The Advanced Reperfusion Era: Implications for Emergency Systems of Ischemic Stroke Care

Circular RNA circEfnb2 promotes cell injury after cerebral infarction by sponging miR-202-5p and regulating TRAF3 expression

BACKGROUND

Exogenous neural cell transplantation may be therapeutic for stroke, cerebral ischemic injury. Among other mechanisms, increasing findings indicated circular RNAs (circRNAs) regulate the pathogenesis progression of cerebral ischemia. Mmu_circ_0015034 (circEfnb2) was upregulated in focal cortical infarction established by middle cerebral artery occlusion (MCAO) in mice. Our study was designed to probe the molecular mechanism of circEfnb2 in the oxygen-glucose deprivation/reperfusion (OGD/R)-induced neuronal damage in cerebral ischemia.

METHODS

We established an in vitro OGD/R cell model. CircEfnb2 and microRNA-202-5p (miR-202-5p) levels were detected using real-time quantitative polymerase chain reaction (RT-qPCR). Lactate dehydrogenase (LDH), malondialdehyde (MDA), and reactive oxygen species (ROS) levels were assessed using specific kits. Tumor necrosis factor-α (TNF-α) and Interleukin-1β (IL-1β) levels were examined using an Enzyme-linked immunosorbent assay (ELISA). Flow cytometry analysis evaluated cell apoptosis. Protein levels of B-cell lymphoma-2 (Bcl-2), Bcl-2 related X protein (Bax), cleaved caspase 3, and Tumor necrosis factor receptor-associated factor 3 (TRAF3) were determined using Western blot assay.

RESULTS

Overall, circEfnb2 was highly expressed whereas miR-202-5p was decreased in OGD/R-treated mouse hippocampal neuronal HT22 cells compared to normal controls (both p > 0.05). From an in vitro functional perspective, circEfnb2 knockdown attenuated an OGD/R-triggered neuronal injury compared to controls (p > 0.05). Mechanically, circEfnb2 acted as a sponge of miR-202-5p; downregulation of miR-202-5p annulled the inhibitory roles of circEfnb2 silencing in an OGD/R-caused neuronal injury model. Our analysis showed that miR-202-5p directly targeted TRAF3 as enhanced TRAF3 abolished the effects of miR-202-5p in the OGD/R-induced neuronal injury. In vivo, lentivirus with a short hairpin (sh)-circEfnb2 inhibited cerebral injury, when injected into cerebral cortex in MCAO mice (p > 0.05).

CONCLUSION

Our results suggest that circEfnb2 deficiency may decrease OGD/R-induced HT22 cell damage by modulating the miR-202-5p/TRAF3 axis. This explanation may provide a new direction for cerebral infarction potential therapeutic targets.

Identification and characterization of biomarkers associated with endoplasmic reticulum protein processing in cerebral ischemia-reperfusion injury

Background

Cerebral ischemia (CI), ranking as the second leading global cause of death, is frequently treated by reestablishing blood flow and oxygenation. Paradoxically, this reperfusion can intensify tissue damage, leading to CI-reperfusion injury. This research sought to uncover biomarkers pertaining to protein processing in the endoplasmic reticulum (PER) during CI-reperfusion injury.

Methods

We utilized the Gene Expression Omnibus (GEO) dataset GSE163614 to discern differentially expressed genes (DEGs) and single out PER-related DEGs. The functions and pathways of these PER-related DEGs were identified via Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses. Core genes were pinpointed through protein-protein interaction (PPI) networks. Subsequent to this, genes with diagnostic relevance were distinguished using external validation datasets. A single-sample gene-set enrichment analysis (ssGSEA) was undertaken to pinpoint genes with strong associations to hypoxia and apoptosis, suggesting their potential roles as primary inducers of apoptosis in hypoxic conditions during ischemia-reperfusion injuries.

Results

Our study demonstrated that PER-related genes, specifically ADCY5, CAMK2A, PLCB1, NTRK2, and DLG4, were markedly down-regulated in models, exhibiting a robust association with hypoxia and apoptosis.

Conclusion

The data indicates that ADCY5, CAMK2A, PLCB1, NTRK2, and DLG4 could be pivotal genes responsible for triggering apoptosis in hypoxic environments during CI-reperfusion injury.

CircRIMS promotes cerebral ischemia-reperfusion injury through increasing apoptosis and targeting the miR-96-5p/JAK/STAT1 axis

OBJECTIVE

This study aims to explore the function of circRIMS in cerebral ischemia/reperfusion (CIR) and its regulatory mechanism.

METHOD

The expression of the circRIMS was examined in GEO chip data and validated by qRT-PCR analysis. A middle cerebral artery occlusion/repression (MCAO/R) model was developed using C57BL/6J mice. Starbase and circinteractome were employed to identify the target miRNA and mRNA. The result was confirmed by dual-luciferase reporter assay, and biotinylated RNA-pulldown assay. The cell viability and apoptosis were confirmed through CCK-8 and flow cytometry assay.

RESULTS

This study revealed that circRIMS expression was upregulated in MCAO mice model and OGD/RX-simulated cell model. Knockdown circRIMS demonstrated the functional of circRIMS in increasing cell viability, reducing apoptosis, LDH activity and inflammatory factors secretion in OGD/RX-simulated CIR injury in vitro. Additionally, miR-96-5p was identified as a target of circRIMS, while the STAT1 gene is a downstream gene of miR-96-5p, and JAK was also considered to be a downstream gene of the JAK-STAT pathway. Furthermore, inhibition of miR-96-5p or overexpression of STAT1 promoted the progression of CIR injury by elevating apoptosis, reducing cell viability, and increasing the secretion of inflammatory cytokines.

CONCLUSION

CircRIMS contributes to the progression of CIR injury via regulating miR-96-5p/JAK/STAT1 axis.

PUM2 aggravates the neuroinflammation and brain damage induced by ischemia-reperfusion through the SLC7A11-dependent inhibition of ferroptosis via suppressing the SIRT1

Cerebral ischemia-reperfusion (I/R) injury occurs due to the restoration of blood perfusion after cerebral ischemia, which results in the damage of the brain structures and functions. Unfortunately, currently there are no effective methods for preventing and treating it. The pumilio 2 (PUM2) is a type of RBPs that has been reported to participate in the progression of several diseases. Ferroptosis is reported to be involved in I/R injury. Whether PUM2 modulated I/R injury through regulating ferroptosis remains to be elucidated. The cerebral I/R models including animal middle cerebral artery occlusion/reperfusion (MCAO/R) model and oxygen-glucose deprivation/reperfusion (OGD/R)-induced cortical neuron injury cell model of were established and, respectively. RT-qPCR was applied for evaluating PUM2, SIRT1 and SLC7A11 expression. Western blot was employed for measuring the protein expression levels. The viability of cortical neurons was tested by MTT assay. The histological damage of the brain tissues was assessed by H&E staining. The level of PUM2 was boosted in both the brain tissues of the MCAO model and OGD/R-induced cortical neuron injury model. Silence of PUM2 alleviated MCAO-induced brain injury and decreased the death of PC12 cell exposed to OGD/R. PUM2 also aggravated the accumulation of free iron in MCAO mice and OGD/R-induced cortical neuron injury model. In addition, PUM2 suppressed SLC7A11 via inhibiting expression of SIRT1. Rescue assays unveiled that downregulation of SLC7A11 reversed PUM2 mediated neuroinflammation and brain damage induced by I/R. PUM2 aggravated I/R-induced neuroinflammation and brain damage through the SLC7A11-dependent inhibition of ferroptosis by suppressing SIRT1, highlighting the role of PUM2 in preventing or treating cerebral I/R injury.

Celastrol assuages oxygen-glucose deprivation and reoxygenation-induced damage in human brain microvascular endothelial cells through the circDLGAP4/miR-6085/GDF11 pathway

The effect of Celastrol on cerebral ischemia-reperfusion remains unknown. The study aims to explore the role of circular RNA DLGAP4 (circDLGAP4) in cerebral ischemia-reperfusion and the underlying mechanism. Ischemia-reperfusion (I/R) injury of human brain microvascular endothelial cells (HBMECs) was induced by oxygen-glucose deprivation and reoxygenation (OGD/R). Reverse transcription quantitative real-time PCR (RT-qPCR) and western blotting analysis were performed to detect the expression of circDLGAP4, microRNA-6085 (miR-6085), growth differentiation factor 11 (GDF11), B-cell lymphoma-2 (BCL2) and BCL2-associated x protein (BAX). Cell viability, proliferation, and apoptosis were analyzed by cell counting kit-8, 5-Ethynyl-2'-deoxyuridine and flow cytometry analysis. Oxidative stress was analyzed by evaluating the levels of Malondialdehyde (MDA) and Reactive Oxygen Species (ROS) and the activity of Superoxide Dismutase (SOD). The associations among circDLGAP4, miR-6085 and GDF11 were identified by dual-luciferase reporter, RNA immunoprecipitation (RIP) and RNA pull-down assays. Celastrol reduced OGD/R-induced inhibition of circDLGAP4 expression in HBMECs. Celastrol treatment protected HBMECs from OGD/R-induced cell proliferation inhibition and apoptosis and oxidative stress promotion; however, circDLGAP4 depletion attenuated these effects. CircDLGAP4 acted as a sponge for miR-6085, and miR-6085 mimics restored circDLGAP4-mediated effects in OGD/R-stimulated HBMECs. In addition, GDF11 was identified as a targte of miR-6085, and participated in the regulation of miR-6085 to OGD/R-induced HBMEC damage. Further, circDLGAP4 absence inhibited GDF11 expression by interacting with miR-6085 under Celastrol treatment. Celastrol ameliorated OGD/R-induced HBMEC apoptosis and oxidative stress by circDLGAP4/miR-6085/GDF11 pathway, supporting the use of Celastrol as a therapeutic agent for cerebral infarction.

Differential Expression and Correlation Analysis of Global Transcriptome for Hemorrhagic Transformation After Acute Ischemic Stroke

In order to explore the epigenetic characteristics of hemorrhagic transformation (HT) after acute ischemic stroke, we used transcriptome sequencing technology to analyze the global transcriptome expression profile of patients with and without HT after acute ischemic stroke and to study the differential expression of messenger RNA (mRNA), long noncoding RNA (lncRNA), circular RNA (circRNA) and mircoRNA (miRNA) between the two groups. To further explore the role of differentially expressed genes in HT, we annotated the function of differentially expressed genes by using gene ontology (GO) and pathway analysis on the results and showed that there were 1,051 differential expressions of lncRNAs, 2,575 differential expressions of mRNAs, 447 differential expressions of circRNAs and 47 miRNAs in patients with HT compared with non-HT patients. Pathway analysis showed that ubiquitin-mediated proteolysis, MAPK signal pathway, axon guidance, HIF-1 signal pathway, NOD-like receptor signal pathway, beta-alanine metabolism, Wnt signal pathway, sphingolipid signal pathway, neuroactive ligand-receptor interaction, and intestinal immune network used in IgA production play an important role in HT. Terms such as iron homeostasis, defense response, immune system process, DNA conformational change, production of transforming growth factor beta-2, and oxidoreductase activity were enriched in the gene list, suggesting a potential correlation with HT. A total of 261 lncRNA-miRNA relationship pairs and 21 circRNA-miRNA relationship pairs were obtained; additionally, 5 circRNAs and 13 lncRNAs were screened, which can be used as competing endogenous RNA (ceRNA) to compete with miRNA in the co-expression network. Co-expression network analysis shows that these differentially expressed circRNA and lncRNA may play a vital role in HT and provide valuable information for new biomarkers or therapeutic targets.

Long non-coding RNA lincRNA-erythroid prosurvival (EPS) alleviates cerebral ischemia/reperfusion injury by maintaining high-temperature requirement protein A1 (Htra1) stability through recruiting heterogeneous nuclear ribonucleoprotein L (HNRNPL)

This study aimed at investigating the role and mechanism of lincRNA-EPS (erythroid prosurvival) in cerebral ischemia/reperfusion (CIR) injury. The results showed that the overexpression of lincRNA-EPS was able to reduce the levels of interleukin-6, tumor necrosis factor-alpha and interleukin-1β stimulated in the OGD-treated Neuro-2a (N-2a) cells. The levels of reactive oxygen species and malondialdehyde were enhanced while the superoxide dismutase levels were reduced by oxygen and glucose deprivation (OGD) treatment, in which the lincRNA-EPS overexpression could reverse this effect in the cells. LincRNA-EPS interacted with high-temperature requirement protein A1 (Htra1) and heterogeneous nuclear ribonucleoprotein L (HNRNPL), and their depletion inhibited the Htra1 mRNA stability in N-2a cells. HNRNPL knockdown blocked lincRNA-EPS overexpression-induced Htra1 expression in the cells. The depletion of Htra1 could rescue lincRNA-EPS overexpression-mediated N-2a cell injury, inflammation, and oxidative stress induced by OGD. Functionally, lincRNA-EPS alleviates CIR injury of the middle cerebral artery occlusion/reperfusion mice in vivo. In conclusion, lincRNA-EPS attenuates CIR injury by maintaining Htra1 stability through recruiting HNRNPL.

miR-204-5p is sponged by TUG1 to aggravate neuron damage induced by focal cerebral ischemia and reperfusion injury through upregulating COX2

Studies have reported that miR-204-5p is involved in multiple biological processes. However, little is known about the expression and mechanism of miR-204-5p in cerebral ischemia and reperfusion injury. This study found that miR-204-5p expression was significantly downregulated in the blood of patients with ischemic stroke, MCAO/R rat brains, and OGD/R neurons. Overexpression of miR-204-5p markedly reduced infarct volume and neurological impairment and alleviated the inflammatory response in vivo. miR-204-5p promoted neuronal viability and reduced apoptotic cells in vitro. Mechanically, miR-204-5p was negatively regulated by the expression lncRNA TUG1 upstream and down-regulated COX2 expression downstream. Therefore, the TUG1/miR-204-5p/COX2 axis was involved in ischemia and reperfusion-induced neuronal damage. This finding may provide a novel strategy for the treatment of cerebral ischemia and reperfusion injury.

LncRNA MEG3 inhibits the proliferation of neural stem cells after ischemic stroke via the miR-493-5P/MIF axis

OBJECTIVE

The proliferation of neural stem cells (NSCs1), or lack thereof, can have profound effects on brain tissue remodeling for ischemic stroke (IS2). In this study, we aimed to reveal the influence of the lncRNA MEG3/miR-493-5p/MIF axis on NSC proliferation after IS.

METHODS

We established an oxygen glucose-deprivation/reoxygenation (OGD/R3) in vitro model of IS in NSCs. We evaluated NSC isolation efficiency and proliferation by NESTIN, SOX2, and PCNA immunofluorescence staining. MEG3 and miR-493-5P levels were assessed by quantitative real-time polymerase chain reaction (qRT-PCR4). Changes in MIF protein expression levels were analyzed using Western blotting. We then evaluated the role of MEG3 and miR-493-5p by transfection of si-MEG3, a miR-493-5p mimic, or miR-493-5p inhibitor. NSC proliferation was quantified using Cell Counting Kit-8 analysis.

RESULTS

NESTIN and SOX2 were co-expressed in endogenous NSCs. Following OGD/R, MEG3 and miR-493-5P were significantly upregulated in NSCs, while MIF levels decreased and proliferation was inhibited. Knockdown of MEG3 inhibited miR-493-5p and rescued expression of MIF and PCNA, restoring cellular proliferation levels. In NSCs transfected with a miR-493-5p mimic or inhibitor, MIF levels were down- or upregulated, respectively. Consistently, transfection of a miR-493-5p mimic reduced NSC proliferation, while transfection with a miR-493-5p inhibitor or si-MEG3 rescued the inhibitory effect of OGD/R on NSC proliferation. After co-transfection of si-MEG3 and a miR-493-5p mimic of OGD/R-induced NSCs, levels of PCNA, an indicator of cellular proliferation, were significantly reduced. Conclusion MEG3 inhibits NSC proliferation of after IS via positive regulation of miR-493-5p and potential subsequent downregulation of MIF.

Circular RNA circ_HECTD1 regulates cell injury after cerebral infarction by miR-27a-3p/FSTL1 axis

Cerebral infarction is a common cerebrovascular disease caused by neural cell injury, with high mortality worldwide. Circular RNAs HECT domain E3 ubiquitin-protein ligase 1 (circ_HECTD1) has been reported to be related to the oxygen-glucose deprivation/reperfusion (OGD/R)-caused neuronal damage in cerebral ischemia. This study is designed to explore the role and mechanism of circ_HECTD1 in OGD/R-induced cell injury in cerebral ischemia. Circ_HECTD1, microRNA-27a-3p (miR-27a-3p), and Follistatin-like 1 (FSTL1) level were detected by real-time quantitative polymerase chain reaction (RT-qPCR). The localization of circ_HECTD1 was analyzed by subcellular fractionation assay. Cell proliferative ability and apoptosis were assessed by 5-ethynyl-2'-deoxyuridine (EdU), 3-(4, 5-dimethyl-2-thiazolyl)-2, 5-diphenyl-2-H-tetrazolium bromide (MTT), and flow cytometry assays. The protein levels of proliferating cell nuclear antigen (PCNA), B-cell lymphoma-2 (Bcl-2), Bcl-2 related X protein (Bax), Cleaved poly-ADP-ribose polymerase (PARP), and FSTL1 were examined by western blot assay. The binding relationship between miR-27a-3p and circ_HECTD1 or FSTL1 was predicted by starbase 3.0 then verified by a dual-luciferase reporter assay. Circ_HECTD1 and FSTL1 were highly expressed, and miR-27a-3p was decreased in OGD/R-treated HT22 cells. Moreover, circ_HECTD1 knockdown could boost cell proliferative ability and repress apoptosis in OGD/R-triggered HT22 cells in vitro. Mechanical analysis discovered that circ_HECTD1 could regulate FSTL1 expression by sponging miR-27a-3p. Circ_HECTD1 deficiency could mitigate OGD/R-induced HT22 cell damage by modulating the miR-27a-3p/FSTL1 axis, providing a promising therapeutic target for cerebral infarction treatment.

Circular RNA TTC3 regulates cerebral ischemia-reperfusion injury and neural stem cells by miR-372-3p/TLR4 axis in cerebral infarction

Background

Stroke serves as a prevalent cerebrovascular disorder with severe cerebral ischemia/reperfusion (CIR) injury, in which neural stem cells (NSCs) play critical roles in the recovery of cerebral function. Circular RNAs (circRNAs) have been widely found to participate in stroke and NSC modulation. However, the role of circRNA TTC3 (circTTC3) in the regulation of CIR injury and NSCs remains elusive. Here, we aimed to explore the impact of circTTC3 on CIR injury and NSCs.

Methods

The middle cerebral artery occlusion/repression (MCAO/R) model was established in C57BL/6J mice. The primary astrocytes were isolated from the cerebellum from C57BL/6J mice. The primary NSCs were obtained from rat embryos. The effect of circTTC3 on CIR injury and NSCs was analyzed by TTC staining, qPCR, Western blot, LDH colorimetric kits, MTT assays, Annexin V-FITC Apoptosis Detection Kit, luciferase reporter gene assays, and others in the system.

Results

Significantly, the expression of circTTC3 was elevated in the MCAO/R mice and oxygen and glucose deprivation (OGD)-treated astrocytes. The depletion of circTTC3 attenuated cerebral infarction, neurological score, and brain water content. The OGD treatment induced apoptosis and the levels of lactate dehydrogenase (LDH) in the astrocytes, in which circTTC3 depletion reduced this phenotype in the system. Moreover, the depletion of circTTC3 promoted the proliferation and upregulated the nestin and β-tubulin III expression in NSCs. Mechanically, circTTC3 was able to sponge miR-372-3p, and miR-372-3p can target Toll-like receptor 4 (TLR4) in NSCs. The miR-372-3p inhibitor or TLR4 overexpression could reverse circTTC3 depletion-mediated astrocyte OGD injury and NSC regulation.

Conclusion

Thus, we conclude that circTTC3 regulates CIR injury and NSCs by the miR-372-3p/TLR4 axis in cerebral infarction. Our finding presents new insight into the mechanism by which circTTC3 modulates CIR injury and NSC dysfunction. CircTTC3, miR-372-3p, and TLR4 may serve as potential targets for the treatment of CIR injury during stroke.

Interhospital Transfer of Intracerebral Hemorrhage Patients Undergoing Minimally Invasive Surgery: The Experience of a New York City Hospital System

OBJECTIVE

The impact of interhospital transfer (IHT) on outcomes of patients with intracerebral hemorrhage (ICH) has not been well studied. We seek to describe the protocolized IHT and systems of care approach of a New York City hospital system, where ICH patients undergoing minimally invasive surgery (MIS) are transferred to a dedicated ICH center.

METHODS

We retrospectively reviewed 100 consecutively admitted patients with spontaneous ICH. We gathered information on demographics, variables related to IHT, clinical and radiographic characteristics, and details about the clinical course and outpatient follow-up. We grouped patients into 2 cohorts: those admitted through IHT and those directly admitted through the emergency department. Primary outcome was good functional outcome at 6 months, defined as modified Rankin Scale score 0-3.

RESULTS

Of 100 patients, 89 underwent IHT and 11 were directly admitted. On multivariable analysis, there were no significant differences in 6-month functional outcome between the 2 cohorts. All transfers were managed by a system-wide transfer center and 24/7 hotline for neuroemergencies. An ICH-specific IHT protocol was followed, in which a neurointensivist provided recommendations for stabilizing patients for transfer. Average transfer time was 199.7 minutes and average distance travelled was 13.6 kilometers.

CONCLUSIONS

In our hospital system, a centralized approach to ICH management and a dedicated ICH center increased access to specialist services, including MIS. Most patients undergoing MIS were transferred from outside hospitals, which highlights the need for additional studies and descriptions of experiences to further elucidate the impact of and best protocols for the IHT of ICH patients.

High-Risk Chief Complaints III: Neurologic Emergencies

A careful history and thorough physical examination are necessary in patients presenting with acute neurologic dysfunction. Patients presenting with headache should be screened for red-flag criteria that suggest a dangerous secondary cause warranting imaging and further diagnostic workup. Dizziness is a vague complaint; focusing on timing, triggers, and examination findings can help reduce diagnostic error. Most patients presenting with back pain do not require emergent imaging, but those with new neurologic deficits or signs/symptoms concerning for acute infection or cord compression warrant MRI. Delay to diagnosis and treatment of acute ischemic stroke is a frequent reason for medical malpractice claims.

LncRNA MALAT1 silencing protects against cerebral ischemia-reperfusion injury through miR-145 to regulate AQP4

BACKGROUND

The present study aimed to verify whether long noncoding RNA (lncRNA) MALAT1 is involved in brain tissue damage induced by ischemia-reperfusion injury, and to explore the mechanism by which MALAT1 regulates aquaporin 4 (AQP4).

METHODS

In this study, we established glucose deprivation (OGD)/reoxygenation (RX) astrocyte cell model and middle cerebral artery occlusion (MCAO)/reperfusion mouse model in vitro and in vivo. Then cell counting kit-8 assay, flow cytometry analysis, Triphenyltetrazolium chloride (TTC) staining, and western blotting were used to determine cell viability, cell apoptosis, cerebral infarction volume, and the abundance of AQP4, respectively.

RESULTS

We found that the level of MALAT1 was significantly upregulated in both the MCAO/reperfusion model and OGD/RX model. Knockdown of MALAT1 increased cell viability and reduced cell apoptosis in MA-C cells, while an AQP4 siRNA combined with a siRNA targeting MALAT1 could not enhance this effect. Further experiments showed that MALAT1 positively regulated AQP4 expression via miR-145. The MALAT1 siRNA did not alleviate the exacerbation of damage after miR-145 inhibitor action. However, an miR-145 inhibitor reversed the protection effects of MALAT1, indicating that MALAT1 silencing protects against cerebral ischemia-reperfusion injury through miR-145. TTC staining showed that the infracted area of whole brain was significantly attenuated in treated with sh-MALAT1 group in vivo.

CONCLUSION

Taken together, our study confirmed that MALAT1 promotes cerebral ischemia-reperfusion injury by affecting AQP4 expression through competitively binding miR-145, indicating that MALAT1 might be a new therapeutic target for treatment cerebral ischemic stroke.

The Extended Treatment Window's Impact on Emergency Systems of Care for Acute Stroke

The window for acute ischemic stroke treatment was previously limited to 4.5 hours for intravenous tissue plasminogen activator and to 6 hours for thrombectomy. Recent studies using advanced imaging selection expand this window for select patients up to 24 hours from last known well. These studies directly affect emergency stroke management, including prehospital triage and emergency department (ED) management of suspected stroke patients. This narrative review summarizes the data expanding the treatment window for ischemic stroke to 24 hours and discusses these implications on stroke systems of care. It analyzes the implications on prehospital protocols to identify and transfer large-vessel occlusion stroke patients, on issues of distributive justice, and on ED management to provide advanced imaging and access to thrombectomy centers. The creation of high-performing systems of care to manage acute ischemic stroke patients requires academic emergency physician leadership attentive to the rapidly changing science of stroke care.

Availability of Hospital Resources and Specialty Services for Stroke Care in North Carolina

OBJECTIVES

Effective regionalization of acute stroke care requires assessment and coordination of limited hospital resources. We described the availability of stroke-specific hospital resources (neurology specialty physicians and neuro-intensive care unit [neuro-ICU] bed capacity) for North Carolina overall and by region and population density. We also assessed daily trends in hospital bed availability.

METHODS

This statewide descriptive study was conducted with data from the State Medical Asset Resource Tracking Tool (SMARTT), a Web-based system used by North Carolina to track available medical resources within the state. The SMARTT system was queried for stroke-specific physician and bed resources at each North Carolina hospital during a 1-year period (June 2015-May 2016), including daily availability of neuro-ICU beds. We compared hospital resources by geographic region and population density (metropolitan, urban, and rural).

RESULTS

Data from 108 acute care hospitals located in 75 of 100 counties in North Carolina were included in the analysis. Fifty-seven percent of hospitals had no neurology specialty physicians. Western and eastern North Carolina had the lowest prevalence of these physicians. Most hospitals (88%) had general ICUs, whereas only 17 hospitals (16%) had neuro-ICUs. Neuro-ICUs were concentrated in metropolitan areas and in central North Carolina. On average, there were 276 general ICU and 27 neuro-ICU beds available statewide each day. Daily neuro-ICU bed availability was lowest in eastern and southeastern regions and during the week compared with weekends.

CONCLUSIONS

In North Carolina, stroke-specific hospital subspecialists and resources are not distributed evenly across the state. Daily bed availability, particularly in neuro-ICUs, is lacking in rural areas and noncentral regions and appears to decrease on weekdays. Regionalization of stroke care needs to consider the geographic distribution and daily variability of hospital resources.

LncRNA SNHG14 promotes inflammatory response induced by cerebral ischemia/reperfusion injury through regulating miR-136-5p /ROCK1

Recently, long non-coding RNAs (lncRNAs) are considered as critical regulators in pathogenesis progression of cerebral ischemia. In present study, lncRNA-small nucleolar RNA host gene 14 (SNHG14) was found upregulated in middle cerebral artery occlusion/reperfusion (MCAO/R) treated brain tissues and oxygen-glucose deprivation and reoxygenation (OGD/R) treated PC-12 cells. Interference of SNHG14 by shRNA vector enhanced neuron survival and suppressed inflammation in response to OGD/R insult. SNHG14 positively regulated the expression of Rho-associated coiled-coil-containing protein kinase 1 (ROCK1) via acting as a sponge of microRNA (miR)-136–5p. SNHG14 promoted neurological impairment and inflammatory response through elevating the expression of ROCK1 while decreasing miR-136–5p level in OGD/R induced damage. Collectively, we illustrated that SNHG14 could be a novel strategy for treatment ischemia stoke.

LncRNA SNHG1 alleviates OGD induced injury in BMEC via miR-338/HIF-1α axis

BACKGROUND

Brain microvascular endothelial cell (BMEC) is an important therapeutic target for the inhibition of brain vascular dysfunction in ischemic stroke. Expression of long non-coding RNA SNHG1 is reportedly upregulated in BMEC after OGD. The present study aims to investigate the potential roles of SNHG1 in OGD-induced injury in BMEC.

METHODS

Mice primary brain microvascular endothelial cells (BMEC) were cultured under "normal" or "oxygen/glucose-deprived" (OGD) conditions. The expression of SNHG1 and miR-338 after OGD were examined by qPCR. shRNA against SNHG1 was used to knockdown SNHG1 in BMEC. MiR-338-3p mimic and inhibitor were used to change the expression of miR-338 in BMEC. The relationship between SNHG1 and miR-338, and the relationship between miR-338 and HIF-1α were clarified using RNA pull-down and luciferase reporter gene assays, respectively.

RESULTS

SNHG1 and miR-338 were upregulated in OGD induced BMEC. SNHG1 silence aggravated OGD-induced cell apoptosis by down-regulating Bcl-2, HIF-1α and VEGF-A, and upregulating caspase 3 activity and Bax. MiR-338 was upregulated in SNHG1-silenced BMEC. RNA pull-down assays showed that SNHG1 could be directly bound by miR-338. In addition, miR-338 overexpression reduced cell viability in OGD while miR-338 inhibition protected BMEC against OGD-induced injury. Furthermore, luciferase reporter assay showed that HIF-1α was a direct target of miR-338.

CONCLUSIONS

SNHG1 exerted protective effects against OGD induced injury via sponging miR-338, thus upregulating HIF-1α/VEGF-A in BMEC.

ASPECTS, Large Vessel Occlusion, and Time of Symptom Onset: Estimation of Eligibility for Endovascular Therapy

BACKGROUND

Understanding how many patients are eligible for endovascular therapy can help develop more effective stroke systems of care.

OBJECTIVE

To determine the proportion of patients eligible for endovascular therapy.

METHODS

In this single center retrospective cohort study, we identified patients with acute ischemic stroke from large vessel occlusion (LVO) from January 2014 to December 2015. Selection criteria including LVO location, Alberta stroke program early computed tomography score (ASPECTS) range, hospital arrival time, and the use of intravenous thrombolysis were applied to calculate proportions of patients eligible for endovascular therapy.

RESULTS

Of 989 patients with acute ischemic stroke, LVO was identified in 224 (23%) cases. Eighty-four percent of patients admitted within 6 h, 75% of patients admitted within 6 to 12 h, and 77% of patients with M1 and internal carotid artery occlusions admitted within 12 to 24 h had favorable ASPECTS for thrombectomy, defined as ASPECTS ≥ 6. Severity of NIHSS (National Institutes of Health Stroke Scale) was predictive of favorable ASPECTS (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.04-0.74; P = .014 for NIHSS > 10 and OR 0.30, 95% CI 0.12-0.80; P = .014 for NIHSS > 20), whereas time of hospital arrival was not (OR 1.73, 95% CI 0.76-4.03; P = .26). Using all class I, Level of Evidence A American Heart Association guidelines criteria, 4% of patients with acute ischemic stroke were eligible for endovascular therapy. Up to 20% of patients were eligible for endovascular therapy with less restrictive criteria (Class IIb; Level of Evidence C).

CONCLUSION

Depending on the sets of selection criteria, between 4% (the most restrictive criteria) and 20% (the least restrictive criteria) of patients with LVO are potentially eligible for endovascular therapy.

Stroke Onset Time Determination Using MRI Relaxation Times without Non-Ischaemic Reference in A Rat Stroke Model

BACKGROUND

Objective timing of stroke in emergency departments is expected to improve patient stratification. Magnetic resonance imaging (MRI) relaxations times, T₂ and T_1ρ , in abnormal diffusion delineated ischaemic tissue were used as proxies of stroke time in a rat model.

METHODS

Both 'non-ischaemic reference'-dependent and -independent estimators were generated. Apparent diffusion coefficient (ADC), T₂ and T_1ρ , were sequentially quantified for up to 6 hours of stroke in rats (n = 8) at 4.7T. The ischaemic lesion was identified as a contiguous collection of voxels with low ADC. T₂ and T_1ρ in the ischaemic lesion and in the contralateral non-ischaemic brain tissue were determined. Differences in mean MRI relaxation times between ischaemic and non-ischaemic volumes were used to create reference-dependent estimator. For the reference-independent procedure, only the parameters associated with log-logistic fits to the T₂ and T_1ρ distributions within the ADC-delineated lesions were used for the onset time estimation.

RESULT

The reference-independent estimators from T₂ and T_1ρ data provided stroke onset time with precisions of ±32 and ±27 minutes, respectively. The reference-dependent estimators yielded respective precisions of ±47 and ±54 minutes.

CONCLUSIONS

A 'non-ischaemic anatomical reference'-independent estimator for stroke onset time from relaxometric MRI data is shown to yield greater timing precision than previously obtained through reference-dependent procedures.