Neuronal protective effects of focal ischemic pre- and/or postconditioning on the model of transient focal cerebral ischemia in rats

Ischemic post-conditioning in acute ischemic stroke thrombectomy: A phase-I duration escalation study

Background

Previous experimental studies have found that ischemic post-conditioning exhibits neuroprotective effects by alleviating ischemia-reperfusion injury in an acute ischemic stroke model, and its efficacy is thought to be related to the duration of ischemic post-conditioning. However, ischemic post-conditioning has not been used in patients with acute ischemic stroke. This study aims to determine the safety, tolerability, and maximum tolerable duration of ischemic post-conditioning in patients with acute ischemic stroke receiving mechanical thrombectomy.

Methods

Patients with acute ischemic stroke with unilateral middle cerebral artery M1 segment occlusion eligible for mechanical thrombectomy will be enrolled. We adopt a 3 + 3 dose-escalation design with a duration escalation schedule of 0, 1, 2, 3, 4, and 5 min × 4 cycles for the ischemic post-conditioning study. After successful reperfusion following mechanical thrombectomy, the balloon for ischemic post-conditioning will be inflated at the site proximal to the culprit lesion four times for 0–5 min with low-pressure (3–4 atmospheres) inflations, each separated by 0–5 min of reflow. We pre-defined the major responses (vessel perforation or rupture, reocclusion of the culprit vessel after ischemic post-conditioning, vessel dissection, severe vasospasm, ischemic post-conditioning related thrombotic events, and rupture of the balloon used for ischemic post-conditioning) as the stopping rules. Each patient will undergo a rigorous evaluation to determine the safety, tolerability, and maximum tolerable duration of ischemic post-conditioning.

Discussion

This will be the first clinical study to ascertain the safety and tolerability of ischemic post-conditioning in patients with acute ischemic stroke receiving mechanical thrombectomy. The maximum tolerable duration obtained in this study will also serve as a starting point for future studies on the efficacy of ischemic post-conditioning.

Clinical trial registration

[https://clinicaltrials.gov], identifier [NCT05153655].

Neuroprotection of Ischemic Preconditioning is Mediated by Anti-inflammatory, Not Pro-inflammatory, Cytokines in the Gerbil Hippocampus Induced by a Subsequent Lethal Transient Cerebral Ischemia

Ischemic preconditioning (IPC) induced by sublethal transient cerebral ischemia could reduce neuronal damage/death following a subsequent lethal transient cerebral ischemia. We, in this study, compared expressions of interleukin (IL)-2 and tumor necrosis factor (TNF)-α as pro-inflammatory cytokines, and IL-4 and IL-13 as anti-inflammatory cytokines in the gerbil hippocampal CA1 region between animals with lethal ischemia and ones with IPC followed by lethal ischemia. In the animals with lethal ischemia, pyramidal neurons in the stratum pyramidale (SP) of the hippocampal CA1 region were dead at 5 days post-ischemia; however, IPC protected the CA1 pyramidal neurons from lethal ischemic injury. Expressions of all cytokines were significantly decreased in the SP after lethal ischemia and hardly detected in the SP at 5 days post-ischemia because the CA1 pyramidal neurons were dead. IPC increased expressions of anti-inflammatory cytokines (IL-4 and IL-13) in the stratum pyramidale of the CA1 region following no lethal ischemia (sham-operation), and the increased expressions of IL-4 and IL-13 by IPC were continuously maintained is the SP of the CA1 region after lethal ischemia. However, pro-inflammatory cytokines (IL-2 and TNF-α) in the SP of the CA1 region were similar those in the sham-operated animals with IPC, and the IL-4 and IL-13 expressions in the SP were maintained after lethal ischemia. In conclusion, this study shows that anti-inflammatory cytokines significantly increased and longer maintained by IPC and this might be closely associated with neuroprotection after lethal transient cerebral ischemia.

Biological networks in ischemic tolerance - rethinking the approach to clinical conditioning

The adaptive response (conditioning) to environmental stressors evokes evolutionarily conserved programs in uni- and multicellular organisms that result in increased fitness and resistance to stressor induced injury. Although the concept of conditioning has been around for a while, its translation into clinical therapies targeting neurovascular diseases has only recently begun. The slow pace of clinical adoption might be partially explained by our poor understanding of underpinning mechanisms and of the complex responses of the organism to the stressor. At the 2(nd) Translational Preconditioning Meeting participants engaged in an intense discussion addressing whether the time has come to more aggressively implement clinical conditioning protocols in the treatment of cerebrovascular diseases or whether it would be better to wait until preclinical data would help to minimize clinical empiricism. This review addresses the complex involvement of biological networks in establishing ischemic tolerance at the organism level using two clinically promising conditioning modalities, namely remote ischemic preconditioning, and per- or post-conditioning, as examples.

The dynamic detection of NO during the ischemic postconditioning against global cerebral ischemia/reperfusion injury

Little is known about role of Nitric Oxide (NO) of ischemic postconditioning in global cerebral ischemia and reperfusion (I/R) injury. In this study, we detected the dynamic change of NO during the ischemic postconditioning against global cerebral I/R in vivo, and compared the effects of six postconditioning conditions with different numbers of cycles and periods for reperfusion/occlusion. The animals underwent postconditioning consisting of 3 or 10 cycles of 15-s reperfusion, followed by 15-s occlusion (post-3-15/15, post-10-15/15), or 3 or 10 cycles of 30-s reperfusion/30-s occlusion (post-3-30/30, post-10-30/30), or 3 or 10 cycles of 60-s reperfusion/15-s occlusion (post-3-60/15, post-10-60/15). The results showed that four groups increased NO concentration, while all groups improved CBF significantly. Different postconditioning groups had different effects on NO and CBF. Post-3-30/30 had the strongest effect on both. Also it reduced infarct size from 33.0% to 24.29%, and downregulated the cell death ratio from 6.71% to 1.04%, showing the strongest protective effect among tested conditions. And we found that post-3-30/30 was an optional method in ischemic postconditioning, which obviously induced a large amount of NO synthesis with a slow speed, increased CBF and reduced the brain injuries. Therefore we concluded that NO is a reliable candidate in mediating ischemic postconditioning neuroprotection.

Ischemic postconditioning protects the neurovascular unit after focal cerebral ischemia/reperfusion injury

Recently, cerebral ischemic postconditioning (Postcond) has been shown to reduce infarction volume in cerebral ischemia/reperfusion (I/R) injury. However, it is unclear if ischemic Postcond offers more extensive neuroprotection than current therapies. The aim of this study was to investigate the neuroprotective effects of ischemic Postcond on the neurovascular unit (NVU). A middle cerebral artery occlusion rat model was used; cerebral infarct volumes, neurologic scores, and transmission electron microscopy were evaluated 24 h after reperfusion. We used Evans blue extravasation, immunohistochemistry, and Western blot analyses to evaluate the integrity of the blood brain barrier (BBB) and the distribution and expression of the tight junction (TJ)-associated proteins of claudin-5 and occludin in brain microvessel endothelium. The Postcond group showed significantly reduced infarct volumes and decreased neurologic impairment scores compared to the I/R group. Also, injuries to the cerebral microvascular endothelial cells, astrocytes, and neurons were minimized in the Postcond group. The permeability of the BBB increased in both the I/R and Postcond groups, but the Postcond group showed a significant decrease in permeability than the I/R group. Expression of both claudin-5 and occludin were higher in the Postcond groups compared to the I/R group, but expression of both proteins decreased in the I/R and Postcond groups compared to the sham group. The results of our study suggest that ischemic Postcond is an effective way to reduce injury to neurons, astrocytes, and endothelial cells, to increase protein expressions of TJ-associated proteins, and to improve BBB intergrity affected by focal I/R. Ischemic Postcond could protect the NVU from I/R injury.

Is there a place for cerebral preconditioning in the clinic?

Preconditioning (PC) describes a phenomenon whereby a sub-injury inducing stress can protect against a later injurious stress. Great strides have been made in identifying the mechanisms of PC-induced protection in animal models of brain injury. While these may help elucidate potential therapeutic targets, there are questions over the clinical utility of cerebral PC, primarily because of questions over the need to give the PC stimulus prior to the injury, narrow therapeutic windows and safety. The object of this review is to address the question of whether there may indeed be a clinical use for cerebral PC and to discuss the deficiencies in our knowledge of PC that may hamper such clinical translation.

Phosphorylation of p38 MAPK mediates hypoxic preconditioning-induced neuroprotection against cerebral ischemic injury via mitochondria translocation of Bcl-xL in mice

Hypoxic preconditioning (HPC) initiates intracellular signaling pathway to provide protection, but the role of p38 mitogen-activated protein kinase (p38 MAPK) in HPC-induced neuroprotection against cerebral ischemic injuries is a matter of debate. In this study, we found that HPC could reduce 6h middle cerebral artery occlusion (MCAO)-induced infarct volume, edema ratio and cell apoptosis, as well as enhancing the up-regulated p38 MAPK phosphorylation (P-p38 MAPK) levels in the peri-infarct region of mice after 6h MCAO. However, intracerebroventricular injection of p38 MAPK inhibitor SB203580 abolished this HPC-induced neuroprotection. HPC significantly increased the translocation of anti-apoptotic Bcl-2-related protein Bcl-xL from the cytosol to the mitochondria in the peri-infarct region of MCAO mice. Interestingly, the results of reciprocal immunoprecipitation showed that Bcl-xL and P-p38 MAPK were coimmunoprecipitated reciprocally only in the peri-infarct region of HPC and MCAO treated mice, while Bcl-xL and total p38 (T-p38 MAPK), not P-p38 MAPK, could be coimmunoprecipited by each other in the brain of normal control mice. In addition, we found SB203580 significantly decreased P-p38 MAPK levels, and inhibited HPC-induced mitochondria translocation of Bcl-xL in the brain of HPC and MCAO treated mice. Taken together, our findings suggested that P-p38 MAPK mediates HPC-induced neuroprotection against cerebral ischemic injury via mitochondria translocation of Bcl-xL, which might be a key anti-cell apoptotic mechanism of HPC.

Complement component 3 inhibition by an antioxidant is neuroprotective after cerebral ischemia and reperfusion in mice

Oxidative stress after stroke is associated with the inflammatory system activation in the brain. The complement cascade, especially the degradation products of complement component 3, is a key inflammatory mediator of cerebral ischemia. We have shown that pro-inflammatory complement component 3 is increased by oxidative stress after ischemic stroke in mice using DNA array. In this study, we investigated whether up-regulation of complement component 3 is directly related to oxidative stress after transient focal cerebral ischemia in mice and oxygen-glucose deprivation in brain cells. Persistent up-regulation of complement component 3 expression was reduced in copper/zinc-superoxide dismutase transgenic mice, and manganese-superoxide dismutase knock-out mice showed highly increased complement component 3 levels after transient focal cerebral ischemia. Antioxidant N-tert-butyl-α-phenylnitrone treatment suppressed complement component 3 expression after transient focal cerebral ischemia. Accumulation of complement component 3 in neurons and microglia was decreased by N-tert-butyl-α-phenylnitrone, which reduced infarct volume and impaired neurological deficiency after cerebral ischemia and reperfusion in mice. Small interfering RNA specific for complement component 3 transfection showed a significant increase in brain cells viability after oxygen-glucose deprivation. Our study suggests that the neuroprotective effect of antioxidants through complement component 3 suppression is a new strategy for potential therapeutic approaches in stroke.

The effect of ischemic post-conditioning on hippocampal cell apoptosis following global brain ischemia in rats

We evaluated the effect of brain ischemic post-conditioning on cell apoptosis in the hippocampus following global brain ischemia in rats. Adult male Sprague-Dawley rats were randomly divided into three groups (n=15/group): sham operation, ischemia/reperfusion (I/R) and ischemic post-conditioning (I PostC). Global brain ischemia was induced by four-vessel occlusion. Ischemic post-conditioning consisted of six cycles of 10s/10s reperfusion/reocclusion at the onset of reperfusion. All rats were sacrificed 24 hours or 72 hours after reperfusion. The hippocampal CA1 regions were analysed using the terminal deoxynucleotidyl transferase-mediated biotinylated deoxyuridine triphosphate nick end-labelling (Tunel) staining technique for determining cell apoptosis. Levels of caspase-3 and Bcl-2 were measured by Western blotting. After 72 hours, fewer Tunel-positive brain cells were observed in rats from the I PostC group than in rats from the I/R group (10.3 ± 2.7% versus 40.8 ± 6.2%, p<0.01). After reperfusion at 24 hours and 72 hours, expression of caspase-3 in the I PostC group was significantly decreased (p<0.01) and expression of Bcl-2 in the I PostC group was significantly increased (p<0.01) compared with the I/R group. We conclude that down-regulation of caspase-3 and up-regulation of Bcl-2 by ischemic post-conditioning may underlie the protective effects of post-conditioning.

Toll-like receptor 4 is involved in ischemic tolerance of postconditioning in hippocampus of tree shrews to thrombotic cerebral ischemia

BACKGROUND

Toll-like receptor 4 (TLR4) is an important mediator of the innate immune response. It significantly contributes to neuroinflammation and may be involved in ischemic tolerance. It is unknown how cerebral ischemia in the cortex and postconditioning might affect inflammatory reactions in the hippocampus or whether TLR4 expression plays a role.

OBJECTIVE

This study explored the mechanistic hypothesis that postconditioning modulates TLR4 expression and thus improves inflammatory reactions in the hippocampus.

METHODS

Thrombotic focal cerebral ischemia was induced by a photochemical reaction in tree shrews. Four hours after the photochemical reaction onset, ischemic postconditioning was established with three repeated five minute cycles of temporary right carotid artery clipping and a five minute reperfusion. Histological changes were assessed over 72h in hippocampal morphology (hematoxylin-and-eosin), myeloperoxidase (MPO) expression (immunohistochemistry), TLR4 expression (Western blot analysis and immunohistochemistry), and TLR4 mRNA expression (semiquantitative RT-PCR).

RESULTS

We found extensive neuronal degeneration in the hippocampus that peaked at 24h after cerebral ischemia. This was significantly attenuated after postconditioning. Cerebral ischemia caused a predominant increase in TLR4 protein expression from 4 to 24h (P<0.05). In contrast, postconditioning caused a decrease in TLR4 protein expression from 4 to 24h (P<0.05), which increased at 72h (P<0.05). Hippocampal TLR4 mRNA levels showed the same trends as those observed in protein expression.

CONCLUSION

These findings indicated that TLR4 signaling and innate immunity may be involved in the protective mechanisms of postconditioning and ischemic tolerance.

Neuroprotective effects of ischemic postconditioning on global brain ischemia in rats through upregulation of hippocampal glutamine synthetase

Brain ischemic postconditioning is the induction of brief periods of ischemia-reperfusion during the early stages following ischemia, and it has been shown to produce neuroprotective effects. The mechanisms underlying these neuroprotective effects are poorly understood. Glutamate excitotoxicity is one cause of postischemic neuronal death. Glutamine synthetase (GS) is an enzyme that is expressed in glial cells and may affect glutamate excitotoxicity. We induced global ischemia in rats and performed postconditioning with 6 cycles of 10 seconds reperfusion and 10 seconds reocclusion before final reperfusion. Hematoxylin and eosin staining revealed extensive neuronal loss (44.0 ± 2.8% cell survival) in the hippocampal CA1 region. Ischemic postconditioning decreased neuronal death (82.0 ± 5.6% cell survival; p<0.05). Western blotting revealed significantly increased GS expression in the hippocampus for the ischemia-reperfusion group over time compared with the sham group (p<0.05). Ischemic postconditioning resulted in significantly increased (p<0.05) GS expression compared with both the sham and ischemia-reperfusion groups, suggesting that upregulation of GS expression after ischemia constitutes a neuroprotective mechanism.

Involvement of Glutamate transporter-1 in neuroprotection against global brain ischemia-reperfusion injury induced by postconditioning in rats

Ischemic postconditioning refers to several transient reperfusion and ischemia cycles after an ischemic event and before a long duration of reperfusion. The procedure produces neuroprotective effects. The mechanisms underlying these neuroprotective effects are poorly understood. In this study, we found that most neurons in the CA1 region died after 10 minutes of ischemia and is followed by 72 hours of reperfusion. However, brain ischemic postconditioning (six cycles of 10 s/10 s reperfusion/re-occlusion) significantly reduced neuronal death. Significant up-regulation of Glutamate transporter-1 was found after 3, 6, 24, 72 hours of reperfusion. The present study showed that ischemic postconditioning decreases cell death and that upregulation of GLT-1 expression may play an important role on this effect.

Ischemic postconditioning protects brain from ischemia/reperfusion injury by attenuating endoplasmic reticulum stress-induced apoptosis through PI3K-Akt pathway

Endoplasmic reticulum (ER) stress has been implicated in the pathology of cerebral ischemia. During prolonged period of stress or when the adaptive response fails, apoptotic cell death ensues. Cerebral ischemic postconditioning (Postcond) has been shown to reduce cerebral ischemia/reperfusion (I/R) injury in both focal and global cerebral ischemia model. However, the mechanism remains to be understood. This study aimed to elucidate whether Postcond attenuates brain I/R damage by suppressing ER stress-induced apoptosis and if the phosphatidylinositol-3kinase/Akt (PI3K/Akt) pathway is involved. A focal cerebral ischemia rat model was used in the study. Rat brain infarct size and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) positive cells in ischemic penumbra were assessed after reperfusion of the brain. The expressions of C/EBP-homologous protein (CHOP), caspase-12, glucose-regulated protein 78 (GRP78) and the phosphorylation of Akt (Ser473) in ischemic penumbra were measured after reperfusion. Our results showed that Postcond significantly attenuated brain I/R injury, as shown by reduction in infarct size, cell apoptosis, CHOP expression, caspase-12 activation and increase in GRP78 expression. LY294002, a phosphoinositide 3-kinase inhibitor, increased the number of TUNEL-positive cells suppressed by Postcond in penumbra. In addition, LY294002 diminished the effect of Postcond on the activation of CHOP, caspase-12 and GRP78. These results suggest that Postcond protects brain from I/R injury by suppressing ER stress-induced apoptosis and PI3K/Akt pathway is involved.