1
|
Crispino P. Hemorrhagic Coagulation Disorders and Ischemic Stroke: How to Reconcile Both? Neurol Int 2023; 15:1443-1458. [PMID: 38132972 PMCID: PMC10745771 DOI: 10.3390/neurolint15040093] [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: 10/15/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
Coagulation and fibrinolytic system disorders are conditions in which the blood's ability to clot is impaired, resulting in an increased risk of thrombosis or bleeding. Although these disorders are the expression of two opposing tendencies, they can often be associated with or be a consequence of each other, contributing to making the prognosis of acute cerebrovascular events more difficult. It is important to recognize those conditions that are characterized by dual alterations in the coagulation and fibrinolytic systems to reduce the prognostic impact of clinical conditions with difficult treatment and often unfortunate outcomes. Management of these individuals can be challenging, as clinicians must balance the need to prevent bleeding episodes with the potential risk of clot formation. Treatment decisions should be made on an individual basis, considering the specific bleeding disorder, its severity, and the patient's general medical condition. This review aims to deal with all those forms in which coagulation and fibrinolysis represent two sides of the same media in the correct management of patients with acute neurological syndrome. Precision medicine, personalized treatment, advanced anticoagulant strategies, and innovations in bleeding control represent future directions in the management of these complex pathologies in which stroke can be the evolution of two different acute events or be the first manifestation of an occult or unknown underlying pathology.
Collapse
Affiliation(s)
- Pietro Crispino
- Medicine Unit, Santa Maria Goretti Hospital, Via Scaravelli Snc, 04100 Latina, Italy
| |
Collapse
|
2
|
Liang H, Wang X, Quan X, Qin B, Zhang J, Liang S, Liang Z. Safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants prior to stroke: a meta-analysis. J Neurol 2023; 270:4192-4200. [PMID: 37314507 DOI: 10.1007/s00415-023-11815-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND To assess the safety and efficacy of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) taking direct oral anticoagulants (DOACs) prior to stroke. METHODS Literature was searched in PubMed, Cochrane Library, and Embase until March 13, 2023. The primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included excellent outcome (modified Rankin Scale [mRS] 0-1), functional independence (mRS 0-2), and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using a random-effects model. RESULTS Five non-randomized studies included 239,879 patients with AIS treated with IVT, with 3400 (1.42%) taking DOACs prior to stroke. The rates of sICH did not differ statistically between patients taking DOACs and those not taking anticoagulants (unadjusted OR 0.98; 95% CI 0.67-1.44; P = 0.92; adjusted OR 0.81; 95% CI 0.64-1.03; P = 0.09). Patients taking DOACs had significantly higher adjusted rates of excellent outcome (adjusted OR 1.22; 95% CI 1.06-1.40; P < 0.01) and functional independence (adjusted OR 1.25; 95% CI 1.10-1.42; P < 0.01) at discharge than those not taking anticoagulants. No significant difference was observed in mortality and other efficacy outcomes between groups after adjustment. CONCLUSION The meta-analysis indicated that taking DOACs prior to stroke does not significantly increase the risk of sICH in selected patients with AIS treated with IVT. Furthermore, the benefits of IVT in selected patients taking DOACs appear to be comparable to those not taking anticoagulants. Further research is warranted to confirm the findings.
Collapse
Affiliation(s)
- Huo Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Xue Wang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Xuemei Quan
- Department of Neurology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, China
| | - Bin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Shuolin Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China.
| |
Collapse
|
3
|
Torrente D, Su EJ, Fredriksson L, Warnock M, Bushart D, Mann KM, Emal CD, Lawrence DA. Compartmentalized Actions of the Plasminogen Activator Inhibitors, PAI-1 and Nsp, in Ischemic Stroke. Transl Stroke Res 2022; 13:801-815. [PMID: 35122213 PMCID: PMC9349468 DOI: 10.1007/s12975-022-00992-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/22/2021] [Accepted: 01/26/2022] [Indexed: 02/08/2023]
Abstract
Tissue plasminogen activator (tPA) is a multifunctional protease. In blood tPA is best understood for its role in fibrinolysis, whereas in the brain tPA is reported to regulate blood-brain barrier (BBB) function and to promote neurodegeneration. Thrombolytic tPA is used for the treatment of ischemic stroke. However, its use is associated with an increased risk of hemorrhagic transformation. In blood the primary regulator of tPA activity is plasminogen activator inhibitor 1 (PAI-1), whereas in the brain, its primary inhibitor is thought to be neuroserpin (Nsp). In this study, we compare the effects of PAI-1 and Nsp deficiency in a mouse model of ischemic stroke and show that tPA has both beneficial and harmful effects that are differentially regulated by PAI-1 and Nsp. Following ischemic stroke Nsp deficiency in mice leads to larger strokes, increased BBB permeability, and increased spontaneous intracerebral hemorrhage. In contrast, PAI-1 deficiency results in smaller infarcts and increased cerebral blood flow recovery. Mechanistically, our data suggests that these differences are largely due to the compartmentalized action of PAI-1 and Nsp, with Nsp deficiency enhancing tPA activity in the CNS which increases BBB permeability and worsens stroke outcomes, while PAI-1 deficiency enhances fibrinolysis and improves recovery. Finally, we show that treatment with a combination therapy that enhances endogenous fibrinolysis by inhibiting PAI-1 with MDI-2268 and reduces BBB permeability by inhibiting tPA-mediated PDGFRα signaling with imatinib significantly reduces infarct size compared to vehicle-treated mice and to mice with either treatment alone.
Collapse
Affiliation(s)
- Daniel Torrente
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Enming Joseph Su
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, 7301 MSRB III, 1150 W. Medical Center Dr, Ann Arbor, MI, 48109-0644, USA
| | - Linda Fredriksson
- Biomedicum, Karolinska Institute, Solnavägen 9, Quarter 6D, 17165, Solna, Sweden
| | - Mark Warnock
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, 7301 MSRB III, 1150 W. Medical Center Dr, Ann Arbor, MI, 48109-0644, USA
| | - David Bushart
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, 7301 MSRB III, 1150 W. Medical Center Dr, Ann Arbor, MI, 48109-0644, USA
- Current affiliation: Ohio State University College of Medicine, Columbus, OH, USA
| | - Kris M Mann
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, 7301 MSRB III, 1150 W. Medical Center Dr, Ann Arbor, MI, 48109-0644, USA
| | - Cory D Emal
- Department of Chemistry, Eastern Michigan University, Ypsilanti, MI, 48197, USA
| | - Daniel A Lawrence
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, 7301 MSRB III, 1150 W. Medical Center Dr, Ann Arbor, MI, 48109-0644, USA.
| |
Collapse
|
4
|
Yawoot N, Sengking J, Wicha P, Govitrapong P, Tocharus C, Tocharus J. Melatonin attenuates reactive astrogliosis and glial scar formation following cerebral ischemia and reperfusion injury mediated by GSK-3β and RIP1K. J Cell Physiol 2021; 237:1818-1832. [PMID: 34825376 DOI: 10.1002/jcp.30649] [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: 06/30/2021] [Revised: 10/26/2021] [Accepted: 11/15/2021] [Indexed: 11/06/2022]
Abstract
Even though astrocytes have been widely reported to support several brain functions, studies have emerged that they exert deleterious effects on the brain after ischemia and reperfusion (I/R) injury. The present study investigated the neuroprotective effects of melatonin on the processes of reactive astrogliosis and glial scar formation, as well as axonal regeneration after transient middle cerebral artery occlusion. Male Wistar rats were randomly divided into four groups: sham-operated, I/R, I/R treated with melatonin, and I/R treated with edaravone. All drugs were administered via intraperitoneal injection at the onset of reperfusion and were continued until the rats were sacrificed on Day 7 or 14 after the surgery. Melatonin presented long-term benefits on cerebral damage after I/R injury, as demonstrated by a decreased infarct volume, histopathological changes, and reduced neuronal cell death. We also found that melatonin attenuated reactive astrogliosis and glial scar formation and, consequently, enhanced axonal regeneration and promoted neurobehavioral recovery. Furthermore, glycogen synthase kinase-3 beta (GSK-3β) and receptor-interacting serine/threonine-protein 1 kinase (RIP1K), which had previously been revealed as proteins involved in astrocyte responses, were significantly reduced after melatonin administration. Taken together, melatonin effectively counteracted the deleterious effects due to astrocyte responses and improved axonal regeneration to promote functional recovery during the chronic phase of cerebral I/R injury by inhibiting GSK-3β and RIP1K activities.
Collapse
Affiliation(s)
- Nuttapong Yawoot
- Department of Physiology, Chiang Mai University, Chiang Mai, Thailand.,Graduate School, Chiang Mai University, Chiang Mai, Thailand
| | - Jirakhamon Sengking
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Piyawadee Wicha
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Chainarong Tocharus
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Jiraporn Tocharus
- Department of Physiology, Chiang Mai University, Chiang Mai, Thailand.,Department of Physiology, Functional Food Research Center for Well-being, Chiang Mai University, Chiang Mai, Thailand
| |
Collapse
|
5
|
Whole body hypothermia extends tissue plasminogen activator treatment window in the rat model of embolic stroke. Life Sci 2020; 256:117450. [PMID: 32087233 DOI: 10.1016/j.lfs.2020.117450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 12/12/2022]
Abstract
Late treatment with tissue plasminogen activator (tPA) leads to reperfusion injury and poor outcome in ischemic stroke. We have recently shown the beneficial effects of local brain hypothermia after late thrombolysis. Herein, we investigated whether transient whole-body hypothermia was neuroprotective and could prevent the side effects of late tPA therapy at 5.5 h after embolic stroke. After induction of stroke, male rats were randomly assigned into four groups: Control, Hypothermia, tPA and Hypothermia+tPA. Hypothermia started at 5 h after embolic stroke and continued for 1 h. Thirty min after hypothermia, tPA was administrated. Infarct volume, brain edema, blood-brain barrier (BBB) and matrix metalloproteinase-9 (MMP-9) were assessed 48 h and neurological functions were assessed 24 and 48 hour post-stroke. Compared with the control or tPA groups, whole-body hypothermia decreased infarct volume (P < 0.01), BBB disruption (P < 0.05) and MMP-9 level (P < 0.05). However, compared with hypothermia alone a combination of hypothermia and tPA was more effective in reducing infarct volume. While hypothermia alone did not show any effect, its combination with tPA reduced brain edema (P < 0.05). Hypothermia alone or when combined with tPA decreased MMP-9 compared with control or tPA groups (P < 0.01). Although delayed tPA therapy exacerbated BBB integrity, general cooling hampered its leakage after late thrombolysis (P < 0.05). Moreover, only combination therapy significantly improved sensorimotor function as well as forelimb muscle strength at 24 or 48 h after stroke (P < 0.01). Transient whole-body hypothermia in combination with delayed thrombolysis therapy shows more neuroprotection and extends therapeutic time window of tPA up to 5.5 h.
Collapse
|
6
|
Jiang RH, Zu QQ, Xu XQ, Wang B, Ding Y, Wang J, Liu S, Shi HB. A Canine Model of Hemorrhagic Transformation Using Recombinant Tissue Plasminogen Activator Administration After Acute Ischemic Stroke. Front Neurol 2019; 10:673. [PMID: 31293509 PMCID: PMC6603151 DOI: 10.3389/fneur.2019.00673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/10/2019] [Indexed: 11/13/2022] Open
Abstract
Early reperfusion of occluded arteries via recombinant tissue plasminogen activator (rtPA) administration is considered to be an effective strategy for the treatment of acute ischemic stroke. However, delayed administration of rtPA may cause severe hemorrhagic transformation (HT) and undesirable neurological outcomes. The current study aims to establish a canine HT model using rtPA administration and to investigate the potential mechanisms underlying HT. Following anesthesia, two autologous clots were injected into the middle cerebral artery (MCA) to induce ischemic stroke. To induce reperfusion, rtPA (2 mg/kg) was administrated intravenously 4.5 h after the establishment of stroke. The occurrence of HT was determined by computed tomography (CT) and by pathological assessment. Transmission electron microscopy was utilized to assess blood-brain barrier (BBB) damage. The expression of matrix metalloprotein 9 (MMP-9) was analyzed by enzyme linked immunosorbent assay (ELISA), immunofluorescence (IF), and western blot. Administration of rtPA 4.5 h after stroke induced reperfusion in 73.9% of the canines, caused evident HT, and did not improve neurological outcomes compared to canines that did not receive rtPA. There was a significant increase in expression of MMP-9 after rtPA administration, accompanied by BBB disruption. We have established a canine HT model that closely mimics human HT by using rtPA administration after the induction of middle cerebral artery occlusion (MCAO) with autologous clots. Our data suggest that a potential mechanism underlying rtPA-caused HT may be related to BBB dysfunction induced by an increase in MMP-9 expression.
Collapse
Affiliation(s)
- Run-Hao Jiang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qing-Quan Zu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Charles T. Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, United States
| | - Xiao-Quan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bin Wang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ye Ding
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Jun Wang
- Department of Toxicology, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Sheng Liu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hai-Bin Shi
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
7
|
Ouk T, Potey C, Maestrini I, Petrault M, Mendyk AM, Leys D, Bordet R, Gautier S. Neutrophils in tPA-induced hemorrhagic transformations: Main culprit, accomplice or innocent bystander? Pharmacol Ther 2019; 194:73-83. [DOI: 10.1016/j.pharmthera.2018.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
8
|
Liu M, Zheng Y, Li G. Safety of Recanalization Therapy in Patients with Acute Ischemic Stroke Under Anticoagulation: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2018; 27:2296-2305. [PMID: 30017747 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Intravenous thrombolysis treatment (IVT) and endovascular therapy (EVT) have been proved as fist-line beneficial option for eligible patients who have acute ischemic stroke (AIS) with major safety concern of symptomatic intracranial hemorrhage (sICH). Unfortunately, the emergency management of patients with AIS taking vitamin K antagonists and with international normalized ratio higher than 1.7 or taking new oral anticoagulants (NOACs) represents a great challenge. We aim to comprehensively determine the safety of EVT in patients under prior-stroke anticoagulants and IVT in patients under NOAC use. METHODS Clinical researches published in the Embase, PubMed, and Cochrane Library electronic databases up to December 2017 were identified for analysis. Subgroup and sensitivity analyses were also conducted to evaluate the robustness of the conclusions. RESULTS Overall, 9 studies involving 3885 patients met the inclusion criteria. The rate of sICH (risk ratio [RR] = .94, 95% CI = .61-1.47, P = .799), mortality (P = .495), and recanalization (P = .655) after EVT did not differ between patients under and those who were not under anticoagulants, although patients under anticoagulants were less likely to achieve good functional outcome (P < .001) than those who were not. Moreover, prior NOAC therapy was not significantly associated with increasing sICH in patients with AIS after IVT (RR = .79, 95% CI = .41-1.53, P = .492). CONCLUSIONS Patients under anticoagulation appear to be safe after EVT with relatively lower rate of good outcome; furthermore, prior NOAC therapy was not associated with an increasing sICH rate after IVT. This offered a practical information to select appropriate therapeutic strategies for patients under anticoagulation, although the level of evidence seems to be quite shaky.
Collapse
Affiliation(s)
- Mingsu Liu
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Yang Zheng
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China
| | - Guangqin Li
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China.
| |
Collapse
|
9
|
Blood-brain barrier permeability assessed by perfusion computed tomography predicts hemorrhagic transformation in acute reperfusion therapy. Neurol Sci 2018; 39:1579-1584. [DOI: 10.1007/s10072-018-3468-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 06/04/2018] [Indexed: 10/14/2022]
|
10
|
Mao L, Li P, Zhu W, Cai W, Liu Z, Wang Y, Luo W, Stetler RA, Leak RK, Yu W, Gao Y, Chen J, Chen G, Hu X. Regulatory T cells ameliorate tissue plasminogen activator-induced brain haemorrhage after stroke. Brain 2017; 140:1914-1931. [PMID: 28535201 DOI: 10.1093/brain/awx111] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 03/26/2017] [Indexed: 01/22/2023] Open
Abstract
Delayed thrombolytic treatment with recombinant tissue plasminogen activator (tPA) may exacerbate blood-brain barrier breakdown after ischaemic stroke and lead to lethal haemorrhagic transformation. The immune system is a dynamic modulator of stroke response, and excessive immune cell accumulation in the cerebral vasculature is associated with compromised integrity of the blood-brain barrier. We previously reported that regulatory T cells, which function to suppress excessive immune responses, ameliorated blood-brain barrier damage after cerebral ischaemia. This study assessed the impact of regulatory T cells in the context of tPA-induced brain haemorrhage and investigated the underlying mechanisms of action. The number of circulating regulatory T cells in stroke patients was dramatically reduced soon after stroke onset (84 acute ischaemic stroke patients with or without intravenous tPA treatment, compared to 115 age and gender-matched healthy controls). Although stroke patients without tPA treatment gradually repopulated the numbers of circulating regulatory T cells within the first 7 days after stroke, post-ischaemic tPA treatment led to sustained suppression of regulatory T cells in the blood. We then used the murine suture and embolic middle cerebral artery occlusion models of stroke to investigate the therapeutic potential of adoptive regulatory T cell transfer against tPA-induced haemorrhagic transformation. Delayed administration of tPA (10 mg/kg) resulted in haemorrhagic transformation in the ischaemic territory 1 day after ischaemia. When regulatory T cells (2 × 106/mouse) were intravenously administered immediately after delayed tPA treatment in ischaemic mice, haemorrhagic transformation was significantly decreased, and this was associated with improved sensorimotor functions. Blood-brain barrier disruption and tight junction damages were observed in the presence of delayed tPA after stroke, but were mitigated by regulatory T cell transfer. Mechanistic studies demonstrated that regulatory T cells completely abolished the tPA-induced elevation of MMP9 and CCL2 after stroke. Using MMP9 and CCL2 knockout mice, we discovered that both molecules partially contributed to the protective actions of regulatory T cells. In an in vitro endothelial cell-based model of the blood-brain barrier, we confirmed that regulatory T cells inhibited tPA-induced endothelial expression of CCL2 and preserved blood-brain barrier integrity after an ischaemic challenge. Lentivirus-mediated CCL2 knockdown in endothelial cells completely abolished the blood-brain barrier protective effect of regulatory T cells in vitro. Altogether, our studies suggest that regulatory T cell adoptive transfer may alleviate thrombolytic treatment-induced haemorrhage in stroke victims. Furthermore, regulatory T cell-afforded protection in the tPA-treated stroke model is mediated by two inhibitory mechanisms involving CCL2 and MMP9. Thus, regulatory T cell adoptive transfer may be useful as a cell-based therapy to improve the efficacy and safety of thrombolytic treatment for ischaemic stroke.
Collapse
Affiliation(s)
- Leilei Mao
- Pittsburgh Institute of Brain Disorders and Recovery and Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.,State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai 200032, China.,Life Science Research Centre of Taishan Medical University, Taishan 271016, Shandong, China
| | - Peiying Li
- Pittsburgh Institute of Brain Disorders and Recovery and Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.,Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
| | - Wen Zhu
- Pittsburgh Institute of Brain Disorders and Recovery and Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA
| | - Wei Cai
- Pittsburgh Institute of Brain Disorders and Recovery and Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA
| | - Zongjian Liu
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing 100010, China
| | - Yanling Wang
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing 100010, China
| | - Wenli Luo
- AstraZeneca Pharmaceutical Company, Waltham, Massachusetts 02452, USA
| | - Ruth A Stetler
- Pittsburgh Institute of Brain Disorders and Recovery and Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.,State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai 200032, China
| | - Rehana K Leak
- Division of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA 15282, USA
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
| | - Yanqin Gao
- State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai 200032, China
| | - Jun Chen
- Pittsburgh Institute of Brain Disorders and Recovery and Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.,State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai 200032, China
| | - Gang Chen
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, China
| | - Xiaoming Hu
- Pittsburgh Institute of Brain Disorders and Recovery and Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.,State Key Laboratory of Medical Neurobiology and Institute of Brain Sciences, Fudan University, Shanghai 200032, China.,China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing 100010, China
| |
Collapse
|
11
|
Zhao XJ, Larkin TM, Lauver MA, Ahmad S, Ducruet AF. Tissue plasminogen activator mediates deleterious complement cascade activation in stroke. PLoS One 2017; 12:e0180822. [PMID: 28700732 PMCID: PMC5507253 DOI: 10.1371/journal.pone.0180822] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 06/21/2017] [Indexed: 11/22/2022] Open
Abstract
The use of intravenous tissue plasminogen activator (tPA) in the treatment of ischemic stroke is limited by its propensity to exacerbate brain edema and hemorrhage. The mechanisms underlying these deleterious effects of tPA remain incompletely understood. The purpose of this study was to delineate a pathway of tPA-mediated complement cascade activation in stroke and to determine whether complement inhibition ameliorates the adverse effects of post-ischemic tPA administration. We found that tPA promotes C3 cleavage both in vitro and in ischemic brain through a plasmin-mediated extrinsic pathway. Using cell culture models, we then showed that the C3a-receptor is strongly expressed on ischemic endothelium and that exogenous C3a dramatically enhances endothelial cell permeability. Next, we assessed the effect of tPA administration on brain edema and hemorrhage in a transient model of focal cerebral ischemia in C57BL/6 mice. We found that intravenous tPA exacerbates brain edema and hemorrhage in stroke, and that these effects are abrogated by a small-molecule antagonist of the C3a receptor. These findings establish for the first time that intravenous tPA dramatically upregulates complement cascade activation in ischemic brain and that pharmacologic complement inhibition protects against the adverse effects of tPA-mediated thrombolysis in stroke.
Collapse
Affiliation(s)
- Xue-Jun Zhao
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Timothy M. Larkin
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Molly A. Lauver
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Saif Ahmad
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States of America
| | - Andrew F. Ducruet
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail:
| |
Collapse
|
12
|
Kurowski D, Jonczak K, Shah Q, Yaghi S, Marshall RS, Ahmad H, McKinney J, Torres J, Ishida K, Cucchiara B. Safety of Endovascular Intervention for Stroke on Therapeutic Anticoagulation: Multicenter Cohort Study and Meta-Analysis. J Stroke Cerebrovasc Dis 2017; 26:1104-1109. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/09/2016] [Accepted: 12/26/2016] [Indexed: 10/20/2022] Open
|
13
|
Chen H, Liu N, Li Y, Wintermark M, Jackson A, Wu B, Su Z, Chen F, Hu J, Zhang Y, Zhu G. Mismatch of Low Perfusion and High Permeability Predicts Hemorrhagic Transformation Region in Acute Ischemic Stroke Patients Treated with Intra-arterial Thrombolysis. Sci Rep 2016; 6:27950. [PMID: 27302077 PMCID: PMC4908417 DOI: 10.1038/srep27950] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 05/27/2016] [Indexed: 01/20/2023] Open
Abstract
This study sought to determine whether the permeability related parameter K(trans), derived from computed tomography perfusion (CTP) imaging, can predict hemorrhagic transformation (HT) in patients with acute ischemic stroke who receive intra-arterial thrombolysis. Data from patients meeting the criterion were examined. CTP was performed and K(trans) maps were used to assess the permeability values in HT and non-HT regions. A receiver operating characteristic (ROC) curve was calculated, showing the sensitivity and specificity of K(trans) for predicting HT risk. Composite images were produced to illustrate the spatial correlations among perfusion, permeability changes and HT. This study examined 41 patients. Twenty-six patients had hemorrhagic infarction and 15 had parenchymal hemorrhage. The mean K(trans) value in HT regions was significantly lower than that in the non-HT regions (0.26 ± 0.21/min vs. 0.78 ± 0.64/min; P < 0.001). The ROC curve analysis identified an optimal cutoff value of 0.334/min for K(trans) to predict HT risk. Composite images suggested ischemic regions with low permeability, or the mismatch area of low perfusion and high permeability, more likely have HT. HT regions after intra-arterial thrombolysis had lower permeability values on K(trans) maps. The mismatch area of lower perfusion and higher permeability are more likely to develop HT.
Collapse
Affiliation(s)
- Hui Chen
- Department of Neurology, Military General Hospital of Beijing PLA, Beijing, 100700, China
| | - Nan Liu
- Department of Neurology, Military General Hospital of Beijing PLA, Beijing, 100700, China
| | - Ying Li
- Department of Neurology, Military General Hospital of Beijing PLA, Beijing, 100700, China
| | - Max Wintermark
- Stanford University, Department of Radiology, Neuroradiology Section, Stanford, CA, USA
| | - Alan Jackson
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK
| | - Bing Wu
- Department of Radiology, Military General Hospital of Beijing PLA, Beijing, 100700, China
| | | | - Fei Chen
- Department of Neurology, Military General Hospital of Beijing PLA, Beijing, 100700, China
| | - Jun Hu
- Department of Neurology, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China
| | - Yongwei Zhang
- Department of Neurology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Guangming Zhu
- Department of Neurology, Military General Hospital of Beijing PLA, Beijing, 100700, China
| |
Collapse
|
14
|
Wang W, Li M, Wang Y, Li Q, Deng G, Wan J, Yang Q, Chen Q, Wang J. GSK-3β inhibitor TWS119 attenuates rtPA-induced hemorrhagic transformation and activates the Wnt/β-catenin signaling pathway after acute ischemic stroke in rats. Mol Neurobiol 2015; 53:7028-7036. [PMID: 26671619 DOI: 10.1007/s12035-015-9607-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
Hemorrhagic transformation (HT) is a devastating complication for patients with acute ischemic stroke who are treated with tissue plasminogen activator (tPA). It is associated with high morbidity and mortality, but no effective treatments are currently available to reduce HT risk. Therefore, methods to prevent HT are urgently needed. In this study, we used TWS119, an inhibitor of glycogen synthase kinase 3β (GSK-3β), to evaluate the role of the Wnt/β-catenin signaling pathway in recombinant tPA (rtPA)-induced HT. Sprague-Dawley rats were subjected to a middle cerebral artery occlusion (MCAO) model of ischemic stroke and then were administered rtPA, rtPA combined with TWS119, or vehicle at 4 h. The animals were sacrificed 24 h after infarct induction. Rats treated with rtPA showed evident HT, had more severe neurologic deficit, brain edema, and blood-brain barrier breakdown, and had larger infarction volume than did the vehicle group. Rats treated with TWS119 had significantly improved outcomes compared with those of rats treated with rtPA alone. In addition, Western blot analysis showed that TWS119 increased the protein expression of β-catenin, claudin-3, and ZO-1 while suppressing the expression of GSK-3β. These results suggest that TWS119 reduces rtPA-induced HT and attenuates blood-brain barrier disruption, possibly through activation of the Wnt/β-catenin signaling pathway. This study provides a potential therapeutic strategy to prevent tPA-induced HT after acute ischemic stroke.
Collapse
Affiliation(s)
- Wei Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Mingchang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Yuefei Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Qian Li
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross Bldg 370B, Baltimore, MD, 21205, USA
| | - Gang Deng
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Jieru Wan
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross Bldg 370B, Baltimore, MD, 21205, USA
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital, Third Military Medical University, Chongqing, 400044, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, China.
| | - Jian Wang
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross Bldg 370B, Baltimore, MD, 21205, USA.
| |
Collapse
|