk of bias and judged it to be unclear for generation of allocation sequence in four studies and low in two studies; unclear for allocation concealment in five studies and low in one study; high for incomplete outcome data (attrition bias) in five studies and unclear in one study; unclear for blinding; high for selective reporting in four studies and unclear in two; and high for other sources of bias in three studies and unclear in the rest. The manufacturer of cerebrolysin, pharmaceutical company EVER Neuro Pharma, supported three multi-centre studies, either totally, or providing cerebrolysin and placebo, randomisation codes, research grants, or statisticians.None of the included trials reported on poor functional outcome defined as death or dependence at the end of the follow-up period or early death (within two weeks of stroke onset).All-cause death: we extracted data from five trials (1417 participants). There was no difference in the number of deaths: 46/714 in cerebrolysin group versus 47/703 in placebo group; risk ratio (RR) 0.91 95% confidence interval (CI) 0.61 to 1.35 (5 trials, 1417 participants, moderate-quality evidence).Serious adverse events (SAEs): there was no significant difference in the total number of SAEs with cerebrolysin (RR 1.16, 95% CI 0.81 to 1.67). This comprised no difference in fatal SAEs (RR 0.90, 95% CI 0.59 to 1.38) and an increase in the number of people with non-fatal SAEs (20/667 with cerebrolysin and 8/668 with placebo: RR 2.47, 95% CI 1.09 to 5.58, P = 0.03) (3 trials, 1335 participants, moderate-quality evidence).Total number of people with adverse events: three trials reported on this. There was no difference in the total number of people with adverse events: 308/667 in cerebrolysin group versus 307/668 in placebo group; RR 0.97 95% CI 0.86 to 1.09, random-effects model (3 trials, 1335 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS The findings of this Cochrane Review do not demonstrate clinical benefits of cerebrolysin for treating acute ischaemic stroke. We found moderate-quality evidence of an increase in non-fatal SAEs with cerebrolysin use but not in total SAEs.
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Affiliation(s)
- Liliya Eugenevna Ziganshina
- Kazan (Volga region) Federal UniversityResearch & Education Centre for Evidence‐Based Medicine Cochrane Russia18 Kremlevskaya Street, 42000814‐15 Malaya Krasnaya Street, 420015KazanRussian Federation
| | - Tatyana Abakumova
- Kazan (Volga region) Federal UniversityDepartment of Basic and Clinical Pharmacology18 Kremlevskaya StreetKazanRussian Federation420008
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16
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Huang X, Liu Y, Bai S, Peng L, Zhang B, Lu H. Granulocyte colony stimulating factor therapy for stroke: A pairwise meta-analysis of randomized controlled trial. PLoS One 2017; 12:e0175774. [PMID: 28406964 PMCID: PMC5391086 DOI: 10.1371/journal.pone.0175774] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 03/22/2017] [Indexed: 01/27/2023] Open
Abstract
Granulocyte colony-stimulating factor (G-CSF) is atherapeutic candidate for stroke that has demonstrated anti-inflammatory and neuroprotective properties. Data from preclinical and clinical studies have suggested the safety and efficacy of G-CSF in stroke; however, the exact effects and utility of this cytokine in patients remain disputed. We performed a meta-analysis of randomized controlled trials of G-CSF in ischemic and hemorrhagic stroke to assess its clinical safety and efficacy. Electronic databases were searched for relevant publications in English and Chinese. A total of 14 trials met the inclusion criteria. G-CSF (cumulative dose range, 1-135μg/kg/day) was tested against placebo in a total of 1037 participants. There was no difference in the rate of mortality between groups (odds ratio, 1.23; 95% confidence interval, 0.76-1.97, p = 0.40). Moreover, the rate of serious adverse events did not differ between groups and provided evidence for the safety of G-CSF administration in stroke patients (odds ratio, 1.11; 95% confidence interval, 0.77-1.61, p = 0.57). No significant outcome benefits were noted with respect to the National Institutes of Health Stroke Scale (mean difference, -0.16; 95% confidence interval, -1.02-0.70, p = 0.72); however, improvements were noted with respect to the Barthel Index (mean difference, 8.65; 95% confidence interval 0.98-16.32; p = 0.03). In conclusion, it appears to be safe in administration of G-CSF, but it will increase leukocyte count. G-CSF was weakly significant benefit with improving the BI scores, while there was no improvement in the NIHSS scores. Larger and more robustly designed trials of G-CSF in stroke are needed to confirm the results.
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Affiliation(s)
- Xin Huang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Yu Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Henan, China
- * E-mail:
| | - Shuang Bai
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Lidan Peng
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Boai Zhang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Hong Lu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Henan, China
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17
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Abstract
BACKGROUND Cerebrolysin is a mixture of low-molecular-weight peptides and amino acids derived from pigs' brain tissue, which has potential neuroprotective and neurotrophic properties. It is widely used in the treatment of acute ischaemic stroke in Russia, Eastern Europe, China, and other Asian and post-Soviet countries. OBJECTIVES To assess the benefits and risks of cerebrolysin for treating acute ischaemic stroke. SEARCH METHODS In May 2016 we searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, Web of Science Core Collection, with Science Citation Index, LILACS, OpenGrey, and a number of Russian Databases. We also searched reference lists, ongoing trials registers and conference proceedings, and contacted the manufacturer of cerebrolysin, EVER Neuro Pharma GmbH (formerly Ebewe Pharma). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing cerebrolysin, started within 48 hours of stroke onset and continued for any time, with placebo or no treatment in people with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently applied inclusion criteria, assessed trial quality and risk of bias, and extracted data. MAIN RESULTS We identified six RCTs (1501 participants) that met the inclusion criteria.We evaluated risk of bias and judged it to be unclear for generation of allocation sequence in four studies and low in two studies; unclear for allocation concealment in five studies and low in one study; high for incomplete outcome data (attrition bias) in five studies and unclear in one study; unclear for blinding; high for selective reporting in four studies and unclear in two; and high for other sources of bias in three studies and unclear in the rest. The manufacturer of cerebrolysin, pharmaceutical company EVER Neuro Pharma, supported three multi-centre studies, either totally, or providing cerebrolysin and placebo, randomisation codes, research grants, or statisticians.None of the included trials reported on poor functional outcome defined as death or dependence at the end of the follow-up period or early death (within two weeks of stroke onset).All-cause death: we extracted data from five trials (1417 participants). There was no difference in the number of deaths: 46/714 in cerebrolysin group versus 47/703 in placebo group; risk ratio (RR) 0.91 95% confidence interval (CI) 0.61 to 1.35 (5 trials, 1417 participants, moderate-quality evidence).Serious adverse events: two trials reported on this outcome, with 90% confidence cerebrolysin increased the risks of serious adverse events by at least one third compared to placebo: 62/589 in cerebrolysin group versus 46/600 in placebo group; RR 1.37 90% CI 1.01 to 1.86 (2 trials, 1189 participants, moderate-quality evidence).Total number of people with adverse events: three trials reported on this. There was no difference in the total number of people with adverse events: 308/667 in cerebrolysin group versus 307/668 in placebo group; RR 0.97 95% CI 0.86 to 1.09, random-effects model (3 trials, 1335 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS The findings of this Cochrane Review do not demonstrate clinical benefits of cerebrolysin for treating acute ischaemic stroke. We found moderate-quality evidence suggesting that serious adverse events may be more common with cerebrolysin use in acute ischaemic stroke.
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Affiliation(s)
- Liliya Eugenevna Ziganshina
- Kazan (Volga region) Federal UniversityDepartment of Basic and Clinical Pharmacology18 Kremlevskaya Street, 42000814‐15 Malaya Krasnaya Street, 420015KazanRussian Federation
| | - Tatyana Abakumova
- Kazan (Volga region) Federal UniversityDepartment of Basic and Clinical Pharmacology18 Kremlevskaya Street, 42000814‐15 Malaya Krasnaya Street, 420015KazanRussian Federation
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18
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England TJ, Sprigg N, Alasheev AM, Belkin AA, Kumar A, Prasad K, Bath PM. Granulocyte-Colony Stimulating Factor (G-CSF) for stroke: an individual patient data meta-analysis. Sci Rep 2016; 6:36567. [PMID: 27845349 PMCID: PMC5109224 DOI: 10.1038/srep36567] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 10/18/2016] [Indexed: 12/11/2022] Open
Abstract
Granulocyte colony stimulating factor (G-CSF) may enhance recovery from stroke through neuroprotective mechanisms if administered early, or neurorepair if given later. Several small trials suggest administration is safe but effects on efficacy are unclear. We searched for randomised controlled trials (RCT) assessing G-CSF in patients with hyperacute, acute, subacute or chronic stroke, and asked Investigators to share individual patient data on baseline characteristics, stroke severity and type, end-of-trial modified Rankin Scale (mRS), Barthel Index, haematological parameters, serious adverse events and death. Multiple variable analyses were adjusted for age, sex, baseline severity and time-to-treatment. Individual patient data were obtained for 6 of 10 RCTs comprising 196 stroke patients (116 G-CSF, 80 placebo), mean age 67.1 (SD 12.9), 92% ischaemic, median NIHSS 10 (IQR 5–15), randomised 11 days (interquartile range IQR 4–238) post ictus; data from three commercial trials were not shared. G-CSF did not improve mRS (ordinal regression), odds ratio OR 1.12 (95% confidence interval 0.64 to 1.96, p = 0.62). There were more patients with a serious adverse event in the G-CSF group (29.6% versus 7.5%, p = 0.07) with no significant difference in all-cause mortality (G-CSF 11.2%, placebo 7.6%, p = 0.4). Overall, G-CSF did not improve stroke outcome in this individual patient data meta-analysis.
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Affiliation(s)
- Timothy J England
- Vascular Medicine, Division of Medical Sciences and GEM, School of Medicine, University of Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, UK
| | | | - Andrey A Belkin
- Institute of Medical Cell Technologies, Yekaterinburg, Russia
| | - Amit Kumar
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Kameshwar Prasad
- Department of Neurology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, UK
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19
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Liepert J. [Drugs for improvement of motor deficits after stroke]. DER NERVENARZT 2016; 87:1082-1085. [PMID: 27630000 DOI: 10.1007/s00115-016-0216-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Randomized controlled trials with a variety of drugs have been performed for approximately 20 years in order to support functional restitution of motor deficits after a stroke. Nowadays, serotonin reuptake inhibitors show the highest level of evidence due to the largest number of positive studies and L‑dopa also seems to be effective; however, much fewer studies have been conducted. In the majority of trials amphetamines provided no additional benefits and D‑cycloserine cannot be recommended either. Future therapeutic approaches, e.g. anti-nogo antibodies and cell therapy are presented.
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Affiliation(s)
- J Liepert
- Kliniken Schmieder Allensbach, Zum Tafelholz 8, 78476, Allensbach, Deutschland. .,Lurija Institut für Rehabilitationswissenschaften und Gesundheitsforschung, Allensbach, Deutschland.
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20
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Granulocyte Colony Stimulating Factor and Physiotherapy after Stroke: Results of a Feasibility Randomised Controlled Trial: Stem Cell Trial of Recovery EnhanceMent after Stroke-3 (STEMS-3 ISRCTN16714730). PLoS One 2016; 11:e0161359. [PMID: 27610616 PMCID: PMC5017715 DOI: 10.1371/journal.pone.0161359] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 08/04/2016] [Indexed: 01/19/2023] Open
Abstract
Background Granulocyte-colony stimulating factor (G-CSF) mobilises endogenous haematopoietic stem cells and enhances recovery in experimental stroke. Recovery may also be dependent on an enriched environment and physical activity. G-CSF may have the potential to enhance recovery when used in combination with physiotherapy, in patients with disability late after stroke. Methods A pilot 2 x 2 factorial randomised (1:1) placebo-controlled trial of G-CSF (double-blind), and/or a 6 week course of physiotherapy, in 60 participants with disability (mRS >1), at least 3 months after stroke. Primary outcome was feasibility, acceptability and tolerability. Secondary outcomes included death, dependency, motor function and quality of life measured 90 and 365 days after enrolment. Results Recruitment to the trial was feasible and acceptable; of 118 screened patients, 92 were eligible and 32 declined to participate. 60 patients were recruited between November 2011 and July 2013. All participants received some allocated treatment. Although 29 out of 30 participants received all 5 G-CSF/placebo injections, only 7 of 30 participants received all 18 therapy sessions. G-CSF was well tolerated but associated with a tendency to more adverse events than placebo (16 vs 10 patients, p = 0.12) and serious adverse events (SAE) (9 vs 3, p = 0.10). On average, patients received 14 (out of 18 planned) therapy sessions, interquartile range [12, 17]. Only a minority (23%) of participants completed all physiotherapy sessions, a large proportion of sessions (114 of 540, 21%) were cancelled due to patient (94, 17%) and therapist factors (20, 4%). No significant differences in functional outcomes were detected in either the G-CSF or physiotherapy group at day 90 or 365. Conclusions Delivery of G-CSF is feasible in chronic stroke. However, the study failed to demonstrate feasibility for delivering additional physiotherapy sessions late after stroke therefore a definitive study using this trial design is not supported. Future work should occur earlier after stroke, alongside on-going clinical rehabilitation. Trial Registration ISRCTN.com ISRCTN16714730
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Beristain X, Golombievski E. Pharmacotherapy to Enhance Cognitive and Motor Recovery Following Stroke. Drugs Aging 2016; 32:765-72. [PMID: 26423272 DOI: 10.1007/s40266-015-0299-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Stroke is a leading cause of disability among older adults and more than half of stroke survivors have some residual neurological impairment. Traditionally, managing the aftermath of stroke has been by the implementation of several physical and language therapy modalities. The limitations of these rehabilitation efforts have sparked an interest in finding other ways to enhance neurological recovery. Some of these novel approaches have included pharmacological interventions, cell-derived treatments, and cortical magnetic stimulation. Mounting evidence over the last 2 decades suggests that pharmacological manipulations may have the potential to modulate practice-dependent neuroplasticity and potentially improve neurological recovery after stroke. Multiple pharmacological agents with different mechanisms of action have been evaluated, showing conflicting results. Some studies suggest some promise, yet the quality of the available studies is suboptimal overall, with most of the studies being underpowered. So far, the most promising agents include the antidepressants for motor recovery and acetylcholinesterase inhibitors and memantine for aphasia. However, large, well-designed clinical trials are needed to address the shortcomings of the available data and before any pharmacological agent can be recommended for routine use as part of the standard algorithm of stroke management.
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Affiliation(s)
- Xabier Beristain
- Department of Neurology, Stritch School of Medicine, Loyola University Medical Center, Maguire Building, #2700, 2160 South 1st Avenue, Maywood, IL, 60153, USA.
| | - Esteban Golombievski
- Department of Neurology, Stritch School of Medicine, Loyola University Medical Center, Maguire Building, #2700, 2160 South 1st Avenue, Maywood, IL, 60153, USA
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Exploring Erythropoietin and G-CSF Combination Therapy in Chronic Stroke Patients. Int J Mol Sci 2016; 17:463. [PMID: 27043535 PMCID: PMC4848919 DOI: 10.3390/ijms17040463] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 03/10/2016] [Accepted: 03/23/2016] [Indexed: 01/13/2023] Open
Abstract
Erythropoietin (EPO) and granulocyte-colony stimulating factor (G-CSF) are known to have neuroprotective actions. Based on previous reports showing the synergistic effects of EPO+G-CSF combination therapy in experimental models, we investigated the safety of EPO+G-CSF combination therapy in patients with chronic stroke. In a pilot study, 3 patients were treated with EPO and G-CSF for 5 consecutive days, with follow-up on day 30. In an exploratory double-blind study, 6 patients were allocated to treatment with either EPO+G-CSF or placebo. Treatment was applied once a day for 5 days per month over 3 months. Participants were followed up for 6 months. To substantiate safety, vital signs, adverse events, and hematological values were measured on days 0, 5, and 30 in each cycle and on day 180. Functional outcomes were determined on day 0 and 180. In the laboratory measurements, EPO+G-CSF combination therapy significantly elevated erythropoietin, CD34⁺ hematopoietic stem cells, white blood cells, and neutrophils on day 5 of each cycle. There were no observations of serious adverse events. In the functional outcomes, the grip power of the dominant hand was increased in the EPO+G-CSF treatment group. In conclusion, this exploratory study suggests a novel strategy of EPO+G-CSF combination therapy for stroke patients.
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Koh SH, Park HH. Neurogenesis in Stroke Recovery. Transl Stroke Res 2016; 8:3-13. [PMID: 26987852 DOI: 10.1007/s12975-016-0460-z] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/01/2016] [Accepted: 03/09/2016] [Indexed: 12/19/2022]
Abstract
Stroke, resulting from limited blood flow to the brain, is one of the most important causes of morbidity and mortality worldwide. Stroke is classified as ischemic, due to lack of blood flow, or hemorrhagic, due to bleeding. Because 87 % of strokes are classified as ischemic, this type will be the predominant focus of this review. Except for thrombolytic therapy, there is no established treatment to reduce the neurological deficits caused by ischemic stroke. Therefore, it is necessary to develop new therapeutic strategies designed to improve neurological functions after ischemic stroke. Recently, therapies to enhance neurogenesis after ischemic stroke have been investigated. However, these approaches have not led to successful clinical outcomes. This review addresses the pathophysiology of stroke, neurogenesis after stroke, and how to stimulate these processes based on the current literature. Finally, ongoing clinical trials to improve neurological functions after stroke by enhancing neurogenesis are discussed in this review.
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Affiliation(s)
- Seong-Ho Koh
- Department of Neurology, Hanyang University College of Medicine, 249-1 Guri Hospital, Gyomun-dong, Guri-si, Gyeonggi-do, 471-701, Republic of Korea. .,Department of Translational Medicine, Hanyang University Graduate School of Biomedical Science & Engineering, Seoul, Republic of Korea.
| | - Hyun-Hee Park
- Department of Neurology, Hanyang University College of Medicine, 249-1 Guri Hospital, Gyomun-dong, Guri-si, Gyeonggi-do, 471-701, Republic of Korea
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Fan H, Song F. An assessment of randomized controlled trials (RCTs) for non-communicable diseases (NCDs): more and higher quality research is required in less developed countries. Sci Rep 2015; 5:13221. [PMID: 26272174 PMCID: PMC4642521 DOI: 10.1038/srep13221] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 07/21/2015] [Indexed: 12/21/2022] Open
Abstract
Research is crucial to implement evidence-based health interventions for control of non-communicable diseases (NCDs). This study aims to assess main features of randomized controlled trials (RCTs) for control of NCDs, and to identify gaps in clinical research on NCDs between high-income and less developed countries. The study included 1177 RCTs in 82 Cochrane Systematic reviews (CSRs) and evaluated interventions for adults with hypertension, diabetes, stroke, or heart diseases. Multivariate logistic regression analyses were conducted to explore factors associated with risk of bias in included RCTs. We found that 78.2% of RCTs of interventions for major NCDs recruited patients in high-income countries. The number of RCTs included in the CSRs was increasing over time, and the increasing speed was more noticeable for RCTs conducted in middle-income countries. RCTs conducted in less developed countries tended to be more recently published, less likely to be published in English, with smaller sample sizes, and at a higher risk of bias. In conclusion, there is still a lack of research evidence for control of NCDs in less developed countries. To brace for rising NCDs and avoid waste of scarce research resources, not only more but also higher quality clinical trials are required in low-and-middle-income countries.
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Affiliation(s)
- Hong Fan
- Department of Social Medicine and Health Education, School of Public Health, Nanjing Medical University, Nanjing, P.R. China
| | - Fujian Song
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, U.K
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Burns TC, Verfaillie CM. From mice to mind: Strategies and progress in translating neuroregeneration. Eur J Pharmacol 2015; 759:90-100. [PMID: 25814255 DOI: 10.1016/j.ejphar.2015.03.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/18/2015] [Accepted: 03/12/2015] [Indexed: 12/20/2022]
Abstract
Decisions about what experimental therapies are advanced to clinical trials are based almost exclusively on findings in preclinical animal studies. Over the past 30 years, animal models have forecast the success of hundreds of neuroprotective pharmacological therapies for stroke, Alzheimer׳s disease, spinal cord injury, traumatic brain injury and amyotrophic lateral sclerosis. Yet almost without exception, all have failed. Rapid advances in stem cell technologies have raised new hopes that these neurological diseases may one day be treatable. Still, how can neuroregenerative therapies be translated into clinical realities if available animal models are such poor surrogates of human disease? To address this question we discuss human and rodent neurogenesis, evaluate mechanisms of action for cellular therapies and describe progress in translating neuroregeneration to date. We conclude that not only are appropriate animal models critical to the development of safe and effective therapies, but that the multiple mechanisms of stem cell-mediated therapies may be particularly well suited to the mechanistically diverse nature of central nervous system diseases in mice and man.
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Affiliation(s)
- Terry C Burns
- Department of Neurosurgery and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, USA.
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Beom J, Kim W, Han TR, Seo KS, Oh BM. Concurrent use of granulocyte-colony stimulating factor with repetitive transcranial magnetic stimulation did not enhance recovery of function in the early subacute stroke in rats. Neurol Sci 2014; 36:771-7. [PMID: 25528461 DOI: 10.1007/s10072-014-2046-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 12/15/2014] [Indexed: 11/28/2022]
Abstract
We investigated the additive effect of repetitive transcranial magnetic stimulation (rTMS) combined with granulocyte-colony stimulating factor (G-CSF) on functional outcome in the early subacute phase of stroke. Seven-week-old male rats were subjected to permanent middle cerebral artery occlusion (MCAo) and were divided into four groups: normal saline administration with sham rTMS (group 1, n = 15), G-CSF administration with sham rTMS (group 2, n = 15), G-CSF with 1 Hz rTMS (group 3, n = 14), and G-CSF with 20 Hz rTMS (group 4, n = 15). Animals received G-CSF or saline for 5 days from the day of MCAo and were concurrently treated with 20-min rTMS on their lesioned hemisphere for 2 weeks. Neurological functional score was worse in group 4 compared to that in group 2 on day 15. In Western blots conducted on day 25, phosphorylation of endothelial nitric oxide synthase was markedly lower in groups 2, 3, and 4 than that in group 1 in the ischemic border zone. PECAM-1 expression at ischemic core was lower in groups 4 than in group 2. Caspase-3 expression was markedly higher in groups 4 than in group 1, 2, 3 at ischemic core. Iba1 expression was higher in groups 4 than in group 1, 2 at ischemic core. G-CSF combined with rTMS administered in the early subacute phase of ischemic stroke may exert a hazardous effect on functional recovery, possibly due to impaired angiogenic mechanism, decreased cell survival, and increased inflammation.
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Affiliation(s)
- Jaewon Beom
- Department of Rehabilitation Medicine, Chungnam National University Hospital, Daejeon, 301-721, Republic of Korea
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Detante O, Jaillard A, Moisan A, Barbieux M, Favre I, Garambois K, Hommel M, Remy C. Biotherapies in stroke. Rev Neurol (Paris) 2014; 170:779-98. [DOI: 10.1016/j.neurol.2014.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 09/29/2014] [Accepted: 10/08/2014] [Indexed: 12/31/2022]
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Gautier S, Ouk T, Tagzirt M, Lefebvre C, Laprais M, Pétrault O, Dupont A, Leys D, Bordet R. Impact of the neutrophil response to granulocyte colony-stimulating factor on the risk of hemorrhage when used in combination with tissue plasminogen activator during the acute phase of experimental stroke. J Neuroinflammation 2014; 11:96. [PMID: 24885160 PMCID: PMC4059099 DOI: 10.1186/1742-2094-11-96] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 05/13/2014] [Indexed: 01/06/2023] Open
Abstract
Background Granulocyte colony-stimulating factor (G-CSF) is a pharmacologic agent inducing neutrophil mobilization and a new candidate for neuroprotection and neuroregeneration in stroke. Its effects when used in combination with tissue plasminogen activator (tPA) were explored during the acute phase of ischemic stroke. Methods We used a middle cerebral artery occlusion (MCAO) model of cerebral ischemia, associated with treatment with tPA, in male spontaneously hypertensive rats (SHR). Granulocyte colony-stimulating factor (G-CSF; 60 μg/kg) was injected just before tPA. Neutrophil response in peripheral blood and in the infarct area was quantified in parallel to the infarct volume. Protease matrix metallopeptidase 9 (MMP-9) release from circulating neutrophils was analyzed by immunochemistry and zymography. Vascular reactivity and hemorrhagic volume in the infarct area was also assessed. Results Twenty four hours after ischemia and tPA, G-CSF administration induced a significant increase of neutrophils in peripheral blood (P <0.05). At 72 hours post-ischemia, G-CSF was significantly associated with an increased risk of hemorrhage in the infarct area (2.5 times more likely; P <0.05) and significant cerebral endothelium-dependent dysfunction. Ex vivo, an increased MMP-9 release from neutrophils after tPA administration correlated to the increased hemorrhagic risk (P <0.05). In parallel, G-CSF administration was associated with a decreased neutrophil infiltration in the infarct area (-50%; P <0.05), with a concomitant significant neuroprotective effect (infarct volume: -40%; P <0.05). Conclusions We demonstrate that G-CSF potentiates the risk of hemorrhage in experimental stroke when used in combination with tPA by inducing neutrophilia. This effect is concomitant to an increased MMP-9 release from peripheral neutrophils induced by the tPA treatment. These results highlight the potential hemorrhagic risk of associating G-CSF to thrombolysis during the acute phase of stroke.
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Affiliation(s)
- Sophie Gautier
- EA 1046 - Département de Pharmacologie médicale, Université de Lille 2 - Faculté de Médecine, 1 place de Verdun, Lille cedex F-59037, France.
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Acosta SA, Tajiri N, Shinozuka K, Ishikawa H, Sanberg PR, Sanchez-Ramos J, Song S, Kaneko Y, Borlongan CV. Combination therapy of human umbilical cord blood cells and granulocyte colony stimulating factor reduces histopathological and motor impairments in an experimental model of chronic traumatic brain injury. PLoS One 2014; 9:e90953. [PMID: 24621603 PMCID: PMC3951247 DOI: 10.1371/journal.pone.0090953] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 02/06/2014] [Indexed: 01/09/2023] Open
Abstract
Traumatic brain injury (TBI) is associated with neuro-inflammation, debilitating sensory-motor deficits, and learning and memory impairments. Cell-based therapies are currently being investigated in treating neurotrauma due to their ability to secrete neurotrophic factors and anti-inflammatory cytokines that can regulate the hostile milieu associated with chronic neuroinflammation found in TBI. In tandem, the stimulation and mobilization of endogenous stem/progenitor cells from the bone marrow through granulocyte colony stimulating factor (G-CSF) poses as an attractive therapeutic intervention for chronic TBI. Here, we tested the potential of a combined therapy of human umbilical cord blood cells (hUCB) and G-CSF at the acute stage of TBI to counteract the progressive secondary effects of chronic TBI using the controlled cortical impact model. Four different groups of adult Sprague Dawley rats were treated with saline alone, G-CSF+saline, hUCB+saline or hUCB+G-CSF, 7-days post CCI moderate TBI. Eight weeks after TBI, brains were harvested to analyze hippocampal cell loss, neuroinflammatory response, and neurogenesis by using immunohistochemical techniques. Results revealed that the rats exposed to TBI treated with saline exhibited widespread neuroinflammation, impaired endogenous neurogenesis in DG and SVZ, and severe hippocampal cell loss. hUCB monotherapy suppressed neuroinflammation, nearly normalized the neurogenesis, and reduced hippocampal cell loss compared to saline alone. G-CSF monotherapy produced partial and short-lived benefits characterized by low levels of neuroinflammation in striatum, DG, SVZ, and corpus callosum and fornix, a modest neurogenesis, and a moderate reduction of hippocampal cells loss. On the other hand, combined therapy of hUCB+G-CSF displayed synergistic effects that robustly dampened neuroinflammation, while enhancing endogenous neurogenesis and reducing hippocampal cell loss. Vigorous and long-lasting recovery of motor function accompanied the combined therapy, which was either moderately or short-lived in the monotherapy conditions. These results suggest that combined treatment rather than monotherapy appears optimal for abrogating histophalogical and motor impairments in chronic TBI.
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Affiliation(s)
- Sandra A. Acosta
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, United States of America
| | - Naoki Tajiri
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, United States of America
| | - Kazutaka Shinozuka
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, United States of America
| | - Hiroto Ishikawa
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, United States of America
| | - Paul R. Sanberg
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, United States of America
- Office of Research and Innovation, University of South Florida, Tampa, Florida, United States of America
| | - Juan Sanchez-Ramos
- James Haley Veterans Affairs Medical Center, Tampa, Florida, United States of America
- Department of Neurology, University of South Florida, Tampa, Florida, United States of America
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida, United States of America
| | - Shijie Song
- James Haley Veterans Affairs Medical Center, Tampa, Florida, United States of America
- Department of Neurology, University of South Florida, Tampa, Florida, United States of America
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida, United States of America
| | - Yuji Kaneko
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, United States of America
| | - Cesar V. Borlongan
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, United States of America
- * E-mail:
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