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Nguyen JN, Chauhan A. Bystanders or not? Microglia and lymphocytes in aging and stroke. Neural Regen Res 2023; 18:1397-1403. [PMID: 36571333 PMCID: PMC10075112 DOI: 10.4103/1673-5374.360345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
As the average age of the world population increases, more people will face debilitating aging-associated conditions, including dementia and stroke. Not only does the incidence of these conditions increase with age, but the recovery afterward is often worse in older patients. Researchers and health professionals must unveil and understand the factors behind age-associated diseases to develop a therapy for older patients. Aging causes profound changes in the immune system including the activation of microglia in the brain. Activated microglia promote T lymphocyte transmigration leading to an increase in neuroinflammation, white matter damage, and cognitive impairment in both older humans and rodents. The presence of T and B lymphocytes is observed in the aged brain and correlates with worse stroke outcomes. Preclinical strategies in stroke target either microglia or the lymphocytes or the communications between them to promote functional recovery in aged subjects. In this review, we examine the role of the microglia and T and B lymphocytes in aging and how they contribute to cognitive impairment. Additionally, we provide an important update on the contribution of these cells and their interactions in preclinical aged stroke.
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Affiliation(s)
- Justin N Nguyen
- University of Texas McGovern Medical School at Houston, Houston, TX, USA
| | - Anjali Chauhan
- Department of Neurology, University of Texas McGovern Medical School at Houston, Houston, TX, USA
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2
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Zbesko JC, Stokes J, Becktel DA, Doyle KP. Targeting foam cell formation to improve recovery from ischemic stroke. Neurobiol Dis 2023; 181:106130. [PMID: 37068641 PMCID: PMC10993857 DOI: 10.1016/j.nbd.2023.106130] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/31/2023] [Accepted: 04/14/2023] [Indexed: 04/19/2023] Open
Abstract
Inflammation is a crucial part of the healing process after an ischemic stroke and is required to restore tissue homeostasis. However, the inflammatory response to stroke also worsens neurodegeneration and creates a tissue environment that is unfavorable to regeneration for several months, thereby postponing recovery. In animal models, inflammation can also contribute to the development of delayed cognitive deficits. Myeloid cells that take on a foamy appearance are one of the most prominent immune cell types within chronic stroke infarcts. Emerging evidence indicates that they form as a result of mechanisms of myelin lipid clearance becoming overwhelmed, and that they are a key driver of the chronic inflammatory response to stroke. Therefore, targeting lipid accumulation in foam cells may be a promising strategy for improving recovery. The aim of this review is to provide an overview of current knowledge regarding inflammation and foam cell formation in the brain in the weeks and months following ischemic stroke and identify targets that may be amenable to therapeutic intervention.
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Affiliation(s)
- Jacob C Zbesko
- Department of Immunobiology, University of Arizona, United States
| | - Jessica Stokes
- Department of Pediatrics, University of Arizona, United States
| | | | - Kristian P Doyle
- Department of Immunobiology, University of Arizona, United States; Departments of Neurology, Neurosurgery, Psychology, Arizona Center on Aging, and the BIO5 Institute, University of Arizona, United States.
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3
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Boutros CF, Khazaal W, Taliani M, Sadier NS, Salameh P, Hosseini H. Factors associated with cognitive impairment at 3, 6, and 12 months after the first stroke among Lebanese survivors. Brain Behav 2023; 13:e2837. [PMID: 36495111 PMCID: PMC9847618 DOI: 10.1002/brb3.2837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 10/10/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION This study aimed to calculate the rate of post-stroke cognitive impairment (PSCI) by evaluating the cognitive domains among Lebanese stroke survivors at 3, 6, and 12 months post-stroke, and to identify the contributing factors including pre- and post-stroke related factors. METHODS A multicenter longitudinal prospective study was conducted in 10 hospitals from Beirut and Mount Lebanon for a 15-month period. Mini-Mental State Examination (MMSE), modified Rankin Scale (mRS), Short Form Health Survey (SF12), National Institutes of Health Stroke Scale (NIHSS), and Hospital Anxiety and Depression Scale (HADS) were used to assess cognitive function, disability degree, Quality of Life (QoL), stroke severity, and levels of anxiety and depression, respectively. Then, univariate and multivariable analyses were performed to identify the predictors of PSCI. RESULTS Low MMSE scores were found among survivors during the first 3 months post-stroke (74.8%) of whom 53.7% presented with an MMSE ≤ 17, followed by 46.7% in the 6 months, and 37.6% at 12 months post-stroke. Follow-up comparisons showed a significant increase of MMSE scores over time (p < .001), indicating a 37% improvement of the cognitive function over time. The most affected cognitive domain was the attention and concentration at the three time points. Independent factors that were positively associated with low MMSE scores were as follows: sedentary behavior ≥ 12 h/day (AOR = 3.062, p = .033), involvement of the left hemisphere (AOR = 2.710, p = .006), HADS ≥ 11 (AOR = 2.536, p = .049), and high NIHSS scores (AOR = 3, p = .009). Age was the main predictor in the three time periods (AOR ≈ 3, p < .05). Inversely, female gender (AOR = 0.09, p = .027), high educational level (AOR = 0.2, p < .02), employment post-stroke (AOR = 0.3, p = .023), high Physical Component Summary (PCS) of Quality of Life (QoL) (AOR = 0.8, p < .001), and the use of anti-diabetic treatment post-stroke (AOR = 0.17, p = .016) improved MMSE scores to > 23. CONCLUSION The risk of PSCI among Lebanese stroke survivors was high especially in the acute phase, depending on various determinants. Health care providers are invited to implement an emergency rehabilitation program for an appropriate successful management of the risk factors in order to reduce stroke burden and to improve overall cognitive performance.
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Affiliation(s)
- Celina F Boutros
- Institut Mondor de Recherche Biomédicale (IMRB)-Inserm U955, Ecole Doctorale Science de la Vie et de la Santé, Université Paris-Est Créteil, Paris, France
| | - Walaa Khazaal
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | - Maram Taliani
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | - Najwane Said Sadier
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon.,College of Health Sciences, Abu Dhabi University, Abu Dhabi, United Arab Emirates
| | - Pascale Salameh
- Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie (INSPECT-LB), Beirut, Lebanon.,Faculty of Pharmacy, Lebanese University, Hadath, Lebanon.,Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
| | - Hassan Hosseini
- Institut Mondor de Recherche Biomédicale (IMRB)-Inserm U955, Ecole Doctorale Science de la Vie et de la Santé, Université Paris-Est Créteil, Paris, France.,Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie (INSPECT-LB), Beirut, Lebanon.,Neurology Department, Hôpital Henri Mondor, AP-HP, Créteil, France
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4
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The immunopathology of B lymphocytes during stroke-induced injury and repair. Semin Immunopathol 2022:10.1007/s00281-022-00971-3. [PMID: 36446955 PMCID: PMC9708141 DOI: 10.1007/s00281-022-00971-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/28/2022] [Indexed: 11/30/2022]
Abstract
B cells, also known as B lymphocytes or lymphoid lineage cells, are a historically understudied cell population with regard to brain-related injuries and diseases. However, an increasing number of publications have begun to elucidate the different phenotypes and roles B cells can undertake during central nervous system (CNS) pathology, including following ischemic and hemorrhagic stroke. B cell phenotype is intrinsically linked to function following stroke, as they may be beneficial or detrimental depending on the subset, timing, and microenvironment. Factors such as age, sex, and presence of co-morbidity also influence the behavior of post-stroke B cells. The following review will briefly describe B cells from origination to senescence, explore B cell function by integrating decades of stroke research, differentiate between the known B cell subtypes and their respective activity, discuss some of the physiological influences on B cells as well as the influence of B cells on certain physiological functions, and highlight the differences between B cells in healthy and disease states with particular emphasis in the context of ischemic stroke.
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5
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DeLong JH, Ohashi SN, O'Connor KC, Sansing LH. Inflammatory Responses After Ischemic Stroke. Semin Immunopathol 2022; 44:625-648. [PMID: 35767089 DOI: 10.1007/s00281-022-00943-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/20/2022] [Indexed: 12/25/2022]
Abstract
Ischemic stroke generates an immune response that contributes to neuronal loss as well as tissue repair. This is a complex process involving a range of cell types and effector molecules and impacts tissues outside of the CNS. Recent reviews address specific aspects of this response, but several years have passed and important advances have been made since a high-level review has summarized the overall state of the field. The present review examines the initiation of the inflammatory response after ischemic stroke, the complex impacts of leukocytes on patient outcome, and the potential of basic science discoveries to impact the development of therapeutics. The information summarized here is derived from broad PubMed searches and aims to reflect recent research advances in an unbiased manner. We highlight valuable recent discoveries and identify gaps in knowledge that have the potential to advance our understanding of this disease and therapies to improve patient outcomes.
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Affiliation(s)
- Jonathan Howard DeLong
- Departments of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Sarah Naomi Ohashi
- Departments of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin Charles O'Connor
- Departments of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Lauren Hachmann Sansing
- Departments of Neurology and Immunobiology, Yale University School of Medicine, New Haven, CT, USA.
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6
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Endres M, Moro MA, Nolte CH, Dames C, Buckwalter MS, Meisel A. Immune Pathways in Etiology, Acute Phase, and Chronic Sequelae of Ischemic Stroke. Circ Res 2022; 130:1167-1186. [PMID: 35420915 DOI: 10.1161/circresaha.121.319994] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Inflammation and immune mechanisms are crucially involved in the pathophysiology of the development, acute damage cascades, and chronic course after ischemic stroke. Atherosclerosis is an inflammatory disease, and, in addition to classical risk factors, maladaptive immune mechanisms lead to an increased risk of stroke. Accordingly, individuals with signs of inflammation or corresponding biomarkers have an increased risk of stroke. Anti-inflammatory drugs, such as IL (interleukin)-1β blockers, methotrexate, or colchicine, represent attractive treatment strategies to prevent vascular events and stroke. Lately, the COVID-19 pandemic shows a clear association between SARS-CoV2 infections and increased risk of cerebrovascular events. Furthermore, mechanisms of both innate and adaptive immune systems influence cerebral damage cascades after ischemic stroke. Neutrophils, monocytes, and microglia, as well as T and B lymphocytes each play complex interdependent roles that synergize to remove dead tissue but also can cause bystander injury to intact brain cells and generate maladaptive chronic inflammation. Chronic systemic inflammation and comorbid infections may unfavorably influence both outcome after stroke and recurrence risk for further stroke. In addition, stroke triggers specific immune depression, which in turn can promote infections. Recent research is now increasingly addressing the question of the extent to which immune mechanisms may influence long-term outcome after stroke and, in particular, cause specific complications such as poststroke dementia or even poststroke depression.
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Affiliation(s)
- Matthias Endres
- Klinik für Neurologie mit Experimenteller Neurologie (M.E., C.H.N., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Excellence Cluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,German Center for Neurodegenerative Diseases, Partner Site Berlin, Germany (M.E.).,German Centre for Cardiovascular Research, Partner Site Berlin, Germany (M.E., C.H.N.)
| | - Maria A Moro
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (M.A.M.).,Departamento de Farmacología yToxicología, Unidad de Investigación Neurovascular, Universidad Complutense de Madrid, Madrid, Spain (M.A.M.).,Instituto Universitario de Investigación en Neuroquímica, UCM, Madrid, Spain (M.A.M.).,Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain (M.A.M.)
| | - Christian H Nolte
- Klinik für Neurologie mit Experimenteller Neurologie (M.E., C.H.N., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,German Centre for Cardiovascular Research, Partner Site Berlin, Germany (M.E., C.H.N.)
| | - Claudia Dames
- Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Institute for Medical Immunology (C.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.S.B.).,Wu Tsai Neurosciences Institute, Stanford University, CA (M.S.B.)
| | - Andreas Meisel
- Klinik für Neurologie mit Experimenteller Neurologie (M.E., C.H.N., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,NeuroCure Clinical Research Center (A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
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7
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Schneider L, Rezaeezade-Roukerd M, Faulkner J, Reichert E, Shaar HAA, Flis A, Rubiano A, Hawryluk GW. The Human Anti-Ganglioside GM1 Autoantibody Response Following Traumatic and Surgical Central Nervous System Insults. Neurosci Res 2022; 181:105-114. [DOI: 10.1016/j.neures.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/03/2022] [Accepted: 03/21/2022] [Indexed: 11/27/2022]
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8
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Recent Advances in the Impact of Infection and Inflammation on Stroke Risk and Outcomes. Curr Neurol Neurosci Rep 2022; 22:161-170. [PMID: 35235168 PMCID: PMC8889053 DOI: 10.1007/s11910-022-01179-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE OF THE REVIEW Inflammation is a key component in the pathogenesis of cerebrovascular diseases. In the past few years, the role of systemic infection and gut dysbiosis in modulating inflammation and stroke risk has been increasingly acknowledged. In this review, we synthesize contemporary literature on the effects of infection and inflammation on stroke risk and outcomes, with a focus on periodontal disease, COVID-19 infection, and gut dysbiosis. RECENT FINDINGS Chronic and acute infections such as periodontitis and COVID-19 induce systemic inflammation that cause atherogenesis and increase cardiac injury and arrhythmias. These infections also directly injure the endothelium leading to worsened secondary inflammation after stroke. Gut dysbiosis engenders a pro-inflammatory state by modulating intestinal lymphocyte populations that can traffic directly to the brain. Additionally, post-stroke immune dysregulation creates a compounding feedback loop of further infections and gut dysbiosis that worsen outcomes. Recent advances in understanding the pathophysiology of how infection and dysbiosis affect the progression of stroke, as well as long-term recovery, have revealed tantalizing glimpses at potential therapeutic targets. We discuss the multidirectional relationship between stroke, infection, and gut dysbiosis, and identify areas for future research to further explore therapeutic opportunities.
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9
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Qiu M, Zong JB, He QW, Liu YX, Wan Y, Li M, Zhou YF, Wu JH, Hu B. Cell Heterogeneity Uncovered by Single-Cell RNA Sequencing Offers Potential Therapeutic Targets for Ischemic Stroke. Aging Dis 2022; 13:1436-1454. [PMID: 36186129 PMCID: PMC9466965 DOI: 10.14336/ad.2022.0212] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/12/2022] [Indexed: 11/06/2022] Open
Abstract
Ischemic stroke is a detrimental neurological disease characterized by an irreversible infarct core surrounded by an ischemic penumbra, a salvageable region of brain tissue. Unique roles of distinct brain cell subpopulations within the neurovascular unit and peripheral immune cells during ischemic stroke remain elusive due to the heterogeneity of cells in the brain. Single-cell RNA sequencing (scRNA-seq) allows for an unbiased determination of cellular heterogeneity at high-resolution and identification of cell markers, thereby unveiling the principal brain clusters within the cell-type-specific gene expression patterns as well as cell-specific subclusters and their functions in different pathways underlying ischemic stroke. In this review, we have summarized the changes in differentiation trajectories of distinct cell types and highlighted the specific pathways and genes in brain cells that are impacted by stroke. This review is expected to inspire new research and provide directions for investigating the potential pathological mechanisms and novel treatment strategies for ischemic stroke at the level of a single cell.
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Affiliation(s)
| | | | | | | | | | | | | | - Jie-hong Wu
- Correspondence should be addressed to: Dr. Bo Hu () and Dr. Jie-hong Wu (), Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Hu
- Correspondence should be addressed to: Dr. Bo Hu () and Dr. Jie-hong Wu (), Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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10
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Elkind MSV, Moon M, Rundek T, Wright CB, Cheung K, Sacco RL, Hornig M. Immune markers are associated with cognitive performance in a multiethnic cohort: The Northern Manhattan Study. Brain Behav Immun 2021; 97:186-192. [PMID: 34320382 PMCID: PMC8453105 DOI: 10.1016/j.bbi.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To determine whether immune protein panels add significant information to correlates of cognition. BACKGROUND Immune mechanisms in vascular cognitive aging are incompletely characterized. DESIGN/METHODS A subsample of the prospective Northern Manhattan Study underwent detailed neuropsychological testing. Cognitive scores were converted into Z-scores and categorized into four domains (memory, language, processing speed, and executive function) based on factor analysis. Blood samples were analyzed using a 60-plex immunoassay. We used least absolute shrinkage and selection operator (LASSO) procedures to select markers and their interactions independently associated with cognitive scores. Linear regression models assessed cross-sectional associations of known correlates of cognition with cognitive scores, and assessed model fit before and after addition of LASSO-selected immune markers. RESULTS Among 1179 participants (mean age 70 ± 8.9 years, 60% women, 68% Hispanic), inclusion of LASSO-selected immune markers improved model fit above age, education, and other risk factors (p for likelihood ratio test < 0.005 for all domains). C-C Motif Chemokine Ligand 11 (CCL 11, eotaxin), C-X-C Motif Chemokine Ligand 9 (CXCL9), hepatocyte growth factor (HGF), and serpin E1 (plasminogen activator inhibitor-1) were associated with each of the domains and with overall cognitive function. Immune marker effects were comparable to conventional risk factors: for executive function, each standard deviation (SD) increase in CCL11 was associated with an effect equivalent to aging three years; for memory, HGF had twice the effect of aging. CONCLUSIONS Immune markers associate with cognitive function in a multi-ethnic cohort. Further work is needed to validate these findings and determine optimal treatment targets.
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Affiliation(s)
- Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Michelle Moon
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami, Miami, FL, USA
| | - Clinton B Wright
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Ken Cheung
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Ralph L Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Mady Hornig
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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11
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Akamatsu Y, Chaitin HJ, Hanafy KA. Post-stroke recrudescence-a possible connection to autoimmunity? Rev Neurosci 2021; 33:207-212. [PMID: 34363383 DOI: 10.1515/revneuro-2021-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/27/2021] [Indexed: 11/15/2022]
Abstract
Early recanalization of the occluded vessel is the only efficient intervention that improves outcome after ischemic stroke. In contrast, interventions for chronic issues facing stroke patients are limited. Recent clinical and preclinical studies have shown a correlation between upregulated immune responses to brain antigens and post-stroke recrudescence (PSR), post-stroke fatigue (PSF), and dementia (PSD); all of which are associated with poor long-term stroke outcome. Recent retrospective studies have demonstrated a strong correlation between the onset of PSR and acute infection during acute stroke, suggesting some adaptive immune system mediated pathology. This review will discuss the mechanisms and epidemiology of PSR based on the current clinical and pre-clinical evidence. Accordingly, PSR does appear correlated with populations that are prone to autoimmunity, infection, and subsequent triggers, which corroborate autoimmune responses to self-brain antigens as an underlying mechanism. Moreover, PSR as well as PSF and PSD seem to be partly explained by the development of a neuro-inflammatory response to brain antigens. Therefore, the future of improving long-term stroke outcome could be bright with more accurate pre-clinical models focusing on the role of adaptive immune-mediated post stroke neuroinflammation and more clinical studies of PSR.
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Affiliation(s)
- Yosuke Akamatsu
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA02215, USA.,Department of Neurosurgery, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate020-0023, Japan
| | - Hersh J Chaitin
- College of Medicine, Florida Atlantic University, 777 Glades Rd., Boca Raton, FL33431, USA
| | - Khalid A Hanafy
- College of Medicine, Florida Atlantic University, 777 Glades Rd., Boca Raton, FL33431, USA.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA02215, USA.,Division of Neurocritical Care, Marcus Neuroscience Institute, Boca Raton Medical Center, Boca Raton, FL, USA
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12
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Grigolashvili MA, Mustafina RM. [The role of the inflammatory process in the development of post-stroke cognitive impairment]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:16-21. [PMID: 33908227 DOI: 10.17116/jnevro202112103216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Post-stroke cognitive impairment (PCI) is a common complication of stroke. PCI in most cases is associated with an increased risk of progression to dementia, with a progression rate of 8-15% per year. When post-stroke cognitive impairment reaches dementia, patients lose independence, professional and social maladjustment occurs, which, in turn, significantly worsen the quality of life and reduce the rehabilitation potential. According to many experimental and clinical studies, the inflammatory process has an important role in the development of PCI. Several previous studies have looked at the association between inflammatory markers and PCI, with some results conflicting with specific biomarkers. Based on the results of studies, inflammatory markers such as IL-8, IL-12 and ESR were closely associated with PCI, high ESR values are associated with worse cognitive impairment, especially memory. The relationship was not confirmed between the markers IFN-gamma, TNF-α and PCI. With regard to IL-1β, IL-6, IL-10, CRP, the results obtained are not unambiguous. Thus, the inflammatory process in the development of PCI has an important role, including a series of complex reactions, the combined effect of which induces neuronal damage and loss of synapses that ultimately leads to cognitive impairment.
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Affiliation(s)
| | - R M Mustafina
- Medical University of Karaganda, Karaganda, Kazakhstan
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13
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Kapitza C, Chunder R, Scheller A, Given KS, Macklin WB, Enders M, Kuerten S, Neuhuber WL, Wörl J. Murine Esophagus Expresses Glial-Derived Central Nervous System Antigens. Int J Mol Sci 2021; 22:ijms22063233. [PMID: 33810144 PMCID: PMC8004938 DOI: 10.3390/ijms22063233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 12/27/2022] Open
Abstract
Multiple sclerosis (MS) has been considered to specifically affect the central nervous system (CNS) for a long time. As autonomic dysfunction including dysphagia can occur as accompanying phenomena in patients, the enteric nervous system has been attracting increasing attention over the past years. The aim of this study was to identify glial and myelin markers as potential target structures for autoimmune processes in the esophagus. RT-PCR analysis revealed glial fibrillary acidic protein (GFAP), proteolipid protein (PLP), and myelin basic protein (MBP) expression, but an absence of myelin oligodendrocyte glycoprotein (MOG) in the murine esophagus. Selected immunohistochemistry for GFAP, PLP, and MBP including transgenic mice with cell-type specific expression of PLP and GFAP supported these results by detection of (1) GFAP, PLP, and MBP in Schwann cells in skeletal muscle and esophagus; (2) GFAP, PLP, but no MBP in perisynaptic Schwann cells of skeletal and esophageal motor endplates; (3) GFAP and PLP, but no MBP in glial cells surrounding esophageal myenteric neurons; and (4) PLP, but no GFAP and MBP in enteric glial cells forming a network in the esophagus. Our results pave the way for further investigations regarding the involvement of esophageal glial cells in the pathogenesis of dysphagia in MS.
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Affiliation(s)
- Christopher Kapitza
- Institute of Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.K.); (R.C.); (M.E.); (S.K.); (W.L.N.)
| | - Rittika Chunder
- Institute of Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.K.); (R.C.); (M.E.); (S.K.); (W.L.N.)
| | - Anja Scheller
- University of Saarland, Department of Molecular Physiology, Center for Integrative Physiology and Molecular Medicine (CIPMM), 66421 Homburg, Germany;
| | - Katherine S. Given
- Department of Cell and Developmental Biology, University of Colorado School of Medicine, Aurora, CO 80045, USA; (K.S.G.); (W.B.M.)
| | - Wendy B. Macklin
- Department of Cell and Developmental Biology, University of Colorado School of Medicine, Aurora, CO 80045, USA; (K.S.G.); (W.B.M.)
| | - Michael Enders
- Institute of Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.K.); (R.C.); (M.E.); (S.K.); (W.L.N.)
| | - Stefanie Kuerten
- Institute of Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.K.); (R.C.); (M.E.); (S.K.); (W.L.N.)
- Department of Neuroanatomy, Institute of Anatomy, University Hospitals Bonn, University Bonn, 53115 Bonn, Germany
| | - Winfried L. Neuhuber
- Institute of Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.K.); (R.C.); (M.E.); (S.K.); (W.L.N.)
| | - Jürgen Wörl
- Institute of Anatomy and Cell Biology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.K.); (R.C.); (M.E.); (S.K.); (W.L.N.)
- Correspondence: ; Tel.: +49-913-1852-2870
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14
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Abstract
PURPOSE OF REVIEW To review new evidence on links between poststroke dementia and inflammation. RECENT FINDINGS Although there are still no treatments for poststroke dementia, recent evidence has improved our understanding that stroke increases the risk of incident dementia and worsens cognitive trajectory for at least a decade afterwards. Within approximately the first year dementia onset is associated with stroke severity and location, whereas later absolute risk is associated with more traditional dementia risk factors, such as age and imaging findings. The molecular mechanisms that underlie increased risk of incident dementia in stroke survivors remain unproven; however new data in both human and animal studies suggests links between cognitive decline and inflammation. These point to a model where chronic brain inflammation, provoked by inefficient clearance of myelin debris and a prolonged innate and adaptive immune response, causes poststroke dementia. These localized immune events in the brain may themselves be influenced by the peripheral immune state at key times after stroke. SUMMARY This review recaps clinical evidence on poststroke dementia, new mechanistic links between the chronic inflammatory response to stroke and poststroke dementia, and proposes a model of immune-mediated neurodegeneration after stroke.
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15
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Weitbrecht L, Berchtold D, Zhang T, Jagdmann S, Dames C, Winek K, Meisel C, Meisel A. CD4 + T cells promote delayed B cell responses in the ischemic brain after experimental stroke. Brain Behav Immun 2021; 91:601-614. [PMID: 33002634 DOI: 10.1016/j.bbi.2020.09.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 08/13/2020] [Accepted: 09/24/2020] [Indexed: 01/20/2023] Open
Abstract
CD4+ T lymphocytes are key mediators of tissue damage after ischemic stroke. However, their infiltration kinetics and interactions with other immune cells in the delayed phase of ischemia remain elusive. We hypothesized that CD4+ T cells facilitate delayed autoreactive B cell responses in the brain, which have been previously linked to post-stroke cognitive impairment (PSCI). Therefore, we treated myelin oligodendrocyte glycoprotein T cell receptor transgenic 2D2 mice of both sexes with anti-CD4 antibody following 60-minute middle cerebral artery occlusion and assessed lymphocyte infiltration for up to 72 days. Anti-CD4-treatment eliminated CD4+ T cells from the circulation and ischemic brain for 28 days and inhibited B cell infiltration into the brain, particularly in animals with large infarcts. Absence of CD4+ T cells did not influence infarct maturation or survival. Once the CD4+ population recovered in the periphery, both CD4+ T and B lymphocytes entered the infarct site forming follicle-like structures. Additionally, we provide further evidence for PSCI that could be attenuated by CD4 depletion. Our findings demonstrate that CD4+ T cells are essential in delayed B cell infiltration into the ischemic brain after stroke. Importantly, lymphocyte infiltration after stroke is a long-lasting process. As CD4 depletion improved cognitive functions in an experimental set-up, these findings set the stage to elaborate more specific immune modulating therapies in treating PSCI.
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Affiliation(s)
- Luis Weitbrecht
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Experimental Neurology, Germany
| | - Daniel Berchtold
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Experimental Neurology, Germany
| | - Tian Zhang
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Experimental Neurology, Germany
| | - Sandra Jagdmann
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Medical Immunology, Germany
| | - Claudia Dames
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Medical Immunology, Germany
| | - Katarzyna Winek
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Experimental Neurology, Germany
| | - Christian Meisel
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Medical Immunology, Germany
| | - Andreas Meisel
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Experimental Neurology, Germany; Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Stroke Research Berlin, Germany; Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Neurocure Cluster of Excellence, Germany; Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurology, Germany.
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16
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Kim E, Cho S. CNS and peripheral immunity in cerebral ischemia: partition and interaction. Exp Neurol 2021; 335:113508. [PMID: 33065078 PMCID: PMC7750306 DOI: 10.1016/j.expneurol.2020.113508] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/28/2020] [Accepted: 10/08/2020] [Indexed: 02/07/2023]
Abstract
Stroke elicits excessive immune activation in the injured brain tissue. This well-recognized neural inflammation in the brain is not just an intrinsic organ response but also a result of additional intricate interactions between infiltrating peripheral immune cells and the resident immune cells in the affected areas. Given that there is a finite number of immune cells in the organism at the time of stroke, the partitioned immune systems of the central nervous system (CNS) and periphery must appropriately distribute the limited pool of immune cells between the two domains, mounting a necessary post-stroke inflammatory response by supplying a sufficient number of immune cells into the brain while maintaining peripheral immunity. Stroke pathophysiology has mainly been neurocentric in focus, but understanding the distinct roles of the CNS and peripheral immunity in their concerted action against ischemic insults is crucial. This review will discuss stroke-induced influences of the peripheral immune system on CNS injury/repair and of neural inflammation on peripheral immunity, and how comorbidity influences each.
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Affiliation(s)
- Eunhee Kim
- Vivian L. Smith Department of Neurosurgery at University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Sunghee Cho
- Burke Neurological Institute, White Plains, NY, United States of America; Feil Brain Mind Research Institute, Weill Cornell Medicine, New York, NY, United States of America.
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17
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Engler-Chiurazzi EB, Monaghan KL, Wan ECK, Ren X. Role of B cells and the aging brain in stroke recovery and treatment. GeroScience 2020; 42:1199-1216. [PMID: 32767220 PMCID: PMC7525651 DOI: 10.1007/s11357-020-00242-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/23/2020] [Indexed: 02/07/2023] Open
Abstract
As mitigation of brain aging continues to be a key public health priority, a wholistic and comprehensive consideration of the aging body has identified immunosenescence as a potential contributor to age-related brain injury and disease. Importantly, the nervous and immune systems engage in bidirectional communication and can exert profound influence on each other. Emerging evidence supports numerous impacts of innate, inflammatory immune responses and adaptive T cell-mediated immunity in neurological function and diseased or injured brain states, such as stroke. Indeed, a growing body of evidence supports key impacts of brain-resident immune cell activation and peripheral immune infiltration in both the post-stroke acute injury phase and the long-term recovery period. As such, modulation of the immune system is an attractive strategy for novel therapeutic interventions for a devastating age-related brain injury for which there are few readily available neuroprotective treatments or neurorestorative approaches. However, the role of B cells in the context of brain function, and specifically in response to stroke, has not been thoroughly elucidated and remains controversial, leaving our understanding of neuroimmune interactions incomplete. Importantly, emerging evidence suggests that B cells are not pathogenic contributors to stroke injury, and in fact may facilitate functional recovery, supporting their potential value as novel therapeutic targets. By summarizing the current knowledge of the role of B cells in stroke pathology and recovery and interpreting their role in the context of their interactions with other immune cells as well as the immunosenescence cascades that alter their function in aged populations, this review supports an increased understanding of the complex interplay between the nervous and immune systems in the context of brain aging, injury, and disease.
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Affiliation(s)
- E. B. Engler-Chiurazzi
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506 USA
- Center for Basic & Translational Stroke Research, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506 USA
| | - K. L. Monaghan
- Center for Basic & Translational Stroke Research, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506 USA
- Department of Microbiology, Immunology & Cell Biology, West Virginia University, Morgantown, WV 26506 USA
| | - E. C. K. Wan
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506 USA
- Center for Basic & Translational Stroke Research, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506 USA
- Department of Microbiology, Immunology & Cell Biology, West Virginia University, Morgantown, WV 26506 USA
| | - X. Ren
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506 USA
- Center for Basic & Translational Stroke Research, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506 USA
- Department of Microbiology, Immunology & Cell Biology, West Virginia University, Morgantown, WV 26506 USA
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18
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Elkind MSV, Boehme AK, Smith CJ, Meisel A, Buckwalter MS. Infection as a Stroke Risk Factor and Determinant of Outcome After Stroke. Stroke 2020; 51:3156-3168. [PMID: 32897811 DOI: 10.1161/strokeaha.120.030429] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Understanding the relationship between infection and stroke has taken on new urgency in the era of the coronavirus disease 2019 (COVID-19) pandemic. This association is not a new concept, as several infections have long been recognized to contribute to stroke risk. The association of infection and stroke is also bidirectional. Although infection can lead to stroke, stroke also induces immune suppression which increases risk of infection. Apart from their short-term effects, emerging evidence suggests that poststroke immune changes may also adversely affect long-term cognitive outcomes in patients with stroke, increasing the risk of poststroke neurodegeneration and dementia. Infections at the time of stroke may also increase immune dysregulation after the stroke, further exacerbating the risk of cognitive decline. This review will cover the role of acute infections, including respiratory infections such as COVID-19, as a trigger for stroke; the role of infectious burden, or the cumulative number of infections throughout life, as a contributor to long-term risk of atherosclerotic disease and stroke; immune dysregulation after stroke and its effect on the risk of stroke-associated infection; and the impact of infection at the time of a stroke on the immune reaction to brain injury and subsequent long-term cognitive and functional outcomes. Finally, we will present a model to conceptualize the many relationships among chronic and acute infections and their short- and long-term neurological consequences. This model will suggest several directions for future research.
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Affiliation(s)
- Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. (M.S.V.E., A.K.B.).,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. (M.S.V.E., A.K.B.)
| | - Amelia K Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. (M.S.V.E., A.K.B.).,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. (M.S.V.E., A.K.B.)
| | - Craig J Smith
- Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom (C.J.S.)
| | - Andreas Meisel
- Center for Stroke Research Berlin, Department for Experimental Neurology, Department of Neurology, NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Germany (A.M.)
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, CA (M.S.B.)
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19
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Drag LL, Mlynash M, Nassar H, Osborn E, Kim DE, Angst MS, Aghaeepour N, Buckwalter M, Lansberg MG. A longitudinal study of the post-stroke immune response and cognitive functioning: the StrokeCog study protocol. BMC Neurol 2020; 20:313. [PMID: 32847540 PMCID: PMC7448308 DOI: 10.1186/s12883-020-01897-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke increases the risk of cognitive impairment even several years after the stroke event. The exact mechanisms of post-stroke cognitive decline are unclear, but the immunological response to stroke might play a role. The aims of the StrokeCog study are to examine the associations between immunological responses and long-term post-stroke cognitive trajectories in individuals with ischemic stroke. METHODS StrokeCog is a single-center, prospective, observational, cohort study. Starting 6-12 months after stroke, comprehensive neuropsychological assessment, plasma and serum, and psychosocial variables will be collected at up to 4 annual visits. Single cell sequencing of peripheral blood monocytes and plasma proteomics will be conducted. The primary outcome will be the change in global and domain-specific neuropsychological performance across annual evaluations. To explain the differences in cognitive change amongst participants, we will examine the relationships between comprehensive immunological measures and these cognitive trajectories. It is anticipated that 210 participants will be enrolled during the first 3 years of this 4-year study. Accounting for attrition, an anticipated final sample size of 158 participants with an average of 3 annual study visits will be available at the completion of the study. Power analyses indicate that this sample size will provide 90% power to detect an average cognitive change of at least 0.23 standard deviations in either direction. DISCUSSION StrokeCog will provide novel insight into the relationships between immune events and cognitive change late after stroke.
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Affiliation(s)
- Lauren L Drag
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA.
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA
| | - Huda Nassar
- Department of Anesthesiology, Perioperative, & Pain Medicine, Stanford University Medical Center, 300 N. Pasteur Dr, Stanford, CA, 94305, USA
| | - Elizabeth Osborn
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA
| | - Da E Kim
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA
| | - Martin S Angst
- Department of Anesthesiology, Perioperative, & Pain Medicine, Stanford University Medical Center, 300 N. Pasteur Dr, Stanford, CA, 94305, USA
| | - Nima Aghaeepour
- Department of Anesthesiology, Perioperative, & Pain Medicine, Stanford University Medical Center, 300 N. Pasteur Dr, Stanford, CA, 94305, USA
| | - Marion Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA
- Department of Neurosurgery, Stanford University Medical Center, 300 N. Pasteur Dr, Stanford, CA, 94305, USA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, 213 Quarry Rd, Palo Alto, CA, 94305, USA
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20
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Miró-Mur F, Urra X, Ruiz-Jaén F, Pedragosa J, Chamorro Á, Planas AM. Antigen-Dependent T Cell Response to Neural Peptides After Human Ischemic Stroke. Front Cell Neurosci 2020; 14:206. [PMID: 32719588 PMCID: PMC7348665 DOI: 10.3389/fncel.2020.00206] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 06/11/2020] [Indexed: 12/20/2022] Open
Abstract
Ischemic stroke causes brain tissue damage and may release central nervous system (CNS)-specific peptides to the periphery. Neural antigen presentation in the lymphoid tissue could prime immune cells and result in adaptive immune response. However, autoimmune responses against neural antigens are not commonly uncovered after stroke. We studied the brain tissue of nine fatal stroke cases and the blood of a cohort of 13 patients and 11 controls. Flow cytometry carried out in three of the brain samples showed CD8 and CD4 T cells in the cerebrospinal fluid (CSF) of the ventricles in the patient deceased 1 day poststroke, T cells with an activated phenotype in the CSF of the patient that died at day 6, and T cells in the ischemic brain tissue in the patient deceased 140 days after stroke onset. Immunohistochemistry showed higher T cell numbers in the core of the lesion of the patient deceased 18 days post-stroke than in the patients deceased from 1 to 5 days post-stroke. In blood samples, we studied whether lymphocytes were primed in the periphery against neural antigens at sequential times (on admission, day 5, and day 90) after stroke. T lymphocytes of stroke patients produced IFN-γ and TNF-α and responded to MBP peptides by increasing their production of TNF-α and IL-10 at admission, but not at later time points. In contrast, IL-4 producing T cells showed progressive increases. Higher percentages of TNF-α producing T lymphocytes at admission were independently associated with poorer outcomes at 90 days. However, we did not detect T cell responses to neural-antigen stimulation 90 days post-stroke. Altogether the results suggest acute T cell priming in the periphery in acute stroke, T cell trafficking from the CSF to the ischemic brain tissue, and the existence of active mechanisms preventing autoreactivity.
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Affiliation(s)
- Francesc Miró-Mur
- Functional Unit of Cerebrovascular Diseases, Hospital Clinic, Barcelona, Spain
| | - Xabier Urra
- Functional Unit of Cerebrovascular Diseases, Hospital Clinic, Barcelona, Spain.,Area of Neuroscience, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Francisca Ruiz-Jaén
- Area of Neuroscience, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Jordi Pedragosa
- Area of Neuroscience, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Department of Brain Ischemia and Neurodegeneration, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), Barcelona, Spain
| | - Ángel Chamorro
- Functional Unit of Cerebrovascular Diseases, Hospital Clinic, Barcelona, Spain.,Area of Neuroscience, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Anna M Planas
- Area of Neuroscience, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Department of Brain Ischemia and Neurodegeneration, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), Barcelona, Spain
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21
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Sobel RA, Eaton MJ, Jaju PD, Lowry E, Hinojoza JR. Anti-Myelin Proteolipid Protein Peptide Monoclonal Antibodies Recognize Cell Surface Proteins on Developing Neurons and Inhibit Their Differentiation. J Neuropathol Exp Neurol 2020; 78:819-843. [PMID: 31400116 PMCID: PMC6703999 DOI: 10.1093/jnen/nlz058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 04/30/2019] [Accepted: 06/18/2019] [Indexed: 12/15/2022] Open
Abstract
Using a panel of monoclonal antibodies (mAbs) to myelin proteolipid protein (PLP) peptides, we found that in addition to CNS myelin, mAbs to external face but not cytoplasmic face epitopes immunostained neurons in immature human CNS tissues and in adult hippocampal dentate gyrus and olfactory bulbs, that is neural stem cell niches (NSCN). To explore the pathobiological significance of these observations, we assessed the mAb effects on neurodifferentiation in vitro. The mAbs to PLP 50-69 (IgG1κ and IgG2aκ), and 178-191 and 200-219 (both IgG1κ) immunostained live cell surfaces and inhibited neurite outgrowth of E18 rat hippocampal precursor cells and of PC12 cells, which do not express PLP. Proteins immunoprecipitated from PC12 cell extracts and captured by mAb-coated magnetic beads were identified by GeLC-MS/MS. Each neurite outgrowth-inhibiting mAb captured a distinct set of neurodifferentiation molecules including sequence-similar M6 proteins and other unrelated membrane and extracellular matrix proteins, for example integrins, Eph receptors, NCAM-1, and protocadherins. These molecules are expressed in adult human NSCN and are implicated in the pathogenesis of many chronic CNS disease processes. Thus, diverse anti-PLP epitope autoantibodies may inhibit neuronal precursor cell differentiation via multispecific recognition of cell surface molecules thereby potentially impeding endogenous neuroregeneration in NSCN and in vivo differentiation of exogenous neural stem cells.
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Affiliation(s)
- Raymond A Sobel
- Laboratory Service, Veterans Affairs Health Care System, Palo Alto, California.,Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Mary Jane Eaton
- Laboratory Service, Veterans Affairs Health Care System, Palo Alto, California.,Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Prajakta Dilip Jaju
- Laboratory Service, Veterans Affairs Health Care System, Palo Alto, California.,Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Eugene Lowry
- Laboratory Service, Veterans Affairs Health Care System, Palo Alto, California.,Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Julian R Hinojoza
- Laboratory Service, Veterans Affairs Health Care System, Palo Alto, California.,Department of Pathology, Stanford University School of Medicine, Stanford, California
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22
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Iadecola C, Buckwalter MS, Anrather J. Immune responses to stroke: mechanisms, modulation, and therapeutic potential. J Clin Invest 2020; 130:2777-2788. [PMID: 32391806 PMCID: PMC7260029 DOI: 10.1172/jci135530] [Citation(s) in RCA: 348] [Impact Index Per Article: 87.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Stroke is the second leading cause of death worldwide and a leading cause of disability. Most strokes are caused by occlusion of a major cerebral artery, and substantial advances have been made in elucidating how ischemia damages the brain. In particular, increasing evidence points to a double-edged role of the immune system in stroke pathophysiology. In the acute phase, innate immune cells invade brain and meninges and contribute to ischemic damage, but may also be protective. At the same time, danger signals released into the circulation by damaged brain cells lead to activation of systemic immunity, followed by profound immunodepression that promotes life-threatening infections. In the chronic phase, antigen presentation initiates an adaptive immune response targeted to the brain, which may underlie neuropsychiatric sequelae, a considerable cause of poststroke morbidity. Here, we briefly review these pathogenic processes and assess the potential therapeutic value of targeting immunity in human stroke.
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Affiliation(s)
- Costantino Iadecola
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Marion S. Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, Stanford, California, USA
| | - Josef Anrather
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
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23
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Okar SV, Topcuoglu MA, Yemisci M, Cakir Aktas C, Oguz KK, Arsava EM. Post-stroke inflammatory response is linked to volume loss in the contralateral hemisphere. J Neuroimmunol 2020; 344:577247. [PMID: 32388192 DOI: 10.1016/j.jneuroim.2020.577247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/20/2020] [Accepted: 04/20/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES There is a delicate homeostatic balance between the central nervous system and immune system. Stroke triggers an immunodepressive state to suppress a potential immune reaction directed against neuroglial tissue; however, this supposedly protective response inadvertently results in an infection-prone, and thereby a pro-inflammatory setting. In this study, we assessed the magnitude of cerebral volume loss in the unaffected contralateral hemisphere following stroke, and determined its relationship with inflammatory cascades. METHODS The volume of the hemisphere contralateral to the ischemic insult was measured on admission and follow-up MRI's in 50 ischemic stroke patients. Information related to clinical features, infectious complications, and markers of inflammation (erythrocyte sedimentation rate, neutrophil/lymphocyte ratio, C-reactive protein) were prospectively collected, and their relationship with hemispheric volume change was evaluated using bivariate and multivariate statistics. RESULTS The contralateral hemisphere volume decreased by a median (interquartile range) of 14 (4-32) mL after a follow-up duration of 101 (63-123) days (p < .001); the volume reduction was 0.8 (0.2-1.8) % per month with respect to baseline. Old age, atrial fibrillation, stroke severity, C-reactive protein level, neutrophil/lymphocyte ratio, and development of infections during hospitalization were significantly associated with volume loss (p < .05). Stroke severity (NIHSS score or infarct volume) and inflammation related parameters (neutrophil/lymphocyte ratio or systemic infections) remained independently and positively associated with volume loss in multivariate regression models. CONCLUSIONS Cerebral tissue changes following stroke are not limited to the ischemic hemisphere. Apart from stroke severity, a pro-inflammatory state and post-stroke infections contribute to cerebral volume loss in the non-ischemic hemisphere.
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Affiliation(s)
- Serhat V Okar
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mehmet A Topcuoglu
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Muge Yemisci
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey; Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Canan Cakir Aktas
- Institute of Neurological Sciences and Psychiatry, Hacettepe University, Ankara, Turkey
| | - Kader K Oguz
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ethem M Arsava
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
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24
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Zera KA, Buckwalter MS. The Local and Peripheral Immune Responses to Stroke: Implications for Therapeutic Development. Neurotherapeutics 2020; 17:414-435. [PMID: 32193840 PMCID: PMC7283378 DOI: 10.1007/s13311-020-00844-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The immune response to stroke is an exciting target for future stroke therapies. Stroke is a leading cause of morbidity and mortality worldwide, and clot removal (mechanical or pharmacological) to achieve tissue reperfusion is the only therapy currently approved for patient use. Due to a short therapeutic window and incomplete effectiveness, however, many patients are left with infarcted tissue that stimulates inflammation. Although this is critical to promote repair, it can also damage surrounding healthy brain tissue. In addition, acute immunodepression and subsequent infections are common and are associated with worse patient outcomes. Thus, the acute immune response is a major focus of researchers attempting to identify ways to amplify its benefits and suppress its negative effects to improve short-term recovery of patients. Here we review what is known about this powerful process. This includes the role of brain resident cells such as microglia, peripherally activated cells such as macrophages and neutrophils, and activated endothelium. The role of systemic immune activation and subsequent immunodepression in the days after stroke is also discussed, as is the chronic immune responses and its effects on cognitive function. The biphasic role of inflammation, as well as complex timelines of cell production, differentiation, and trafficking, suggests that the relationship between the acute and chronic phases of stroke recovery is complex. Gaining a more complete understanding of this intricate process by which inflammation is initiated, propagated, and terminated may potentially lead to therapeutics that can treat a larger population of stroke patients than what is currently available. The immune response plays a critical role in patient recovery in both the acute and chronic phases after stroke. In patients, the immune response can be beneficial by promoting repair and recovery, and also detrimental by propagating a pro-inflammatory microenvironment. Thus, it is critical to understand the mechanisms of immune activation following stroke in order to successfully design therapeutics.
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Affiliation(s)
- Kristy A Zera
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA.
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, USA.
- Department of Neurosurgery, Stanford Univeristy School of Medicine, Stanford, CA, USA.
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B cells migrate into remote brain areas and support neurogenesis and functional recovery after focal stroke in mice. Proc Natl Acad Sci U S A 2020; 117:4983-4993. [PMID: 32051245 PMCID: PMC7060723 DOI: 10.1073/pnas.1913292117] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Neuroinflammation occurs immediately after stroke onset in the ischemic infarct, but whether neuroinflammation occurs in remote regions supporting plasticity and functional recovery remains unknown. We used advanced imaging to quantify whole-brain diapedesis of B cells, an immune cell capable of producing neurotrophins. We identify bilateral B cell diapedesis into remote regions, outside of the injury, that support motor and cognitive recovery in young male mice. Poststroke depletion of B cells confirms a positive role in neurogenesis, neuronal survival, and recovery of motor coordination, spatial learning, and anxiety. More than 80% of stroke survivors have long-term disability uniquely affected by age and lifestyle factors. Thus, identifying beneficial neuroinflammation during long-term recovery increases the opportunity of therapeutic interventions to support functional recovery. Lymphocytes infiltrate the stroke core and penumbra and often exacerbate cellular injury. B cells, however, are lymphocytes that do not contribute to acute pathology but can support recovery. B cell adoptive transfer to mice reduced infarct volumes 3 and 7 d after transient middle cerebral artery occlusion (tMCAo), independent of changing immune populations in recipient mice. Testing a direct neurotrophic effect, B cells cocultured with mixed cortical cells protected neurons and maintained dendritic arborization after oxygen-glucose deprivation. Whole-brain volumetric serial two-photon tomography (STPT) and a custom-developed image analysis pipeline visualized and quantified poststroke B cell diapedesis throughout the brain, including remote areas supporting functional recovery. Stroke induced significant bilateral B cell diapedesis into remote brain regions regulating motor and cognitive functions and neurogenesis (e.g., dentate gyrus, hypothalamus, olfactory areas, cerebellum) in the whole-brain datasets. To confirm a mechanistic role for B cells in functional recovery, rituximab was given to human CD20+ (hCD20+) transgenic mice to continuously deplete hCD20+-expressing B cells following tMCAo. These mice experienced delayed motor recovery, impaired spatial memory, and increased anxiety through 8 wk poststroke compared to wild type (WT) littermates also receiving rituximab. B cell depletion reduced stroke-induced hippocampal neurogenesis and cell survival. Thus, B cell diapedesis occurred in areas remote to the infarct that mediated motor and cognitive recovery. Understanding the role of B cells in neuronal health and disease-based plasticity is critical for developing effective immune-based therapies for protection against diseases that involve recruitment of peripheral immune cells into the injured brain.
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Editorial: Advances in understanding causes and outcomes in stroke. Curr Opin Neurol 2020; 33:1-3. [DOI: 10.1097/wco.0000000000000784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Krishnan S, Lawrence CB. Old Dog New Tricks; Revisiting How Stroke Modulates the Systemic Immune Landscape. Front Neurol 2019; 10:718. [PMID: 31312180 PMCID: PMC6614437 DOI: 10.3389/fneur.2019.00718] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/18/2019] [Indexed: 12/27/2022] Open
Abstract
Infections in the post-acute phase of cerebral ischaemia impede optimal recovery by exacerbating morbidity and mortality. Our review aims to reconcile the increased infection susceptibility of patients post-stroke by consolidating our understanding of compartmentalised alterations to systemic immunity. Mounting evidence has catalogued alterations to numerous immune cell populations but an understanding of the mechanisms of long-range communication between the immune system, nervous system and other organs beyond the involvement of autonomic signalling is lacking. By taking our cues from established and emerging concepts of neuro-immune interactions, immune-mediated inter-organ cross-talk, innate immune training and the role of microbiota-derived signals in central nervous system (CNS) function we will explore mechanisms of how cerebral ischaemia could shape systemic immune function. In this context, we will also discuss a key question: how are immune requirements critical for mediating repair of the ischaemic insult balanced by the need for anti-microbial immunity post-stroke, given that they are mediated by mutually exclusive immune networks? Our reformed understanding of the immune landscape post-stroke and novel mechanisms at play could guide targeted therapeutic interventions and initiate a step-change in the clinical management of these infectious complications post-stroke.
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Affiliation(s)
- Siddharth Krishnan
- Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, United Kingdom.,Manchester Collaborative Centre for Inflammation Research, University of Manchester, Manchester, United Kingdom.,Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Catherine B Lawrence
- Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, United Kingdom.,Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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O'Connell GC, Stafford P, Walsh KB, Adeoye O, Barr TL. High-Throughput Profiling of Circulating Antibody Signatures for Stroke Diagnosis Using Small Volumes of Whole Blood. Neurotherapeutics 2019; 16:868-877. [PMID: 30783962 PMCID: PMC6694452 DOI: 10.1007/s13311-019-00720-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Accurate stroke recognition during triage can streamline care and afford patients earlier access to life-saving interventions. However, the tools currently available to clinicians for prehospital and early in-hospital identification of stroke are limited. The peripheral immune system is intricately involved in stroke pathology and thus may be targetable for the development of immunodiagnostics. In this preliminary study, we sought to determine whether the circulating antibody pool is altered early in stroke, and whether such alterations could be leveraged for diagnosis. One hundred microliters of peripheral whole blood was sampled from 19 ischemic stroke patients, 17 hemorrhagic stroke patients, and 20 stroke mimics in the acute phase of care. A custom-fabricated high-density peptide array comprising 125,000 unique probes was used to assess the binding characteristics of blood-borne antibodies, and a random forest-based approach was used to select a parsimonious set of probes with an optimal ability to discriminate between groups. The coordinate antibody binding intensities of the top 17 probes identified in our analysis displayed an ability to differentiate the total pool of stroke patients from stroke mimics with 92% sensitivity and 90% specificity, as well as detect hemorrhage with 88% sensitivity and 87% specificity, as determined using a same-set cross-validation. These preliminary findings suggest that stroke-associated alterations in the circulating antibody pool may have clinical utility for diagnosis during triage, and that such a possibility warrants further investigation.
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Affiliation(s)
- Grant C O'Connell
- School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio, 44106-4904, USA.
| | - Phillip Stafford
- Biodesign Institute, Arizona State University, Tempe, Arizona, USA
| | - Kyle B Walsh
- Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, Ohio, USA
| | - Opeolu Adeoye
- Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, Ohio, USA
| | - Taura L Barr
- Valtari Bio Incorporated, Morgantown, West Virginia, USA
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29
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Javidi E, Magnus T. Autoimmunity After Ischemic Stroke and Brain Injury. Front Immunol 2019; 10:686. [PMID: 31001280 PMCID: PMC6454865 DOI: 10.3389/fimmu.2019.00686] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/13/2019] [Indexed: 12/20/2022] Open
Abstract
Ischemic Stroke is a major cause of morbidity and mortality worldwide. Sterile inflammation occurs after both stroke subtypes and contributes to neuronal injury and damage to the blood-brain barrier with release of brain antigens and a potential induction of autoimmune responses that escape central and peripheral tolerance mechanisms. In stroke patients, the detection of T cells and antibodies specific to neuronal antigens suggests a role of humoral adaptive immunity. In experimental models stroke leads to a significant increase of autoreactive T and B cells to CNS antigens. Lesion volume and functional outcome in stroke patients and murine stroke models are connected to antigen-specific responses to brain proteins. In patients with traumatic brain injury (TBI) a range of antibodies against brain proteins can be detected in serum samples. In this review, we will summarize the role of autoimmunity in post-lesional conditions and discuss the role of B and T cells and their potential neuroprotective or detrimental effects.
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Affiliation(s)
- Ehsan Javidi
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Magnus
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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30
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LoPresti P. Silent Free Fall at Disease Onset: A Perspective on Therapeutics for Progressive Multiple Sclerosis. Front Neurol 2018; 9:973. [PMID: 30542317 PMCID: PMC6277889 DOI: 10.3389/fneur.2018.00973] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 10/29/2018] [Indexed: 01/08/2023] Open
Abstract
Central nervous system (CNS) degeneration occurs during multiple sclerosis (MS) following several years of reversible autoimmune demyelination. Progressive CNS degeneration appears later during the course of relapsing-remitting MS (RRMS), although it starts insidiously at disease onset. We propose that there is an early subclinical phase also for primary-progressive (PP) MS. Consensus exists that many different cell types are involved during disease onset. Furthermore, the response to the initial damage, which is specific for each individual, would result in distinct pathological pathways that add complexity to the disease and the mechanisms underlying progressive CNS degeneration. Progressive MS is classified as either active or not active, as well as with or without progression. Different forms of progressive MS might reflect distinct or overlapping pathogenetic pathways. Disease mechanisms should be determined for each patient at diagnosis and the time of treatment. Until individualized and time-sensitive treatments that specifically target the molecular mechanisms of the progressive aspect of the disease are identified, combined therapies directed at anti-inflammation, regeneration, and neuroprotection are the most effective for preventing MS progression. This review presents selected therapeutics in support of the overall idea of a multidimensional therapy applied early in the disease. This approach could limit damage and increase CNS repair. By targeting several cellular populations (i.e., microglia, astrocytes, neurons, oligodendrocytes, and lymphocytes) and multiple pathological processes (e.g., inflammation, demyelination, synaptopathy, and excitatory/inhibitory imbalance) progressive MS could be attenuated. Early timing for such multidimensional therapy is proposed as the prerequisite for effectively halting progressive MS.
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Affiliation(s)
- Patrizia LoPresti
- Department of Psychology, University of Illinois at Chicago, Chicago, IL, United States
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31
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Povroznik JM, Ozga JE, Haar CV, Engler-Chiurazzi EB. Executive (dys)function after stroke: special considerations for behavioral pharmacology. Behav Pharmacol 2018; 29:638-653. [PMID: 30215622 PMCID: PMC6152929 DOI: 10.1097/fbp.0000000000000432] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Stroke is a worldwide leading cause of death and long-term disability with concurrent secondary consequences that are largely comprised of mood dysfunction, as well as sensory, motor, and cognitive deficits. This review focuses on the cognitive deficits associated with stroke specific to executive dysfunction (including decision making, working memory, and cognitive flexibility) in humans, nonhuman primates, and additional animal models. Further, we review some of the cellular and molecular underpinnings of the individual components of executive dysfunction and their neuroanatomical substrates after stroke, with an emphasis on the changes that occur during biogenic monoamine neurotransmission. We concentrate primarily on changes in the catecholaminergic (dopaminergic and noradrenergic) and serotonergic systems at the levels of neurotransmitter synthesis, distribution, reuptake, and degradation. We also discuss potential secondary stroke-related behavioral deficits (specifically, poststroke depression as well as drug-abuse potential and addiction) and their relationship with stroke-induced deficits in executive function, an especially important consideration given that the average age of the human stroke population is decreasing. In the final sections, we address pharmacological considerations for the treatment of ischemia and the subsequent functional impairment, as well as current limitations in the field of stroke and executive function research.
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Affiliation(s)
- Jessica M. Povroznik
- Center for Basic and Translational Stroke Research, West Virginia University, Morgantown, WV, USA
- Department of Physiology, Pharmacology, and Neuroscience, West Virginia University, Morgantown, WV, USA
- Rodent Behavior Core, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Jenny E. Ozga
- Injury and Recovery Laboratory, Department of Psychology, West Virginia University, Morgantown, WV, USA
| | - Cole Vonder Haar
- Injury and Recovery Laboratory, Department of Psychology, West Virginia University, Morgantown, WV, USA
| | - Elizabeth B. Engler-Chiurazzi
- Center for Basic and Translational Stroke Research, West Virginia University, Morgantown, WV, USA
- Department of Physiology, Pharmacology, and Neuroscience, West Virginia University, Morgantown, WV, USA
- Rodent Behavior Core, Health Sciences Center, West Virginia University, Morgantown, WV, USA
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32
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Chaney A, Cropper HC, Johnson EM, Lechtenberg KJ, Peterson TC, Stevens MY, Buckwalter MS, James ML. 11C-DPA-713 Versus 18F-GE-180: A Preclinical Comparison of Translocator Protein 18 kDa PET Tracers to Visualize Acute and Chronic Neuroinflammation in a Mouse Model of Ischemic Stroke. J Nucl Med 2018; 60:122-128. [PMID: 29976695 PMCID: PMC6354224 DOI: 10.2967/jnumed.118.209155] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/23/2018] [Indexed: 12/12/2022] Open
Abstract
Neuroinflammation plays a key role in neuronal injury after ischemic stroke. PET imaging of translocator protein 18 kDa (TSPO) permits longitudinal, noninvasive visualization of neuroinflammation in both preclinical and clinical settings. Many TSPO tracers have been developed, however, it is unclear which tracer is the most sensitive and accurate for monitoring the in vivo spatiotemporal dynamics of neuroinflammation across applications. Hence, there is a need for head-to-head comparisons of promising TSPO PET tracers across different disease states. Accordingly, the aim of this study was to directly compare 2 promising second-generation TSPO tracers, 11C-DPA-713 and 18F-GE-180, for the first time at acute and chronic time points after ischemic stroke. Methods: After distal middle cerebral artery occlusion or sham surgery, mice underwent consecutive PET/CT imaging with 11C-DPA-713 and 18F-GE-180 at 2, 6, and 28 d after stroke. T2-weighted MR images were acquired to enable delineation of ipsilateral (infarct) and contralateral brain regions of interest (ROIs). PET/CT images were analyzed by calculating percentage injected dose per gram in MR-guided ROIs. SUV ratios were determined using the contralateral thalamus (SUVTh) as a pseudoreference region. Ex vivo autoradiography and immunohistochemistry were performed to verify in vivo findings. Results: Significantly increased tracer uptake was observed in the ipsilateral compared with contralateral ROI (SUVTh, 50-60 min summed data) at acute and chronic time points using 11C-DPA-713 and 18F-GE-180. Ex vivo autoradiography confirmed in vivo findings demonstrating increased TSPO tracer uptake in infarcted versus contralateral brain tissue. Importantly, a significant correlation was identified between microglial/macrophage activation (cluster of differentiation 68 immunostaining) and 11C-DPA-713- PET signal, which was not evident with 18F-GE-180. No significant correlations were observed between TSPO PET and activated astrocytes (glial fibrillary acidic protein immunostaining). Conclusion: 11C-DPA-713 and 18F-GE-180 PET enable detection of neuroinflammation at acute and chronic time points after cerebral ischemia in mice. 11C-DPA-713 PET reflects the extent of microglial activation in infarcted distal middle cerebral artery occlusion mouse brain tissue more accurately than 18F-GE-180 and appears to be slightly more sensitive. These results highlight the potential of 11C-DPA-713 for tracking microglial activation in vivo after stroke and warrant further investigation in both preclinical and clinical settings.
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Affiliation(s)
- Aisling Chaney
- Department of Radiology, Stanford University, Stanford California
| | - Haley C Cropper
- Department of Radiology, Stanford University, Stanford California
| | - Emily M Johnson
- Department of Radiology, Stanford University, Stanford California
| | - Kendra J Lechtenberg
- Department of Neurology and Neurological Sciences, Stanford University, Stanford California; and
| | - Todd C Peterson
- Department of Neurology and Neurological Sciences, Stanford University, Stanford California; and
| | - Marc Y Stevens
- Department of Radiology, Stanford University, Stanford California
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University, Stanford California; and.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michelle L James
- Department of Radiology, Stanford University, Stanford California .,Department of Neurology and Neurological Sciences, Stanford University, Stanford California; and
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Zheng H, Han Y, Du Y, Shi X, Huang H, Yu X, Tan X, Hu C, Wang Y, Zhou S. Regulation of Hypertension for Secondary Prevention of Stroke: The Possible 'Bridging Function' of Acupuncture. Complement Med Res 2018; 25:45-51. [PMID: 29393105 DOI: 10.1159/000475930] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Worldwide, stroke is the leading cause of mortality and disability, with hypertension being an independent risk factor for a secondary stroke. Acupuncture for the treatment of hypertension gains more attention in alternative and complementary medicine, but the results are inconsistent. Few studies regarding the secondary prevention of stroke by managing hypertension with acupuncture have been carried out as there are some problems regarding the antihypertensive drug status in the secondary prevention of stroke. Still, the potential of acupuncture in regulating the blood pressure for secondary stroke prevention deserves our focus. This review is based on papers recorded in the PubMed, Embase, and Web of Science databases, from their inception until March 28, 2017, and retrieved with the following search terms: hypertension and acupuncture, limited in spontaneously hypertensive rats (SHRs), stress-induced (or cold-induced) hypertensive or pre-hypertensive models. We find that, in these hypertensive animals, acupuncture could mainly influence factors related to the nervous system, oxidative stress, the endocrine system, cardiovascular function, and hemorheology, which are closely associated with the stroke outcome. This trend may give us a hint that acupuncture might well participate in the secondary prevention of stroke through these pathways when used in the management of hypertension.
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Fu Y, Yan Y. Emerging Role of Immunity in Cerebral Small Vessel Disease. Front Immunol 2018; 9:67. [PMID: 29422904 PMCID: PMC5788893 DOI: 10.3389/fimmu.2018.00067] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/10/2018] [Indexed: 01/06/2023] Open
Abstract
Cerebral small vessel disease (CSVD) is one of the main causes of vascular dementia in older individuals. Apart from risk containment, efforts to prevent or treat CSVD are ineffective due to the unknown pathogenesis of the disease. CSVD, a subtype of stroke, is characterized by recurrent strokes and neurodegeneration. Blood-brain barrier (BBB) impairment, chronic inflammatory responses, and leukocyte infiltration are classical pathological features of CSVD. Understanding how BBB disruption instigates inflammatory and degenerative processes may be informative for CSVD therapy. Antigens derived from the brain are found in the peripheral blood of lacunar stroke patients, and antibodies and sensitized T cells against brain antigens are also detected in patients with leukoaraiosis. These findings suggest that antigen-specific immune responses could occur in CSVD. This review describes the neurovascular unit features of CSVD, the immune responses to specific neuronal and glial processes that may be involved in a distinct mechanism of CSVD, and the current evidence of the association between mechanisms of inflammation and interventions in CSVD. We suggest that autoimmune activity should be assessed in future studies; this knowledge would benefit the development of effective therapeutic interventions in CSVD.
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Affiliation(s)
- Ying Fu
- Key Laboratory of the Ministry of Education for Medicinal Resources and Natural Pharmaceutical Chemistry, National Engineering Laboratory for Resource Development of Endangered Crude Drugs in Northwest of China, College of Life Sciences, Shaanxi Normal University, Xi'an, China
| | - Yaping Yan
- Key Laboratory of the Ministry of Education for Medicinal Resources and Natural Pharmaceutical Chemistry, National Engineering Laboratory for Resource Development of Endangered Crude Drugs in Northwest of China, College of Life Sciences, Shaanxi Normal University, Xi'an, China
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Harpaz D, Eltzov E, Seet RCS, Marks RS, Tok AIY. Point-of-Care-Testing in Acute Stroke Management: An Unmet Need Ripe for Technological Harvest. BIOSENSORS 2017; 7:E30. [PMID: 28771209 PMCID: PMC5618036 DOI: 10.3390/bios7030030] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 12/20/2022]
Abstract
Stroke, the second highest leading cause of death, is caused by an abrupt interruption of blood to the brain. Supply of blood needs to be promptly restored to salvage brain tissues from irreversible neuronal death. Existing assessment of stroke patients is based largely on detailed clinical evaluation that is complemented by neuroimaging methods. However, emerging data point to the potential use of blood-derived biomarkers in aiding clinical decision-making especially in the diagnosis of ischemic stroke, triaging patients for acute reperfusion therapies, and in informing stroke mechanisms and prognosis. The demand for newer techniques to deliver individualized information on-site for incorporation into a time-sensitive work-flow has become greater. In this review, we examine the roles of a portable and easy to use point-of-care-test (POCT) in shortening the time-to-treatment, classifying stroke subtypes and improving patient's outcome. We first examine the conventional stroke management workflow, then highlight situations where a bedside biomarker assessment might aid clinical decision-making. A novel stroke POCT approach is presented, which combines the use of quantitative and multiplex POCT platforms for the detection of specific stroke biomarkers, as well as data-mining tools to drive analytical processes. Further work is needed in the development of POCTs to fulfill an unmet need in acute stroke management.
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Affiliation(s)
- Dorin Harpaz
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
| | - Evgeni Eltzov
- Agriculture Research Organization (ARO), Volcani Centre, Rishon LeTsiyon 15159, Israel.
| | - Raymond C S Seet
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore.
| | - Robert S Marks
- Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- The National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
- The Ilse Katz Centre for Meso and Nanoscale Science and Technology, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
| | - Alfred I Y Tok
- School of Material Science & Engineering, Nanyang Technology University, 50 Nanyang Avenue, Singapore 639798, Singapore.
- Institute for Sports Research (ISR), Nanyang Technology University and Loughborough University, Nanyang Avenue, Singapore 639798, Singapore.
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Doyle KP, Buckwalter MS. Does B lymphocyte-mediated autoimmunity contribute to post-stroke dementia? Brain Behav Immun 2017; 64:1-8. [PMID: 27531189 PMCID: PMC5305803 DOI: 10.1016/j.bbi.2016.08.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/01/2016] [Accepted: 08/12/2016] [Indexed: 01/02/2023] Open
Abstract
Post-stroke cognitive decline and dementia pose a significant public health problem, with 30% of stroke survivors suffering from dementia. The reason for this high prevalence is not well understood. Pathogenic B cell responses to the damaged CNS are one possible contributing factor. B-lymphocytes and antibodies are present in and around the stroke core of some human subjects who die with stroke and dementia, and mice that develop delayed cognitive dysfunction after stroke have clusters of B-lymphocytes in the stroke lesion, and antibody infiltration in the stroked hemisphere. The ablation of B-lymphocytes prevents post-stroke cognitive impairment in mice. Multiple drugs that target B cells are FDA approved, and so if pathogenic B cell responses are occurring in a subset of stroke patients, this is potentially treatable. However, it has also been demonstrated that regulatory B cells can be beneficial in mouse models of stroke. Consequently, it is important to understand the relative contribution of B-lymphocytes to recovery versus pathogenicity, and if this balance is heterogeneous in different individuals. Therefore, the purpose of this review is to summarize the current state of knowledge with regard to the role of B-lymphocytes in the etiology of post-stroke dementia.
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Affiliation(s)
- Kristian P. Doyle
- Department of Immunobiology, Department of Neurology, and the Arizona Center on Aging, University of Arizona, Tucson, Arizona, USA
| | - Marion S. Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA,Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
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Becker KJ, Buckwalter M. Stroke, Inflammation and the Immune Response: Dawn of a New Era. Neurotherapeutics 2016; 13:659-660. [PMID: 27677606 PMCID: PMC5081111 DOI: 10.1007/s13311-016-0478-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Kyra J Becker
- University of Washington School of Medicine, Seattle, WA, USA.
| | - Marion Buckwalter
- Stanford University School of Medicine, Stanford University, Stanford, CA, USA
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Abstract
Stroke induces a local inflammatory reaction and a plethora of innate immune responses in the brain where antigen-presenting cells become prominent. However, to date, it is still unclear whether antigen presentation is relevant to the neuropathological and functional outcome of stroke. Stroke does not trigger overt autoimmune reactions, but neural antigens have been found in lymphoid tissues of patient with stroke and it is unknown whether they promote tolerance or immune reactions that under certain conditions might contribute to the functional worsening observed in some patients. Autoantibodies to neural molecules have also been reported in patients with stroke, but the subclass of antibodies is important for their function, and the contribution of such findings to stroke outcome is not yet clear. Notably, stroke induces immunodepression highlighted by a transient lymphopenia, lymphoid organ atrophy, and monocyte deactivation. While these effects might reduce the chances of autoreactivity, they increase the risk of infection in patients with stroke and most frequently in those with severe stroke. Therefore any potential brain protective effect of stroke-induced immunodepression by attenuating or preventing lymphocyte-mediated brain damage is confounded by stroke severity and an increased incidence of infections. Systemic inflammation due to a number of comorbidities that are frequent in patients with stroke is also associated to a poor outcome. Herein, we review some relevant findings regarding the identification of neural antigens in stroke and discuss their potential contribution to the functional outcome of stroke.
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Affiliation(s)
- Francesc Miró-Mur
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Xabier Urra
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain
| | - Mattia Gallizioli
- Department of Brain Ischemia and Neurodegeneration, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), Barcelona, Spain
| | - Angel Chamorro
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain
| | - Anna M Planas
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
- Department of Brain Ischemia and Neurodegeneration, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), Barcelona, Spain.
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39
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Wu P, Zhou YM, Zeng F, Li ZJ, Luo L, Li YX, Fan W, Qiu LH, Qin W, Chen L, Bai L, Nie J, Zhang S, Xiong Y, Bai Y, Yin CX, Liang FR. Regional brain structural abnormality in ischemic stroke patients: a voxel-based morphometry study. Neural Regen Res 2016; 11:1424-1430. [PMID: 27857744 PMCID: PMC5090843 DOI: 10.4103/1673-5374.191215] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2016] [Indexed: 02/05/2023] Open
Abstract
Our previous study used regional homogeneity analysis and found that activity in some brain areas of patients with ischemic stroke changed significantly. In the current study, we examined structural changes in these brain regions by taking structural magnetic resonance imaging scans of 11 ischemic stroke patients and 15 healthy participants, and analyzing the data using voxel-based morphometry. Compared with healthy participants, patients exhibited higher gray matter density in the left inferior occipital gyrus and right anterior white matter tract. In contrast, gray matter density in the right cerebellum, left precentral gyrus, right middle frontal gyrus, and left middle temporal gyrus was less in ischemic stroke patients. The changes of gray matter density in the middle frontal gyrus were negatively associated with the clinical rating scales of the Fugl-Meyer Motor Assessment (r = -0.609, P = 0.047) and the left middle temporal gyrus was negatively correlated with the clinical rating scales of the nervous functional deficiency scale (r = -0.737, P = 0.010). Our findings can objectively identify the functional abnormality in some brain regions of ischemic stroke patients.
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Affiliation(s)
- Ping Wu
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Yu-mei Zhou
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Fang Zeng
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Zheng-jie Li
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Lu Luo
- China Academy of Chinese Medical Sciences, World Federation of Acupuncture-Moxibustion Societies, Beijing, China
| | - Yong-xin Li
- Institute of Clinical Anatomy, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Wei Fan
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Li-hua Qiu
- Radiology Department, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Wei Qin
- Life Sciences Research Center, School of Life Sciences and Technology, Xidian University, Xi’an, Shaanxi Province, China
| | - Lin Chen
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Lin Bai
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Juan Nie
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - San Zhang
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Yan Xiong
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Yu Bai
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Can-xin Yin
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Fan-rong Liang
- Acupuncture and Tuina School/Third Teaching Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
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