Fast neuroprotection (fast-NPRX) for acute ischemic stroke victims: the time for treatment is now

Improvements in Gulf War Illness Symptoms After Near-Infrared Transcranial and Intranasal Photobiomodulation: Two Case Reports

At least one-fourth of US veterans who served in the 1990-1991 Gulf War (GW) are affected by the chronic symptomatic illness known as Gulf War illness (GWI). This condition typically includes some combination of fatigue, headaches, cognitive dysfunction, musculoskeletal pain, and respiratory, gastrointestinal and dermatologic complaints. To date, effective treatments for GWI have been elusive. Photobiomodulation (PBM) describes the non-pharmacological, non-thermal use of light to stimulate, heal, and protect tissue that has either been injured, is degenerating, or else is at risk of dying. Significant benefits have been reported following application of transcranial PBM to humans with acute stoke, traumatic brain injury (TBI), and dementia. This report describes the first documentation of improved GWI symptoms in two GW veterans following 12 weeks of PBM treatments.

Protective effects of 2-(2-benzonfuranyl)-2-imidazoline combined with tissue plasminogen activator after embolic stroke in rats

Stroke is the third leading cause of death and disability in developing countries. The effective therapy for acute ischemic stroke is thrombolysis with recombinant tissue plasminogen activator (rt-PA) within 4.5 h of stroke onset. An effective post-ischemic neuroprotectant would extend the advantages of rt-PA, and protect against complications of thrombolysis. We previously reported that 2-(2-benzofuranyl)-2-imidazoline (2-BFI), a newly discovered ligand for high-affinity type 2 imidazoline receptor (I2R), provides neuroprotection against ischemic stroke in rats. Here we investigated the protective effects of 2-BFI in combination with delayed intravenous rt-PA after stroke induced by embolic middle cerebral artery occlusion (eMCAO) in rats. Infarct size was determined using 2,3,5-triphenyltrazolium chloride staining, while neurological deficit was assessed based on neurological score. Numbers of apoptotic cells in vivo were estimated using TUNEL stain, and expression of the pro-apoptotic protein BAX and anti-apoptotic protein BCL-2 were quantified by Western blotting. The results showed that 2-BFI (3 mg/kg) administered at 0.5 h after embolic MCAO combined with rt-PA (10 mg/kg) administered at 6 h reduced brain infarct size, mitigated neurological deficit, decreased the number of TUNEL-positive cells, down-regulated BAX expression, and up-regulated BCL-2 expression. These findings suggest that 2-BFI may extend the therapeutic window of rt-PA to 6 h after embolic stroke onset in rats.

Evaluation of the implementation of a 24-hr stroke thrombolysis emergency treatment for patients with acute ischaemic stroke

AIMS AND OBJECTIVES

To assess the trends of intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) among patients with acute ischaemic stroke (AIS) admitted to our hospital between 2012-2014 and investigate the effects of a 24-hr stroke thrombolysis emergency treatment on the intrahospital clinical data and outcomes of these patients treated with IV rt-PA thrombolysis.

BACKGROUND

Although prenotification of stroke by emergency medical services has been endorsed by the national recommendations and implemented in some developed countries, the development in China is limited.

DESIGN

A retrospective, single-centre, observational study.

METHODS

Patients with AIS admitted to our hospital between January 2012-December 2014 were included; those who received IV rt-PA thrombolysis within 4.5 hr of onset were investigated. Demographic characteristics, including age and sex, and clinical data and outcomes, including onset-to-treatment time (OTT), door-to-needle time (DNT), premorbid modified Rankin Scale score and proportion of patients treated per year, were all recorded.

RESULTS

The proportion of patients with AIS who received thrombolytic therapy within 4.5 hr increased from 2012-2014. The baseline characteristics of all patients were similar. Since the implementation of 24-hr stroke thrombolysis emergency treatment in 2013, the median DNT significantly decreased in 2014 after implementation (42 min) compared with that in 2012 before implementation (81 min) (p < .05). Moreover, the admission-to-imaging time (37 vs. 33 vs. 36 min) and OTT (176 vs. 147 vs. 124 min) significantly decreased during the 3 years (p < .05).

CONCLUSIONS

The 24-hr stroke thrombolysis emergency treatment reduced in-hospital delay before thrombolytic therapy but had no effect on the functional outcomes of the patients with AIS.

RELEVANCE TO CLINICAL PRACTICE

This study provides opportunities to improve the experiences in using 24-h stroke thrombolysis emergency treatment in patients with AIS in clinical practice.

The High Cost of Stroke and Stroke Cytoprotection Research

Acute ischemic stroke is inadequately treated in the USA and worldwide due to a lengthy history of neuroprotective drug failures in clinical trials. The majority of victims must endure life-long disabilities that not only affect their livelihood, but also have an enormous societal economic impact. The rapid development of a neuroprotective or cytoprotective compound would allow future stroke victims to receive a treatment to reduce disabilities and further promote recovery of function. This opinion article reviews in detail the enormous costs associated with developing a small molecule to treat stroke, as well as providing a timely overview of the cell-death time-course and relationship to the ischemic cascade. Distinct temporal patterns of cell-death of neurovascular unit components provide opportunities to intervene and optimize new cytoprotective strategies. However, adequate research funding is mandatory to allow stroke researchers to develop and test their novel therapeutic approach to treat stroke victims.

Shining light on the head: Photobiomodulation for brain disorders

Photobiomodulation (PBM) describes the use of red or near-infrared light to stimulate, heal, regenerate, and protect tissue that has either been injured, is degenerating, or else is at risk of dying. One of the organ systems of the human body that is most necessary to life, and whose optimum functioning is most worried about by humankind in general, is the brain. The brain suffers from many different disorders that can be classified into three broad groupings: traumatic events (stroke, traumatic brain injury, and global ischemia), degenerative diseases (dementia, Alzheimer's and Parkinson's), and psychiatric disorders (depression, anxiety, post traumatic stress disorder). There is some evidence that all these seemingly diverse conditions can be beneficially affected by applying light to the head. There is even the possibility that PBM could be used for cognitive enhancement in normal healthy people. In this transcranial PBM (tPBM) application, near-infrared (NIR) light is often applied to the forehead because of the better penetration (no hair, longer wavelength). Some workers have used lasers, but recently the introduction of inexpensive light emitting diode (LED) arrays has allowed the development of light emitting helmets or "brain caps". This review will cover the mechanisms of action of photobiomodulation to the brain, and summarize some of the key pre-clinical studies and clinical trials that have been undertaken for diverse brain disorders.

G-CSF attenuates neuroinflammation and stabilizes the blood-brain barrier via the PI3K/Akt/GSK-3β signaling pathway following neonatal hypoxia-ischemia in rats

OBJECTIVE

Neonatal hypoxia occurs in approximately 60% of premature births and is associated with a multitude of neurological disorders. While various treatments have been developed, translating them from bench to bedside has been limited. We previously showed G-CSF administration was neuroprotective in a neonatal hypoxia-ischemia rat pup model, leading us to hypothesize that G-CSF inactivation of GSK-3β via the PI3K/Akt pathway may attenuate neuroinflammation and stabilize the blood-brain barrier (BBB).

METHODS

P10 Sprague-Dawley rat pups were subjected to unilateral carotid artery ligation followed by hypoxia for 2.5h. We assessed inflammation by measuring expression levels of IKKβ, NF-κB, TNF-α, IL-1β, IL-10, and IL-12 as well as neutrophil infiltration. BBB stabilization was evaluated by measuring Evans blue extravasation, and Western blot analysis of Claudin-3, Claudin-5, ICAM-1, and VCAM-1.

MEASUREMENTS AND MAIN RESULTS

First, the time course study showed that p-β-catenin/β-catenin, IKKβ, and NF-κB expression levels peaked at 48h post-HI. The knockdown of GSK-3β with siRNA prevented the HI-induced increase of p-β-catenin/β-catenin, IKKβ, and NF-κB expression levels 48h after HI. G-CSF treatment reduced brain water content and neuroinflammation by downregulating IKKβ, NF-κB, TNF-α, IL-1β, and IL-12 and upregulating IL-10, thereby reducing neutrophil infiltration. Additionally, G-CSF stabilizes the BBB by downregulating VCAM-1 and ICAM-1, as well as upregulating Claudins 3 and 5 in endothelial cells. G-CSFR knockdown by siRNA and Akt inhibition by Wortmannin reversed G-CSF's neuroprotective effects.

CONCLUSIONS

We demonstrate G-CSF plays a pivotal role in attenuating neuroinflammation and BBB disruption following HI by inactivating GSK-3β through the PI3K/Akt pathway.

Critical early thrombolytic and endovascular reperfusion therapy for acute ischemic stroke victims: a call for adjunct neuroprotection

Today, there is an enormous amount of excitement in the field of stroke victim care due to the recent success of MR. CLEAN, SWIFT PRIME, ESCAPE, EXTEND-IA, and REVASCAT endovascular trials. Successful intravenous (IV) recombinant tissue plasminogen activator (rt-PA) clinical trials [i.e., National Institute of Neurological Disorders and Stroke (NINDS) rt-PA trial, Third European Cooperative Acute Stroke Study (ECASSIII), and Third International Stroke study (IST-3)] also need to be emphasized. In the recent endovascular and thrombolytic trials, there is statistically significant improvement using both the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Score (mRS) scale, but neither approach promotes complete recovery in patients enrolled within any particular NIHSS or mRS score tier. Absolute improvement (mRS 0-2 at 90 days) with endovascular therapy is 13.5-31 %, whereas thrombolytics alone also significantly improve patient functional independence, but to a lesser degree (NINDS rt-PA trial 13 %). This article has 3 main goals: (1) first to emphasize the utility and cost-effectiveness of rt-PA to treat stroke; (2) second to review the recent endovascular trials with respect to efficacy, safety, and cost-effectiveness as a stroke treatment; and (3) to further consider and evaluate strategies to develop novel neuroprotective drugs. A thesis will be put forth so that future stroke trials and therapy development can optimally promote recovery so that stroke victims can return to "normal" life.

An Outcome Model for Intravenous rt-PA in Acute Ischemic Stroke

Most early phase trials in stroke and brain trauma have failed in phase 3, including efforts to improve acute ischemic stroke outcomes beyond that achieved by intravenous recombinant tissue plasminogen activator (t-PA) (IVT). With the exception of more recent stent retriever trials, most subsequent phase 3 trials failed. We previously showed that baseline imbalances, non-linear relationships of these factors to outcome, and unrepresentative control populations invalidate traditional statistical analysis in early trials of heterogeneous diseases such as stroke. We developed an alternative approach using a pooled outcome model derived from control arms of randomized clinical trial (RCTs). This model then permits comparing treatment trials to an expected outcome of a pooled population. Here, we hypothesized we could develop such a model for IVT and tested it against outcomes without IVT. We surveyed literature for all trials involving one arm with IVT reporting baseline National Institute Stroke Scale (NIHSS), age, and outcome. A non-linear fit was performed including multi-dimensional statistical intervals (±95 %) permitting visual comparison of outcomes at their own baselines. We compared models derived from non-IVT control arms. Models from 24 IVT RCTs representing 3195 subjects were successfully generated for functional outcome, modified Rankin Scale (mRS) 0-2 (r(2) = 0. 83, p < 0.001), and mortality (r(2) = 0.54; p = 0.001). We confirmed better outcomes compared to no IVT and mixed use IVT models across the range of baseline factors. It was possible to generate an expected outcome model for IVT from existing literature. We confirmed benefit compared to placebo. This model should be useful to compare to new agents without the need for statistical manipulation.

Effect of the Pleiotropic Drug CNB-001 on Tissue Plasminogen Activator (tPA) Protease Activity in vitro: Support for Combination Therapy to Treat Acute Ischemic Stroke

Current state-of-the-art acute ischemic stroke clinical trials are designed to study neuroprotectants when administered following thrombolysis; tissue plasminogen activator (tPA) is administered to patients within 3-4.5 hours of an ischemic event. Thus, in order to develop a novel neuroprotectant and move it forward to a clinical trial, it is important to assess the effects of the drug on tPA's proteolytic activity in vitro, prior to extensive in vivo analysis. In this study, we determined if CNB-001 [4-((1E)-2-(5-(4-hydroxy-3-methoxystyryl-)-1-phenyl-1H-pyrazoyl-3-yl)vinyl)-2-methoxy-phenol)], would affect, either enhance or inhibit tPA activity in vitro. In this tPA-inhibitor (plasminogen activator inhibitor-1; PAI-1 and 2,7-Bis-(4-Amidinobenzylidene)-Cycloheptan-1-One Dihydrochloride; tPA stop) controlled study, we used a chromogenic substrate (CH3SO2-D-hexahydrotyrosine-Gly-Arg-p-nitroanilide•AcOH) to study drug interactions in vitro, spectrophotometrically measuring protease released p-Nitroaniline from the substrate. We found that PAI-1 (0.25 μM) and tPA stop (5 μM) significantly (p<0.0001) inhibited substrate release, by 98.6% and 83.4%, respectively, thus inhibiting tPA activity in vitro. In comparison, CNB-001 (0.7-7 μM) reduced tPA activity by 28-32%, with an extrapolated IC50 value of 65.2-704 μM. Thus, although high concentrations of CNB-001 does affects tPA activity in vitro, the study supports the use of CNB-001 in combination with tPA to treat stroke, However, CNB-001 should be administered following thrombolysis to promote neuroprotection and repair.

Vascular neural network: the importance of vein drainage in stroke

This perspective commentary summarized the stroke pathophysiology evolution, especially the focus in the past on neuroprotection and neurovascular protection and highlighted the newer term for stroke pathophysiology: vascular neural network. Emphasis is on the role of venules and veins after an acute stroke and as potential treatment targets. Vein drainage may contribute to the acute phase of brain edema and the outcomes of stroke patients.