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Jia J, Jiao W, Wang G, Wu J, Huang Z, Zhang Y. Drugs/agents for the treatment of ischemic stroke: Advances and perspectives. Med Res Rev 2024; 44:975-1012. [PMID: 38126568 DOI: 10.1002/med.22009] [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: 07/13/2023] [Revised: 11/20/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
Ischemic stroke (IS) poses a significant threat to global human health and life. In recent decades, we have witnessed unprecedented progresses against IS, including thrombolysis, thrombectomy, and a few medicines that can assist in reopening the blocked brain vessels or serve as standalone treatments for patients who are not eligible for thrombolysis/thrombectomy therapies. However, the narrow time windows of thrombolysis/thrombectomy, coupled with the risk of hemorrhagic transformation, as well as the lack of highly effective and safe medications, continue to present big challenges in the acute treatment and long-term recovery of IS. In the past 3 years, several excellent articles have reviewed pathophysiology of IS and therapeutic medicines for the treatment of IS based on the pathophysiology. Regretfully, there is no comprehensive overview to summarize all categories of anti-IS drugs/agents designed and synthesized based on molecular mechanisms of IS pathophysiology. From medicinal chemistry view of point, this article reviews a multitude of anti-IS drugs/agents, including small molecule compounds, natural products, peptides, and others, which have been developed based on the molecular mechanism of IS pathophysiology, such as excitotoxicity, oxidative/nitrosative stresses, cell death pathways, and neuroinflammation, and so forth. In addition, several emerging medicines and strategies, including nanomedicines, stem cell therapy and noncoding RNAs, which recently appeared for the treatment of IS, are shortly introduced. Finally, the perspectives on the associated challenges and future directions of anti-IS drugs/agents are briefly provided to move the field forward.
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Affiliation(s)
- Jian Jia
- State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Drug Discovery for Metabolic Diseases, Center of Drug Discovery, China Pharmaceutical University, Nanjing, China
- Novel Technology Center of Pharmaceutical Chemistry, Shanghai Institute of Pharmaceutical Industry Co., Ltd., China State Institute of Pharmaceutical Industry, Shanghai, China
| | - Weijie Jiao
- State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Drug Discovery for Metabolic Diseases, Center of Drug Discovery, China Pharmaceutical University, Nanjing, China
| | - Guan Wang
- Novel Technology Center of Pharmaceutical Chemistry, Shanghai Institute of Pharmaceutical Industry Co., Ltd., China State Institute of Pharmaceutical Industry, Shanghai, China
| | - Jianbing Wu
- State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Drug Discovery for Metabolic Diseases, Center of Drug Discovery, China Pharmaceutical University, Nanjing, China
| | - Zhangjian Huang
- State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Drug Discovery for Metabolic Diseases, Center of Drug Discovery, China Pharmaceutical University, Nanjing, China
| | - Yihua Zhang
- State Key Laboratory of Natural Medicines, Jiangsu Key Laboratory of Drug Discovery for Metabolic Diseases, Center of Drug Discovery, China Pharmaceutical University, Nanjing, China
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2
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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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3
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Na S, Ko Y, Ham SJ, Sung YS, Kim MH, Shin Y, Jung SC, Ju C, Kim BS, Yoon K, Kim KW. Sequence-Type Classification of Brain MRI for Acute Stroke Using a Self-Supervised Machine Learning Algorithm. Diagnostics (Basel) 2023; 14:70. [PMID: 38201379 PMCID: PMC10804387 DOI: 10.3390/diagnostics14010070] [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: 11/21/2023] [Revised: 12/18/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
We propose a self-supervised machine learning (ML) algorithm for sequence-type classification of brain MRI using a supervisory signal from DICOM metadata (i.e., a rule-based virtual label). A total of 1787 brain MRI datasets were constructed, including 1531 from hospitals and 256 from multi-center trial datasets. The ground truth (GT) was generated by two experienced image analysts and checked by a radiologist. An ML framework called ImageSort-net was developed using various features related to MRI acquisition parameters and used for training virtual labels and ML algorithms derived from rule-based labeling systems that act as labels for supervised learning. For the performance evaluation of ImageSort-net (MLvirtual), we compare and analyze the performances of models trained with human expert labels (MLhumans), using as a test set blank data that the rule-based labeling system failed to infer from each dataset. The performance of ImageSort-net (MLvirtual) was comparable to that of MLhuman (98.5% and 99%, respectively) in terms of overall accuracy when trained with hospital datasets. When trained with a relatively small multi-center trial dataset, the overall accuracy was relatively lower than that of MLhuman (95.6% and 99.4%, respectively). After integrating the two datasets and re-training them, MLvirtual showed higher accuracy than MLvirtual trained only on multi-center datasets (95.6% and 99.7%, respectively). Additionally, the multi-center dataset inference performances after the re-training of MLvirtual and MLhumans were identical (99.7%). Training of ML algorithms based on rule-based virtual labels achieved high accuracy for sequence-type classification of brain MRI and enabled us to build a sustainable self-learning system.
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Affiliation(s)
- Seongwon Na
- Department of Computer Science and Engineering, Konkuk University, Seoul 05029, Republic of Korea;
- Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Yousun Ko
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; (Y.K.)
| | - Su Jung Ham
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; (Y.K.)
| | - Yu Sub Sung
- Clinical Research Center, Asan Medical Center, Seoul 05505, Republic of Korea
- Department of Convergence Medicine, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Mi-Hyun Kim
- Trialinformatics Inc., Seoul 05505, Republic of Korea
- Department of Radiation Science & Technology, Jeonbuk National University, Jeonju 56212, Republic of Korea
| | - Youngbin Shin
- Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Seung Chai Jung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; (Y.K.)
| | - Chung Ju
- Shin Poong Pharm. Co., Ltd., Seoul 06246, Republic of Korea
- Graduate School of Clinical Pharmacy, CHA University, Pocheon-si 11160, Republic of Korea
| | - Byung Su Kim
- Shin Poong Pharm. Co., Ltd., Seoul 06246, Republic of Korea
| | - Kyoungro Yoon
- Department of Computer Science and Engineering, Konkuk University, Seoul 05029, Republic of Korea;
- Department of Smart ICT Convergence Engineering, Konkuk University, Seoul 05029, Republic of Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; (Y.K.)
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Babenko VA, Fedulova KS, Silachev DN, Rahimi-Moghaddam P, Kalyuzhnaya YN, Demyanenko SV, Plotnikov EY. The Role of Matrix Metalloproteinases in Hemorrhagic Transformation in the Treatment of Stroke with Tissue Plasminogen Activator. J Pers Med 2023; 13:1175. [PMID: 37511788 PMCID: PMC10381732 DOI: 10.3390/jpm13071175] [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: 06/17/2023] [Revised: 07/15/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
Ischemic stroke is a leading cause of disability and mortality worldwide. The only approved treatment for ischemic stroke is thrombolytic therapy with tissue plasminogen activator (tPA), though this approach often leads to a severe complication: hemorrhagic transformation (HT). The pathophysiology of HT in response to tPA is complex and not fully understood. However, numerous scientific findings suggest that the enzymatic activity and expression of matrix metalloproteinases (MMPs) in brain tissue play a crucial role. In this review article, we summarize the current knowledge of the functioning of various MMPs at different stages of ischemic stroke development and their association with HT. We also discuss the mechanisms that underlie the effect of tPA on MMPs as the main cause of the adverse effects of thrombolytic therapy. Finally, we describe recent research that aimed to develop new strategies to modulate MMP activity to improve the efficacy of thrombolytic therapy. The ultimate goal is to provide more targeted and personalized treatment options for patients with ischemic stroke to minimize complications and improve clinical outcomes.
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Affiliation(s)
- Valentina A Babenko
- Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia
| | - Ksenia S Fedulova
- Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia
| | - Denis N Silachev
- Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia
| | - Parvaneh Rahimi-Moghaddam
- Department of Pharmacology, School of Medicine, Iran University of Medical Sciences, Tehran 14496-14535, Iran
| | - Yulia N Kalyuzhnaya
- Academy of Biology and Biotechnology, Southern Federal University, 344090 Rostov-on-Don, Russia
| | - Svetlana V Demyanenko
- Academy of Biology and Biotechnology, Southern Federal University, 344090 Rostov-on-Don, Russia
| | - Egor Y Plotnikov
- Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia
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Okonkwo ON, Agweye CT, Akanbi T. Neuroprotection for Nonarteritic Central Retinal Artery Occlusion: Lessons from Acute Ischemic Stroke. Clin Ophthalmol 2023; 17:1531-1543. [PMID: 37284058 PMCID: PMC10239763 DOI: 10.2147/opth.s403433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/19/2023] [Indexed: 06/08/2023] Open
Abstract
Nonarteritic central retinal artery occlusion (NA-CRAO) is a variant of acute ischemic stroke (AIS) and is a cause of sudden severe loss of vision. There are guidelines by the American Heart Association and the American Stroke Association for the care of CRAO patients. This review explores the basis of retinal neuroprotection for CRAO and its potential for improving the outcome of NA-CRAO. Recently, there have been significant advances in research into the use of neuroprotection to treat retinal diseases, including retinal detachment, age-related macular degeneration, and inherited retinal diseases. Also, neuroprotective research in AIS has been extensive, and newer drugs tested, including Uric acid, Nerinetide, and Otaplimastat, with promising results. Progress in cerebral neuroprotection after AIS offers hope for retinal neuroprotection after CRAO; and a possibility of extrapolating research findings from AIS into CRAO. Combining neuroprotection and thrombolysis can extend the therapeutic window for NA-CRAO treatment and potentially improve outcomes. Experimented neuroprotection for CRAO includes Angiopoietin (Comp Ang1), KUS 121, Gene therapy (XIAP), and hypothermia. Efforts in the field of neuroprotection for NA-CRAO should focus on better imaging to delineate the penumbra after an acute episode of NA-CRAO (using a combination of high-definition optical coherence angiography and electrophysiology). Also, research should explore details of pathophysiologic mechanisms involved in NA-CRAO, allowing for further neuroprotective intervention, and closing the gap between preclinical and clinical neuroprotection.
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Affiliation(s)
- Ogugua Ndubuisi Okonkwo
- Department of Ophthalmology, Eye Foundation Hospital and Eye Foundation Retina Institute, Ikeja, Lagos, Nigeria
| | - Chineze Thelma Agweye
- Department of Ophthalmology, University of Calabar and University of Calabar Teaching Hospital, Cross River, Nigeria
| | - Toyin Akanbi
- Department of Ophthalmology, Eye Foundation Hospital and Eye Foundation Retina Institute, Ikeja, Lagos, Nigeria
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Thrombolysis for acute ischaemic stroke: current status and future perspectives. Lancet Neurol 2023; 22:418-429. [PMID: 36907201 DOI: 10.1016/s1474-4422(22)00519-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 03/14/2023]
Abstract
Alteplase is currently the only approved thrombolytic agent for treatment of acute ischaemic stroke, but interest is burgeoning in the development of new thrombolytic agents for systemic reperfusion with an improved safety profile, increased efficacy, and convenient delivery. Tenecteplase has emerged as a potential alternative thrombolytic agent that might be preferred over alteplase because of its ease of administration and reported efficacy in patients with large vessel occlusion. Ongoing research efforts are also looking at potential improvements in recanalisation with the use of adjunct therapies to intravenous thrombolysis. New treatment strategies are also emerging that aim to reduce the risk of vessel reocclusion after intravenous thrombolysis administration. Other research endeavors are looking at the use of intra-arterial thrombolysis after mechanical thrombectomy to induce tissue reperfusion. The growing implementation of mobile stroke units and advanced neuroimaging could boost the number of patients who can receive intravenous thrombolysis by shortening onset-to-treatment times and identifying patients with salvageable penumbra. Continued improvements in this area will be essential to facilitate the ongoing research endeavors and to improve delivery of new interventions.
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Mechtouff L, Eker OF, Nighoghossian N, Cho TH. Fisiopatologia dell’ischemia cerebrale. Neurologia 2022. [DOI: 10.1016/s1634-7072(22)46428-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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8
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Vos EM, Geraedts VJ, van der Lugt A, Dippel DWJ, Wermer MJH, Hofmeijer J, van Es ACGM, Roos YBWEM, Peeters-Scholte CMPCD, van den Wijngaard IR. Systematic Review - Combining Neuroprotection With Reperfusion in Acute Ischemic Stroke. Front Neurol 2022; 13:840892. [PMID: 35370911 PMCID: PMC8969766 DOI: 10.3389/fneur.2022.840892] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/17/2022] [Indexed: 12/22/2022] Open
Abstract
Background Clinical trials of neuroprotection in acute ischemic stroke (AIS) have provided disappointing results. Reperfusion may be a necessary condition for positive effects of neuroprotective treatments. This systematic review provides an overview of efficacy of neuroprotective agents in combination with reperfusion therapy in AIS. Methods A literature search was performed on the following databases, namely PubMed, Embase, Web of Science, Cochrane Library, Emcare. All databases were searched up to September 23rd 2021. All randomized controlled trials in which patients were treated with neuroprotective strategies within 12 h of stroke onset in combination with intravenous thrombolysis (IVT), endovascular therapy (EVT), or both were included. Results We screened 1,764 titles/abstracts and included 30 full reports of unique studies with a total of 16,160 patients. In 15 studies neuroprotectants were tested for clinical efficacy, where all patients had to receive reperfusion therapies, either IVT and/or EVT. Heterogeneity in reported outcome measures was observed. Treatment was associated with improved clinical outcome for: 1) uric acid in patients treated with EVT and IVT, 2) nerinetide in patients who underwent EVT without IVT, 3) imatinib in stroke patients treated with IVT with or without EVT, 4) remote ischemic perconditioning and IVT, and 5) high-flow normobaric oxygen treatment after EVT, with or without IVT. Conclusion Studies specifically testing effects of neuroprotective agents in addition to IVT and/or EVT are scarce. Future neuroprotection studies should report standardized functional outcome measures and combine neuroprotective agents with reperfusion therapies in AIS or aim to include prespecified subgroup analyses for treatment with IVT and/or EVT.
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Affiliation(s)
- E. M. Vos
- Department of Neurology, The Hague Medical Center, The Hague, Netherlands
- *Correspondence: E. M. Vos
| | - V. J. Geraedts
- Department of Neurology, The Hague Medical Center, The Hague, Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - A. van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - D. W. J. Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - M. J. H. Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - J. Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
- Department of Clinical Neurophysiology, Technical Medical Centre, University of Twente, Enschede, Netherlands
| | - A. C. G. M. van Es
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Radiology, The Hague Medical Center, The Hague, Netherlands
| | - Y. B. W. E. M. Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | | | - I. R. van den Wijngaard
- Department of Neurology, The Hague Medical Center, The Hague, Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
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Frisullo G, Bellavia S, Scala I, Rizzo P, Broccolini A, Brunetti V, Pepe M, Pilato F, Morosetti R, Marca GD, Calabresi P. Cerebral edema in acute stroke: Effect of thrombolytic treatment. J Neurol Sci 2022; 436:120206. [DOI: 10.1016/j.jns.2022.120206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/27/2022] [Accepted: 02/20/2022] [Indexed: 11/29/2022]
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The Quinazoline Otaplimastat (SP-8203) Reduces the Hemorrhagic Transformation and Mortality Aggravated after Delayed rtPA-Induced Thrombolysis in Cerebral Ischemia. Int J Mol Sci 2022; 23:ijms23031403. [PMID: 35163322 PMCID: PMC8835804 DOI: 10.3390/ijms23031403] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/24/2022] [Indexed: 02/01/2023] Open
Abstract
Acute ischemic stroke is the leading cause of morbidity and mortality worldwide. Recombinant tissue plasminogen activator (rtPA) is the only agent clinically approved by FDA for patients with acute ischemic stroke. However, delayed treatment of rtPA (e.g., more than 3 h after stroke onset) exacerbates ischemic brain damage by causing intracerebral hemorrhage and increasing neurotoxicity. In the present study, we investigated whether the neuroprotant otaplimastat reduced delayed rtPA treatment-evoked neurotoxicity in male Sprague Dawley rats subjected to embolic middle cerebral artery occlusion (eMCAO). Otaplimastat reduced cerebral infarct size and edema and improved neurobehavioral deficits. In particular, otaplimastat markedly reduced intracerebral hemorrhagic transformation and mortality triggered by delayed rtPA treatment, consequently extending the therapeutic time window of rtPA. We further found that ischemia-evoked extracellular matrix metalloproteases (MMPs) expression was closely correlated with cerebral hemorrhagic transformation and brain damage. In ischemic conditions, delayed rtPA treatment further increased brain injury via synergistic expression of MMPs in vascular endothelial cells. In oxygen-glucose-deprived endothelial cells, otaplimastat suppressed the activity rather than protein expression of MMPs by restoring the level of tissue inhibitor of metalloproteinase (TIMP) suppressed in ischemia, and consequently reduced vascular permeation. This paper shows that otaplimastat under clinical trials is a new drug which can inhibit stroke on its own and extend the therapeutic time window of rtPA, especially when administered in combination with rtPA.
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Spronk E, Sykes G, Falcione S, Munsterman D, Joy T, Kamtchum-Tatuene J, Jickling GC. Hemorrhagic Transformation in Ischemic Stroke and the Role of Inflammation. Front Neurol 2021; 12:661955. [PMID: 34054705 PMCID: PMC8160112 DOI: 10.3389/fneur.2021.661955] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/29/2021] [Indexed: 01/01/2023] Open
Abstract
Hemorrhagic transformation (HT) is a common complication in patients with acute ischemic stroke. It occurs when peripheral blood extravasates across a disrupted blood brain barrier (BBB) into the brain following ischemic stroke. Preventing HT is important as it worsens stroke outcome and increases mortality. Factors associated with increased risk of HT include stroke severity, reperfusion therapy (thrombolysis and thrombectomy), hypertension, hyperglycemia, and age. Inflammation and the immune system are important contributors to BBB disruption and HT and are associated with many of the risk factors for HT. In this review, we present the relationship of inflammation and immune activation to HT in the context of reperfusion therapy, hypertension, hyperglycemia, and age. Differences in inflammatory pathways relating to HT are discussed. The role of inflammation to stratify the risk of HT and therapies targeting the immune system to reduce the risk of HT are presented.
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Affiliation(s)
- Elena Spronk
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Gina Sykes
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sarina Falcione
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Danielle Munsterman
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Twinkle Joy
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Joseph Kamtchum-Tatuene
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Glen C Jickling
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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12
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Chamorro Á, Lo EH, Renú A, van Leyen K, Lyden PD. The future of neuroprotection in stroke. J Neurol Neurosurg Psychiatry 2021; 92:129-135. [PMID: 33148815 DOI: 10.1136/jnnp-2020-324283] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022]
Abstract
Investigators acknowledge the limitations of rodent or non-human primate stroke models, hundreds of putative neuroprotectants have been evaluated in preclinical models, but not one has entered the clinical realm. Initial studies focused on the neuron, but in recent years the focus has widened to also include other neural cells including astrocytes, pericytes and endothelial cells, which together form the neurovascular unit. Some new developments raise renewed hope for neuroprotection: the appearance of new compounds with multiple mechanisms of action, or the promulgation of new standards for a rigorous preclinical testing. At the bedside in the last 5 years, uric acid and nerinetide are the only compounds tested for clinical efficacy in randomised controlled trials (RCTs), where all patients had to receive reperfusion therapies, either intravenous thrombolysis and/or mechanical thrombectomy. In addition, otaplimastat, 3K3A-activated protein C (APC), intra-arterial verapamil and intra-arterial hypothermia were also assessed in combination with reperfusion therapy, but in RCTs that only included feasibility or safety outcomes. Some of these compounds yielded promising results which are discussed in this review. Altogether, a deeper knowledge of the mechanisms involved in the ischaemic death process at the neurovascular unit, an improved preselection and evaluation of drugs at the preclinical stage and the testing of putative neuroprotectants in enriched clinical studies of patients receiving reperfusion therapies, might prove more effective than in the past to reverse a dismal situation that has lasted already too long.
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Affiliation(s)
- Ángel Chamorro
- Neurology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Eng H Lo
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arturo Renú
- Neurology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Klaus van Leyen
- Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Pozdnyakov D, Chernikov M, Sarkisyan K, Rybalko I. Neuroprotective potential of pyrimidine-4-H1-OHa derivatives in experimental cerebral ischemia. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:63-68. [DOI: 10.17116/jnevro202112112163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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14
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Otsu Y, Namekawa M, Toriyabe M, Ninomiya I, Hatakeyama M, Uemura M, Onodera O, Shimohata T, Kanazawa M. Strategies to prevent hemorrhagic transformation after reperfusion therapies for acute ischemic stroke: A literature review. J Neurol Sci 2020; 419:117217. [PMID: 33161301 DOI: 10.1016/j.jns.2020.117217] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/09/2020] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Reperfusion therapies by tissue plasminogen activator (tPA) and mechanical thrombectomy (MT) have ushered in a new era in the treatment of acute ischemic stroke (AIS). However, reperfusion therapy-related HT remains an enigma. AIM To provide a comprehensive review focused on emerging concepts of stroke and therapeutic strategies, including the use of protective agents to prevent HT after reperfusion therapies for AIS. METHODS A literature review was performed using PubMed and the ClinicalTrials.gov database. RESULTS Risk of HT increases with delayed initiation of tPA treatment, higher baseline glucose level, age, stroke severity, episode of transient ischemic attack within 7 days of stroke onset, and hypertension. At a molecular level, HT that develops after thrombolysis is thought to be caused by reactive oxygen species, inflammation, remodeling factor-mediated effects, and tPA toxicity. Modulation of these pathophysiological mechanisms could be a therapeutic strategy to prevent HT after tPA treatment. Clinical mechanisms underlying HT after MT are thought to involve smoking, a low Alberta Stroke Program Early CT Score, use of general anesthesia, unfavorable collaterals, and thromboembolic migration. However, the molecular mechanisms are yet to be fully investigated. Clinical trials with MT and protective agents have also been planned and good outcomes are expected. CONCLUSION To fully utilize the easily accessible drug-tPA-and the high recanalization rate of MT, it is important to reduce bleeding complications after recanalization. A future study direction could be to investigate the recovery of neurological function by combining reperfusion therapies with cell therapies and/or use of pleiotropic protective agents.
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Affiliation(s)
- Yutaka Otsu
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masaki Namekawa
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masafumi Toriyabe
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan; Department of Medical Technology, Graduate School of Health Sciences, Niigata University, Niigata, Japan
| | - Itaru Ninomiya
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masahiro Hatakeyama
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masahiro Uemura
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masato Kanazawa
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan.
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15
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Yeh CY, Schulien AJ, Molyneaux BJ, Aizenman E. Lessons from Recent Advances in Ischemic Stroke Management and Targeting Kv2.1 for Neuroprotection. Int J Mol Sci 2020; 21:ijms21176107. [PMID: 32854248 PMCID: PMC7503403 DOI: 10.3390/ijms21176107] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 12/20/2022] Open
Abstract
Achieving neuroprotection in ischemic stroke patients has been a multidecade medical challenge. Numerous clinical trials were discontinued in futility and many were terminated in response to deleterious treatment effects. Recently, however, several positive reports have generated the much-needed excitement surrounding stroke therapy. In this review, we describe the clinical studies that significantly expanded the time window of eligibility for patients to receive mechanical endovascular thrombectomy. We further summarize the results available thus far for nerinetide, a promising neuroprotective agent for stroke treatment. Lastly, we reflect upon aspects of these impactful trials in our own studies targeting the Kv2.1-mediated cell death pathway in neurons for neuroprotection. We argue that recent changes in the clinical landscape should be adapted by preclinical research in order to continue progressing toward the development of efficacious neuroprotective therapies for ischemic stroke.
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Affiliation(s)
- Chung-Yang Yeh
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (C.-Y.Y.); (A.J.S.)
- Pittsburgh Institute for Neurodegenerative Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA;
| | - Anthony J. Schulien
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (C.-Y.Y.); (A.J.S.)
- Pittsburgh Institute for Neurodegenerative Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA;
| | - Bradley J. Molyneaux
- Pittsburgh Institute for Neurodegenerative Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA;
- UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Elias Aizenman
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (C.-Y.Y.); (A.J.S.)
- Pittsburgh Institute for Neurodegenerative Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA;
- Correspondence:
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