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Bindal P, Kumar V, Kapil L, Singh C, Singh A. Therapeutic management of ischemic stroke. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:2651-2679. [PMID: 37966570 DOI: 10.1007/s00210-023-02804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/19/2023] [Indexed: 11/16/2023]
Abstract
Stroke is the third leading cause of years lost due to disability and the second-largest cause of mortality worldwide. Most occurrences of stroke are brought on by the sudden occlusion of an artery (ischemic stroke), but sometimes they are brought on by bleeding into brain tissue after a blood vessel has ruptured (hemorrhagic stroke). Alteplase is the only therapy the American Food and Drug Administration has approved for ischemic stroke under the thrombolysis category. Current views as well as relevant clinical research on the diagnosis, assessment, and management of stroke are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for the available therapeutic regimes in the past, present, and future. With the advent of endovascular therapy in 2015 and intravenous thrombolysis in 1995, the therapeutic options for ischemic stroke have expanded significantly. A novel approach such as vagus nerve stimulation could be life-changing for many stroke patients. Therapeutic hypothermia, the process of cooling the body or brain to preserve organ integrity, is one of the most potent neuroprotectants in both clinical and preclinical contexts. The rapid intervention has been linked to more favorable clinical results. This study focuses on the pathogenesis of stroke, as well as its recent advancements, future prospects, and potential therapeutic targets in stroke therapy.
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Affiliation(s)
- Priya Bindal
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Vishal Kumar
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Lakshay Kapil
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India
| | - Charan Singh
- Department of Pharmaceutical Sciences, HNB Garhwal University (A Central University), Chauras Campus, Distt. Tehri Garhwal, Uttarakhand, 246174, India
| | - Arti Singh
- Department of Pharmacology, ISF College of Pharmacy, Moga 142001, Affiliated to I.K Gujral Punjab Technical University, Jalandhar, Punjab, India.
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2
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Dammavalam V, Lin S, Nessa S, Daksla N, Stefanowski K, Costa A, Bergese S. Neuroprotection during Thrombectomy for Acute Ischemic Stroke: A Review of Future Therapies. Int J Mol Sci 2024; 25:891. [PMID: 38255965 PMCID: PMC10815099 DOI: 10.3390/ijms25020891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Stroke is a major cause of death and disability worldwide. Endovascular thrombectomy has been impactful in decreasing mortality. However, many clinical results continue to show suboptimal functional outcomes despite high recanalization rates. This gap in recanalization and symptomatic improvement suggests a need for adjunctive therapies in post-thrombectomy care. With greater insight into ischemia-reperfusion injury, recent preclinical testing of neuroprotective agents has shifted towards preventing oxidative stress through upregulation of antioxidants and downstream effectors, with positive results. Advances in multiple neuroprotective therapies, including uric acid, activated protein C, nerinetide, otaplimastat, imatinib, verapamil, butylphthalide, edaravone, nelonemdaz, ApTOLL, regional hypothermia, remote ischemic conditioning, normobaric oxygen, and especially nuclear factor erythroid 2-related factor 2, have promising evidence for improving stroke care. Sedation and blood pressure management in endovascular thrombectomy also play crucial roles in improved stroke outcomes. A hand-in-hand approach with both endovascular therapy and neuroprotection may be the key to targeting disability due to stroke.
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Affiliation(s)
- Vikalpa Dammavalam
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Sandra Lin
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Sayedatun Nessa
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Neil Daksla
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Kamil Stefanowski
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (V.D.); (K.S.)
| | - Ana Costa
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.L.); (N.D.); (A.C.)
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3
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Xu BT, Li MF, Chen KC, Li X, Cai NB, Xu JP, Wang HT. Mitofusin-2 mediates cannabidiol-induced neuroprotection against cerebral ischemia in rats. Acta Pharmacol Sin 2023; 44:499-512. [PMID: 36229600 PMCID: PMC9958179 DOI: 10.1038/s41401-022-01004-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/21/2022] [Indexed: 11/09/2022] Open
Abstract
Cannabidiol (CBD) reportedly exerts protective effects against many psychiatric disorders and neurodegenerative diseases, but the mechanisms are poorly understood. In this study, we explored the molecular mechanism of CBD against cerebral ischemia. HT-22 cells or primary cortical neurons were subjected to oxygen-glucose deprivation insult followed by reoxygenation (OGD/R). In both HT-22 cells and primary cortical neurons, CBD pretreatment (0.1, 0.3, 1 μM) dose-dependently attenuated OGD/R-induced cell death and mitochondrial dysfunction, ameliorated OGD/R-induced endoplasmic reticulum (ER) stress, and increased the mitofusin-2 (MFN2) protein level in HT-22 cells and primary cortical neurons. Knockdown of MFN2 abolished the protective effects of CBD. CBD pretreatment also suppressed OGD/R-induced binding of Parkin to MFN2 and subsequent ubiquitination of MFN2. Overexpression of Parkin blocked the effects of CBD in reducing MFN2 ubiquitination and reduced cell viability, whereas overexpressing MFN2 abolished Parkin's detrimental effects. In vivo experiments were conducted on male rats subjected to middle cerebral artery occlusion (MCAO) insult, and administration of CBD (2.5, 5 mg · kg-1, i.p.) dose-dependently reduced the infarct volume and ER stress in the brains. Moreover, the level of MFN2 within the ischemic penumbra of rats was increased by CBD treatment, while the binding of Parkin to MFN2 and the ubiquitination of MFN2 was decreased. Finally, short hairpin RNA against MFN2 reversed CBD's protective effects. Together, these results demonstrate that CBD protects brain neurons against cerebral ischemia by reducing MFN2 degradation via disrupting Parkin's binding to MFN2, indicating that MFN2 is a potential target for the treatment of cerebral ischemia.
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Affiliation(s)
- Bing-Tian Xu
- Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China
- Department of Neurology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, China
| | - Meng-Fan Li
- Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China
| | - Ke-Chun Chen
- Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China
| | - Xing Li
- Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China
| | - Ning-Bo Cai
- Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China
| | - Jiang-Ping Xu
- Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China.
- Key Laboratory of Mental Health of the Ministry of Education, Southern Medical University, Guangzhou, 510515, China.
- Center for Brain Science and Brain-Inspired Intelligence, Guangdong-Hong Kong-Macao Greater Bay Area, Guangzhou, 510515, China.
| | - Hai-Tao Wang
- Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, 510515, China.
- Key Laboratory of Mental Health of the Ministry of Education, Southern Medical University, Guangzhou, 510515, China.
- Center for Brain Science and Brain-Inspired Intelligence, Guangdong-Hong Kong-Macao Greater Bay Area, Guangzhou, 510515, China.
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Wang Y, Kisler K, Nikolakopoulou AM, Fernandez JA, Griffin JH, Zlokovic BV. 3K3A-Activated Protein C Protects the Blood-Brain Barrier and Neurons From Accelerated Ischemic Injury Caused by Pericyte Deficiency in Mice. Front Neurosci 2022; 16:841916. [PMID: 35431776 PMCID: PMC9005806 DOI: 10.3389/fnins.2022.841916] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/16/2022] [Indexed: 11/16/2022] Open
Abstract
Pericytes, mural cells of brain capillaries, maintain the blood-brain barrier (BBB), regulate cerebral blood flow (CBF), and protect neurons against ischemic damage. To further investigate the role of pericytes in ischemia, we induced stroke by 45-min transient middle cerebral artery occlusion (tMCAo) in 6-month-old pericyte-deficient Pdgfrb + /- mice and control Pdgfrb+/+ littermates. Compared to controls, Pdgfrb + /- mice showed a 26% greater loss of CBF during early reperfusion, and 40-50% increase in the infarct and edema volumes and motor neurological score 24 h after tMCAo. These changes were accompanied by 50% increase in both immunoglobulin G and fibrinogen pericapillary deposits in the ischemic cortex 8 h after tMCAo indicating an accelerated BBB breakdown, and 35 and 55% greater losses of pericyte coverage and number of degenerating neurons 24 h after tMCAo, respectively. Treatment of Pdgfrb + /- mice with 3K3A-activated protein C (APC), a cell-signaling analog of plasma protease APC, administered intravenously 10 min and 4 h after tMCAo normalized CBF during the early reperfusion phase and reduced infarct and edema volume and motor neurological score by 55-60%, with similar reductions in BBB breakdown and number of degenerating neurons. Our data suggest that pericyte deficiency results in greater brain injury, BBB breakdown, and neuronal degeneration in stroked mice and that 3K3A-APC protects the brain from accelerated injury caused by pericyte deficiency. These findings may have implications for treatment of ischemic brain injury in neurological conditions associated with pericyte loss such as those seen during normal aging and in neurodegenerative disorders such as Alzheimer's disease.
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Affiliation(s)
- Yaoming Wang
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, United States
| | - Kassandra Kisler
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, United States
| | - Angeliki Maria Nikolakopoulou
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, United States
| | - Jose A. Fernandez
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, United States
| | - John H. Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, United States
- Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, San Diego, CA, United States
| | - Berislav V. Zlokovic
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, United States
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5
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Patalakh II. L-ARGININE AND L-GLUTAMIC ACID INCREASE THE CONTENT OF PROTEIN C IN THE EARLY STAGES OF ISOLATION FROM DONOR PLASMA. BIOTECHNOLOGIA ACTA 2021. [DOI: 10.15407/biotech14.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Current large-scale production of blood-derived pharmacological preparations is aimed at expanding the list of products and deeper extraction of target proteins especially at the pre-purification stage. In particular, this problem becomes critical for the isolation of proteins like protein C (PC), which is present in plasma in trace amounts. Aim. We aimed to improve the buffer composition to minimize the interaction of PC with other proteins and lipids that are inevitably present in the stock material. Methods. The content of protein C in plasma and its derivatives was assessed by the amidolytic activity to the chromogenic substrate S2366. A decrease in homologous impurities and plasma enrichment with protein C was provided by selective bulk adsorption on DEAE-cellulose. Results. Here we describe that an equimolar mixture of two amino acids (L-arginine and L-glutamic acid) essentially increased the content of protein C at the stage of cryo-depleted plasma pre-purification, including initial dilution and subsequent enrichment of plasma with protein C due to selective bulk adsorption on DEAE- cellulose. Additionally, it was revealed that solutions of these amino acids, when combined, inhibit the induced amidolytic activity of protein C and increase its solubility (in contrast to other plasma proteases). Conclusion. Pre-adding of a mixture of amino acids L-arginine and L-glutamic acid to cryo-depleted plasma significantly optimizes the pre-purification stage of protein C, providing a 5-fold increase in its yield after elution from DEAE-cellulose.
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6
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Matei N, Camara J, Zhang JH. The Next Step in the Treatment of Stroke. Front Neurol 2021; 11:582605. [PMID: 33551950 PMCID: PMC7862333 DOI: 10.3389/fneur.2020.582605] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/23/2020] [Indexed: 12/12/2022] Open
Abstract
Although many patients do not receive reperfusion therapy because of delayed presentation and/or severity and location of infarct, new reperfusion approaches are expanding the window of intervention. Novel application of neuroprotective agents in combination with the latest methods of reperfusion provide a path to improved stroke intervention outcomes. We examine why neuroprotective agents have failed to translate to the clinic and provide suggestions for new approaches. New developments in recanalization therapy in combination with therapeutics evaluated in parallel animal models of disease will allow for novel, intra-arterial deployment of therapeutic agents over a vastly expanded therapeutic time window and with greater likelihood success. Although the field of neuronal, endothelial, and glial protective therapies has seen numerous large trials, the application of therapies in the context of newly developed reperfusion strategies is still in its infancy. Given modern imaging developments, evaluation of the penumbra will likely play a larger role in the evolving management of stroke. Increasingly more patients will be screened with neuroimaging to identify patients with adequate collateral blood supply allowing for delayed rescue of the penumbra. These patients will be ideal candidates for therapies such as reperfusion dependent therapeutic agents that pair optimally with cutting-edge reperfusion techniques.
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Affiliation(s)
- Nathanael Matei
- Department of Ophthalmology, University of Southern California, Los Angeles, CA, United States
| | - Justin Camara
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States
| | - John H Zhang
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, United States.,Department of Anesthesiology, Loma Linda University, Loma Linda, CA, United States.,Department of Neurosurgery, Loma Linda University, Loma Linda, CA, United States
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7
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Lyden PD, Pryor KE, Minigh J, Davis TP, Griffin JH, Levy H, Zlokovic BV. Stroke Treatment With PAR-1 Agents to Decrease Hemorrhagic Transformation. Front Neurol 2021; 12:593582. [PMID: 33790846 PMCID: PMC8005555 DOI: 10.3389/fneur.2021.593582] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/08/2021] [Indexed: 12/20/2022] Open
Abstract
Ischemic stroke is the most widespread cause of disability and a leading cause of death in developed countries. To date, the most potent approved treatment for acute stroke is recanalization therapy with thrombolytic drugs such as tissue plasminogen activator (rt-PA or tPA) or endovascular mechanical thrombectomy. Although tPA and thrombectomy are widely available in the United States, it is currently estimated that only 10-20% of stroke patients get tPA treatment, in part due to restrictive selection criteria. Recently, however, tPA and thrombectomy selection criteria have loosened, potentially allowing more patients to qualify. The relatively low rate of treatment may also reflect the perceived risk of brain hemorrhage following treatment with tPA. In translational research and a single patient study, protease activated receptor 1 (PAR-1) targeted therapies given along with thrombolysis and thrombectomy appear to reduce hemorrhagic transformation after recanalization. Such adjuncts may likely enhance the availability of recanalization and encourage more physicians to use the recently expanded selection criteria for applying recanalization therapies. This narrative review discusses stroke therapies, the role of hemorrhagic transformation in producing poor outcomes, and presents the data suggesting that PAR-1 acting agents show promise for decreasing hemorrhagic transformation and improving outcomes.
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Affiliation(s)
- Patrick D. Lyden
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, United States
- *Correspondence: Patrick D. Lyden
| | | | | | - Thomas P. Davis
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - John H. Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, United States
| | - Howard Levy
- Howard Levy Consulting LLC, Hopewell, NJ, United States
| | - Berislav V. Zlokovic
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, United States
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8
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Ye F, Garton HJL, Hua Y, Keep RF, Xi G. The Role of Thrombin in Brain Injury After Hemorrhagic and Ischemic Stroke. Transl Stroke Res 2020; 12:496-511. [PMID: 32989665 DOI: 10.1007/s12975-020-00855-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 02/06/2023]
Abstract
Thrombin is increased in the brain after hemorrhagic and ischemic stroke primarily due to the prothrombin entry from blood either with a hemorrhage or following blood-brain barrier disruption. Increasing evidence indicates that thrombin and its receptors (protease-activated receptors (PARs)) play a major role in brain pathology following ischemic and hemorrhagic stroke (including intracerebral, intraventricular, and subarachnoid hemorrhage). Thrombin and PARs affect brain injury via multiple mechanisms that can be detrimental or protective. The cleavage of prothrombin into thrombin is the key step of hemostasis and thrombosis which takes place in every stroke and subsequent brain injury. The extravascular effects and direct cellular interactions of thrombin are mediated by PARs (PAR-1, PAR-3, and PAR-4) and their downstream signaling in multiple brain cell types. Such effects include inducing blood-brain-barrier disruption, brain edema, neuroinflammation, and neuronal death, although low thrombin concentrations can promote cell survival. Also, thrombin directly links the coagulation system to the immune system by activating interleukin-1α. Such effects of thrombin can result in both short-term brain injury and long-term functional deficits, making extravascular thrombin an understudied therapeutic target for stroke. This review examines the role of thrombin and PARs in brain injury following hemorrhagic and ischemic stroke and the potential treatment strategies which are complicated by their role in both hemostasis and brain.
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Affiliation(s)
- Fenghui Ye
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Hugh J L Garton
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
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9
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Andjelkovic AV, Xiang J, Stamatovic SM, Hua Y, Xi G, Wang MM, Keep RF. Endothelial Targets in Stroke: Translating Animal Models to Human. Arterioscler Thromb Vasc Biol 2019; 39:2240-2247. [PMID: 31510792 DOI: 10.1161/atvbaha.119.312816] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cerebral ischemia (stroke) induces injury to the cerebral endothelium that may contribute to parenchymal injury and worsen outcome. This review focuses on current preclinical studies examining how to prevent ischemia-induced endothelial dysfunction. It particularly focuses on targets at the endothelium itself. Those include endothelial tight junctions, transcytosis, endothelial cell death, and adhesion molecule expression. It also examines how such studies are being translated to the clinic, especially as adjunct therapies for preventing intracerebral hemorrhage during reperfusion of the ischemic brain. Identification of endothelial targets may prove valuable in a search for combination therapies that would specifically protect different cell types in ischemia.
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Affiliation(s)
- Anuska V Andjelkovic
- From the Departments of Neurosurgery (A.V.A., J.X., Y.H., G.X., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI.,Pathology (A.V.A., S.M.S.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Jianming Xiang
- From the Departments of Neurosurgery (A.V.A., J.X., Y.H., G.X., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Svetlana M Stamatovic
- Pathology (A.V.A., S.M.S.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Ya Hua
- From the Departments of Neurosurgery (A.V.A., J.X., Y.H., G.X., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Guohua Xi
- From the Departments of Neurosurgery (A.V.A., J.X., Y.H., G.X., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Michael M Wang
- Neurology (M.M.W.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI.,Molecular and Integrative Physiology (M.M.W., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
| | - Richard F Keep
- From the Departments of Neurosurgery (A.V.A., J.X., Y.H., G.X., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI.,Molecular and Integrative Physiology (M.M.W., R.F.K.), University of Michigan, Ann Arbor and Department of Veterans Affairs, Neurology Service, VA Ann Arbor Healthcare System, MI
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10
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Kim JS. tPA Helpers in the Treatment of Acute Ischemic Stroke: Are They Ready for Clinical Use? J Stroke 2019; 21:160-174. [PMID: 31161761 PMCID: PMC6549064 DOI: 10.5853/jos.2019.00584] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/15/2019] [Indexed: 12/12/2022] Open
Abstract
Tissue plasminogen activator (tPA) is the only therapeutic agent approved to treat patients with acute ischemic stroke. The clinical benefits of tPA manifest when the agent is administered within 4.5 hours of stroke onset. However, tPA administration, especially delayed administration, is associated with increased intracranial hemorrhage (ICH), hemorrhagic transformation (HT), and mortality. In the ischemic brain, vascular remodeling factors are upregulated and microvascular structures are destabilized. These factors disrupt the blood brain barrier (BBB). Delayed recanalization of the vessels in the presence of relatively matured infarction appears to damage the BBB, resulting in HT or ICH, also known as reperfusion injury. Moreover, tPA itself activates matrix metalloproteases, further aggravating BBB disruption. Therefore, attenuation of edema, HT, or ICH after tPA treatment is an important therapeutic strategy that may enable clinicians to extend therapeutic time and increase the probability of excellent outcomes. Recently, numerous agents with various mechanisms have been developed to interfere with various steps of ischemia/ reperfusion injuries or BBB destabilization. These agents successfully reduce infarct volume and decrease the incidence of ICH and HT after delayed tPA treatment in various animal stroke models. However, only some have entered into clinical trials; the results have been intriguing yet unsatisfactory. In this narrative review, I describe such drugs and discuss the problems and future directions. These “tPA helpers” may be clinically used in the future to increase the efficacy of tPA in patients with acute ischemic stroke.
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Affiliation(s)
- Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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11
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12
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Activated Protein C in Cutaneous Wound Healing: From Bench to Bedside. Int J Mol Sci 2019; 20:ijms20040903. [PMID: 30791425 PMCID: PMC6412604 DOI: 10.3390/ijms20040903] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 02/14/2019] [Accepted: 02/16/2019] [Indexed: 12/12/2022] Open
Abstract
Independent of its well-known anticoagulation effects, activated protein C (APC) exhibits pleiotropic cytoprotective properties. These include anti-inflammatory actions, anti-apoptosis, and endothelial and epithelial barrier stabilisation. Such beneficial effects have made APC an attractive target of research in a plethora of physiological and pathophysiological processes. Of note, the past decade or so has seen the emergence of its roles in cutaneous wound healing-a complex process involving inflammation, proliferation and remodelling. This review will highlight APC's functions and mechanisms, and detail its pre-clinical and clinical studies on cutaneous wound healing.
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13
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Lazic D, Sagare AP, Nikolakopoulou AM, Griffin JH, Vassar R, Zlokovic BV. 3K3A-activated protein C blocks amyloidogenic BACE1 pathway and improves functional outcome in mice. J Exp Med 2019; 216:279-293. [PMID: 30647119 PMCID: PMC6363429 DOI: 10.1084/jem.20181035] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 10/05/2018] [Accepted: 10/30/2018] [Indexed: 12/29/2022] Open
Abstract
3K3A-activated protein C (APC), a cell-signaling analogue of endogenous blood serine protease APC, exerts vasculoprotective, neuroprotective, and anti-inflammatory activities in rodent models of stroke, brain injury, and neurodegenerative disorders. 3K3A-APC is currently in development as a neuroprotectant in patients with ischemic stroke. Here, we report that 3K3A-APC inhibits BACE1 amyloidogenic pathway in a mouse model of Alzheimer's disease (AD). We show that a 4-mo daily treatment of 3-mo-old 5XFAD mice with murine recombinant 3K3A-APC (100 µg/kg/d i.p.) prevents development of parenchymal and cerebrovascular amyloid-β (Aβ) deposits by 40-50%, which is mediated through NFκB-dependent transcriptional inhibition of BACE1, resulting in blockade of Aβ generation in neurons overexpressing human Aβ-precursor protein. Consistent with reduced Aβ deposition, 3K3A-APC normalized hippocampus-dependent behavioral deficits and cerebral blood flow responses, improved cerebrovascular integrity, and diminished neuroinflammatory responses. Our data suggest that 3K3A-APC holds potential as an effective anti-Aβ prevention therapy for early-stage AD.
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Affiliation(s)
- Divna Lazic
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA.,Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, CA.,Department of Neurobiology, Institute for Biological Research, University of Belgrade, Belgrade, Republic of Serbia
| | - Abhay P Sagare
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA.,Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Angeliki M Nikolakopoulou
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA.,Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - John H Griffin
- The Scripps Research Institute, La Jolla, CA.,Department of Medicine, University of California, San Diego, San Diego, CA
| | - Robert Vassar
- Department of Cell and Molecular Biology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Berislav V Zlokovic
- Zilkha Neurogenetic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA .,Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Griffin JH, Zlokovic BV, Mosnier LO. Activated protein C, protease activated receptor 1, and neuroprotection. Blood 2018; 132:159-169. [PMID: 29866816 PMCID: PMC6043978 DOI: 10.1182/blood-2018-02-769026] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/01/2018] [Indexed: 02/08/2023] Open
Abstract
Protein C is a plasma serine protease zymogen whose active form, activated protein C (APC), exerts potent anticoagulant activity. In addition to its antithrombotic role as a plasma protease, pharmacologic APC is a pleiotropic protease that activates diverse homeostatic cell signaling pathways via multiple receptors on many cells. Engineering of APC by site-directed mutagenesis provided a signaling selective APC mutant with 3 Lys residues replaced by 3 Ala residues, 3K3A-APC, that lacks >90% anticoagulant activity but retains normal cell signaling activities. This 3K3A-APC mutant exerts multiple potent neuroprotective activities, which require the G-protein-coupled receptor, protease activated receptor 1. Potent neuroprotection in murine ischemic stroke models is linked to 3K3A-APC-induced signaling that arises due to APC's cleavage in protease activated receptor 1 at a noncanonical Arg46 site. This cleavage causes biased signaling that provides a major explanation for APC's in vivo mechanism of action for neuroprotective activities. 3K3A-APC appeared to be safe in ischemic stroke patients and reduced bleeding in the brain after tissue plasminogen activator therapy in a recent phase 2 clinical trial. Hence, it merits further clinical testing for its efficacy in ischemic stroke patients. Recent studies using human fetal neural stem and progenitor cells show that 3K3A-APC promotes neurogenesis in vitro as well as in vivo in the murine middle cerebral artery occlusion stroke model. These recent advances should encourage translational research centered on signaling selective APC's for both single-agent therapies and multiagent combination therapies for ischemic stroke and other neuropathologies.
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Affiliation(s)
- John H Griffin
- The Scripps Research Institute, La Jolla, CA
- Department of Medicine, University of California, San Diego, CA; and
| | - Berislav V Zlokovic
- Zilkha Neurogenetic Institute, University of Southern California, Keck School of Medicine, Los Angeles, CA
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Affiliation(s)
- Myron D Ginsberg
- Peritz Scheinberg Professor of Neurology, University of Miami Miller School of Medicine, Miami, FL, United States.
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